Respiratory IV - Neoplasms Flashcards
Bronchogenic carcinomas are derived from …
endoderm or a derivative (neuroendocrine)
What is the difference in treatment between small cell carcinomas and non-small cell carcinomas?
Small cell - not resectable, but sensitive to chemo
Non-small cell - resectable, but less responsive to chemo
Tobacco smoking is related to bronchogenic carcinoma.
What % of lung cancers are in smokers?
What other cancers are smokers at risk for?
What changes are seen in respiratory epithelium?
Why is smoking related?
80% of lung cancer in smokers
Other risk: lip, tongue, floor of mouth, pharynx, esophagus, urinary bladder, pancreas
Histologic changes in lining epithelium
- -squamous metaplasia / atypia in central airways
- -goblet (glandular) metaplasia in peripheral airways
Smoke contains polycyclic aromatic hydrocarbons, phnol derivates, contaminants
What industrial and environmental hazards pose a risk of bronchogenic carcinoma?
- Asbestos
- Radiation (miners, accidental, war)
- Nickel, chromates, coal, mustard gas, arsenic, beryllium, iron
- Air pollution
- Radon – bulk of cancers in nonsmokers
There is also a genetic component involved in bronchogenic carcinoma. What genes are involved?
C-myc – small cell
K-ras – adenocarcinoma
p53
We don’t really know the association, but it seems that previous injury is associated with a certain cancer. Which cancer?
Scarring is usually associated with adenocarinoma
Bronchogenic carcinoma morphology
- -where does it originate?
- -what is the tissue like?
- -how does it metastasize? where to?
3/4 take origin from 1st, 2nd, or 3rd order bronchi
- -tissue is gray-white and firm
- -two paths: fungate into lumen or infiltrate along wall
- -extension to pleural surface, mediastinum, pericardium, regional lymph nodes
- -early metastasis through both lymphatic and hematogenous routes
- -most common sites: ADRENALS; liver, brain, bone
What secondary pathologies can develop as a result of bronchogenic carcinoma?
- -partial obstruction - focal emphysema
- -total obstruction - atelectasis
- -impaired drainage - severe suppurative or ulcerative bronchitis, bronchiolitis, bronchiectasis
- -pulmonary abscesses
- -superior vena cava syndrome
- -pleuritis, pleural effusions, pericarditis
(secondary pathologies are related anatomic changes distal to bronchial involvement)
What are the types of bronchogenic carcinomas?
- Squamous cell carcinoma (40%)
- Adenocarcinoma (35%)
- Small cell carcinoma (25%)
- -Large cell carcinoma
- -Bronchioalveolar carcinoma
- -Carcinoid tumor
Squamous cell carcinoma
- -correlated with?
- -what histologic features are seen?
- -where do they arise?
- -spread?
- -what paraneoplastic syndrome is this associated with?
–closely correlated with a smoking history
- -production of keratin and intercellular bridges in well- differentiated forms
- -less well-differentiated tumors merge with large cell tumors
–arises in larger, more central bronchi
- -tends to spread locally
- -metastasizes somewhat later but grows more rapidly
–associated with hypercalcemia syndrome
Adenocarcinoma
- -derived from?
- -common in who?
- -located where?
- -histology?
- -growth?
- -bronchial-derived adenocarcinoma (glandular metaplasia in small airways)
- -most common type in women and non-smokers
- -more peripherally located, smaller
- -vary histologically from well-differentiated to papillary lesions to solid masses
- -80% contain mucin
- -grow more slowly
- -may be associated with scarring; less frequently associated with smoking
Large cell carcinoma
- -what kind of tumor?
- -histology?
- -anaplastic with larger, more polygonal cells and vesicular nuclei
- -probably undifferentiated squamous cell carcinomas and adenocarcinomas
- -intracellular mucin, multinucleate giant cells
- -also “clear cell” and “spindle cell” types
Small cell carcinoma
- -malignant?
- -what do the cells look like?
- -how do the cells grow?
–highly malignant tumor
- -cells are small with little cytoplasm; round or oval
- –lymphocyte-like, but twice the size of lymphocytes “oat cells”
- –some others spindle-shaped or polygonal
- -resemble Kulchitsky’s neuroendocrine cells seen along bronchial epithelium in fetus and neonate
- –on EM, dense-core neurosecretory granules
–grow in clusters without glandular or squamous organization
Small cell carcinoma
- -associated with?
- -most often where?
- -can it be cured?
- -associated with paraneoplastic syndromes
- –ADH - hyponatremia
- –ACTH - cushings
- -strong relationship to cigarette smoking - only 1% occur in nonsmokers
- -most often hilar or central; most aggressive; metastasize widely
- -virtually incurable
Small cell carcinomas can metastasize easily. Explain how being derived from neuroendocrine cells affects this.
Neuroendocrine cells don’t grow with other cells, so they already have the advantage of being able to spread without having to detach from each other
Staging of bronchogenic carcinoma
Stage I - localized disease
Stage II - local disease plus ipsilateral nodes
Stage III - extension or contralateral nodes
Stage IV - distant metastasis
Bronchogenic carcinomas are of the most insidious and aggressive neoplasms. Why?
Discovered in 6th decade generally after secondary spread
Presenting complaints: cough, weight loss, chest pain, dyspnea, increased sputum production
Patients die very quickly after diagnosis
Bronchogenic carcinoma
- -prognosis
- -can the tumors be resected easily
- -difference in small cell and localized solitary tumor in terms of survival rate
overall 5-year survival approx. 10%; mean survival 1 year
- -not more than 20-30% permit resection
- -adenocarcinoma and squamous cell remain localized longer
- -surgical resection of small cell ineffective, but sensitive to chemotherapy; potential cure rates of 15-25% for limited disease
- -localized solitary tumor < 4 cm: 30-40% 5-year survival
Which neoplasm is associated with hypercalcemia?
Squamous cell carcinoma
Lambert-eaton myasthenic syndrome
autoimmune antibodies to neuronal calcium channel; muscle weakness
associated with small cell carcinoma
Pancoast’s tumor
apical tumors invading neural structures including cervial sympathetic plexus
- – 95% NSCC
- – 50% squamous; 25% large cell; 25% adenocacarcinoma
Bronchoalveolar / bronchioalveolar carcinoma
- -prognosis?
- -what are the cells like?
- -where do these tumors form?
- -tx?
rare (90% at 5 years)
–3rd decade to advanced years; M=F
- -distinctive tall, columnar to cuboidal epithelial cells that line up along alveolar septa
- -abundant mucinous secretions
–peripheral lung, project into alveolar spaces; papillary formations
–solitary lesions resectable; metastasize late
Bronchial carcinoid tumor
- -originates from?
- -what % of tumors? malignant?
- -invasive?
- -course? survival?
- -patient demographic
tumor of neuroendocrine origin; similar to GI counterpart
- -represent 1-5% of all lung tumors
- -malignant, but not as aggressive as small cell carcinoma
- -often locally invasive and capable of metastasis (rare)
- -usually benign course with 50-95% 5-10 year survival
- -most patients <40 years; M=F
- -no known relationship to smoking or other environmental factors
There are two forms of bronchial carcinoid tumor. What are they?
- -where are they found?
- -histology
- -associated with carcinoid syndrome of the heart?
1) intraluminal polypoid masses
2) penetrate bronchial wall
- -confined to main-stem bronchus; rarely exceed 3-4 cm
- -symptoms from intraluminal growth
- -nests, cords, and masses of cells similar to lymphocytes; infrequent mitoses
- -dense-core neurosecretory granules
- -few secrete vasoactive amines (diarrhea, flushing, cyanosis)
–not associated with carcinoid syndrome of the heart
Metastatic cancer
–usually spread how?
hematogenous
What is ht most common cause of heart failure with bronchogenic carcinoma?
Hydrothorax (pleural effusion in pulmonary edema)
What is Meig’s syndrome
Isolated R sided hydrothorax
What is the difference between spontaneous idiopathic pneumothorax and tension pneumothorax?
spontaneous idiopathic pneumothorax
- -rupture of small, peripheral, usually apical subpleural blebs
- -mediastinal shift towards collapsed lung
tension pneumothorax
- -ball-valve or flap mechanism - build up of pressurized air in the thorax
- -compression of mediastinal structures toward contralateral lung
Pleural neoplasms - secondary or metastatic tumors
far more common than primary tumors
- -most frequent from lung (Stage III) and breast
- -direct extension or lymphatic spread
- -also ovarian carcinomas
- –Meig’s syndrome – ovarian fibroma with right- sided pleural effusion
–most associated with serosanguinous effusion that contains desquamated tumor cells
Benign mesothelioma
- -localized growth attached to pleural surface (1-2 cm)
- -remains confined to surface of the lung
- -no pleural effusion
- -?fibromas
- -no relationship to asbestos exposure
Malignant mesothelioma
- -uncommon, but associated with asbestos exposure
- -latent period of 25 - 45 years
- -NOT associated with smoking
Morphology of mesothelioma
- -descrive the lesion and spread
- -cell types
- -other features
- -diffuse lesion that spreads widely in pleural space
- -affected lung ensheathed by a thick layer of soft, gelatinous, grayish-pink tumor
- -two cell types
- –mesenchymal component resembling fibrosarcoma
- –epithelial component forming tubular and papillary structures
–other features: positive staining mucopolysaccharide; lack of CEA, staining for keratin proteins
Clinical features of mesothelioma
–presenting complaints: chest pain, dyspnea, recurrent pleural effusions
–50% die within 12 months
- -lung invaded directly with metastatic spread to hilar lymph nodes
- -also peritoneal mesotheliomas
