Tumors of the Lung and pleura

Question 1

A patient comes in with leg weakness, dry mouth, and drooping eye lids.

What type of cancer could be causing his symptoms?

Answer 1

This patient has Lambert-Eaton Myasthenic Syndrome an auto immune disease that attacks the pre-synaptic Ca++ channels at the neuromuscular junction.

Lambert-Eaton Myasthenic Syndrome occurs in about 60% of patients with Small Cell Lung Cancer

Question 2

Small Cell Carcinoma

. . . is most commonly associated with a history of ____?

. . . with mutations in what three genes?

Answer 2

Small Cell Carcinoma is strongly associated with cigarette smoking

mutations in

p53 (50-80% of cases)

RB1 (80-100%)

Bcl2 (90%)

Question 3

This is the most common type of cancer in women and non-smokers

Answer 3

Adenocarcinoma

Question 4

A 60 year old female with no history of smoking comes to your office. She has been diagnosed with a mucin producing tumor with glandular differentiation. The tumor is EGFR (+)

What type of cancer is this and what drug would you treat it with to target EGFR?

Answer 4

This patient has an Adenocarcinoma.

We would treat her cancer with Erlotinib- and EGFR inhibitor that binds to the ATP binding site of the tyrosine kinase and reduces downstream effects like proliferation

Question 5

A 60 year old female with no history of smoking comes to your office. She has been diagnosed with a mucin producing tumor with glandular differentiation. The tumor is EGFR (+) and has rearrangements in the ALK gene.

You have tried Erlotinib but it did not stop the progression of the cancer. What is another choice for this patient

Answer 5

Because this tumor has rearrangements in the ALK gene, the tumor is resistant to tyrosine kinase inhibitors. The drug of choice for this patient is Crizotinib which will inhibit the fusion of EML4 and ALK proteins.

The fusion of these proteins promotes malignant behavior

Question 6

This lesion is <5mm ad is characterized by dysplastic pneumocytes lining alveolar walls.

This lesion is a precursor for what?

What gene is likely mutated?

Answer 6

This lesion is an Atypical Adenomatous Hyperplasia. It is a precursor for adenocarcinoma (remember: some, but not all adenocarcinomas arise from these lesions)

Atypical Adenomatous Hyperplastic lesions have mutations in EGFR

Question 7

This lesion is >3cm, non-mucinous, and made of cuboidal to columnar cells.

What is it?

what is the survival rate after a complete resection?

Answer 7

a >3cm, non-mucinous lesion is a

non-mucininous adenocarcinoma in-situ

the survival rate for this type of cancer is 100% after a complete resection

Question 8

This type of lesion is >3cm, made of tall, columnar cells with cytoplasmic and intra-alveolar mucin.

what type of lesion is this?

what is the most frequent mutation?

Answer 8

This lesion is

Mucinous sybtype of adenocarcnioma in-situ

KRAS mutations are more frequent in the mucinous subtype and have a worse prognosis

Question 9

What morphologic pattern of invasive adenocarcinoma has the best prognosis?

worst prognosis?

1) lepidic
2) Acinar
3) Papillary
4) Solid

Answer 9

Lepidic has the best prognosis

Solid has the worst prognosis

Question 10

What is the body’s first response to an inhaled noxious stimulus (i.e. smoke).

If exposure continues, the columnar epithelium eventually turn to what type of cells?

Answer 10

increase mucus production to help clear toxins

goblet cell hyperplasia

the columnar epithelium eventually turns into squamous cells (squamous metaplasia) which can lead to squamous cell carcinoma

Question 11

a 65 yo man with a 20 year pack history comes to your office complaining of belly aches, increased anxiety, and increased frequency of urination.

What is one possible cause of his symptoms?

Answer 11

His symptoms are due to increased PThRP causing hypercalcemia. This paraneoplastic syndrome is associated with Squamous cell carcinoma

(hypercalcemia: “stones, bones, groans, thrones, and psychiatric overtones)

Question 12

What factor can distinguish squamous cell carcinoma from adenocarcinoma on IHC?

Answer 12

TTF-1.

TTF-1 (-) in SSC

TTF-1 (+) in adenocarcinoma

Question 13

“Salt and Pepper Pattern” on histology are buzzwords for what type of tumor?

Answer 13

Neuroendocrine tumors

(carcinoid tumors)

Question 14

a 35 year old patient comes into your office complaining of a persistent cough, hemoptysis. You suspect a type of lung cancer that has an equal incidence in both sexes and has the ability to produce serotonin and cause classical carcinoid syndrome.

What is it?

what features of this tumor might make it more worrisome?

Answer 14

Bronchial Carcinoid tumor

atypical features include:

pleomorphism and prominent nucleii

p53 mutations

increased expression of BCL2

Question 15

a patient comes in with a drooping left eye lid, constricted pupil, and isn’t sweating on his left side despite the day being quite humid and warm.

what type of lung tumor could be causing his symptoms?

Answer 15

Pancost Tumor

the tumor is in the apex of the lungs and can grow into the regional nerves and vessels causing horner syndrome

Question 16

This type of tumor is rare but occurs more often in children. You will see a single, round, and well-defined periperal mass with calcium deposits.

What gene is mutated?

Answer 16

Inflammatory myofibroblastic tumor

presentation can be asymptomatic or fever, cough, chest pain, and hemoptysis.

ALK gene on 2p23

Question 17

This type of lesion is characterized by nodules containing both lung tissue and cartilage

Answer 17

Pulmonary Hamartoma

Question 18

This type of cancer is associated with exposure to asbestos.

Where does it arise?

is there an increased life-time risk associated with smoking?

Answer 18

Malignant Mesothelioma

arises from either the visceral or parietal pleura

there is no increased risk for mesothelioma among asbestos workers who smoke because the smoke does not affect the pleura- there is, however, an increased risk of asbestos-related LUNG cancer in smokers.