Zaman: Lung 6 & 7

Question 1

Identify. What would be your main concern?

Answer 1

Pulmonary Hamartoma (shows a coin lesion formed by a fibromixoid material). Worry about cancer. (this particular one is benign)

Question 2

Pulmonary arterial hypertension (PAH) is defined by WHO as sustained elevation of pulmonary arterial pressure greater than ___________ at rest or greater than ___________ with exercise, with a mean pulmonary capillary wedge pressure and left-ventricular end-diastolic pressure of less than __________.

Answer 2

25 mmHg; 30 mmHg; 15 mmHg

Question 3

In half of all familial cases of PAH and 25% of sporadic cases, the gene associated is ________.

Answer 3

BMPR2. may require a trigger: two-hit hypothesis.

Question 4

In PAH, ___________ & ___________ are decreased and _____________ is increased leading to VC.

Answer 4

Prostaglandin and NO; endothelan.

Question 5

Identify.

Answer 5

Pulmonary Arterial HTN. (Plug in lower pic).

Thick vascular wall restricting lumen – pressure is increased as a result.

Question 6

Sarcoidosis is characterized by __________________ granulomas.

Answer 6

non-caseating

Question 7

Sarcoidosis seems to be a dysfunction of?

Answer 7

Circulating T cells with overactive B cells

Question 8

In Sarcoidosis, the BAL will show?

Answer 8

• CD4/CD8 ratio 5-15:1
• oligoclonal expansion of T-cell subsets, and increased TNF concentration

Question 9

Identify.

Answer 9

Sarcoidosis. Lower pic shows giant cell with asteroid body. (SAR -> STAR).

Question 10

What is the main classification of lung cancer?

Answer 10

Small cell (oat cell) and non-small cell (adenocarcinoma)

• small cell usually tx’d with chemo
• non-small cell usually tx’d with surgery if localized (rare)
• lung cancers are either “central” (bronchogenic) or “peripheral” (subplural; scars)

Question 11

Squamous Cell Carcinoma microscopic findings include?

Answer 11

Keratin pearls and intercellular bridge to poor- differentiated neoplasm having only minimal residual squamous features and dyskeratocytes.

Usually sheets of large cells that have keratinization (keratin pearls) and or intercellular bridges (diagnostically important).

Question 12

Identify.

Answer 12

Squamous Cell Carcinoma.

Question 13

What are the common clinical features and symptoms of adenocarcinoma?

Answer 13

peripheral tumors (frequently asymptomatic with x-ray lesion as presenting symptom in 50%)

Late symptoms of : chest pain, weight loss, dyspnea

(a silent disease as sx come late)

Question 14

Identify.

Answer 14

Adenocarcinoma. Evidence of gland formation/musuc production.

Question 15

Identify. Most of these are positive for _______ & _______ and negative for __________.

Answer 15

Adenocarcinoma. TTF1; Cytokeratin 7. Cytokeratin 20.

(pinkish stain shows positive for mucin.)

Question 16

Patients with which type of carcinoma may have ectopic hormones produced, such as ADH and ACTH?

Answer 16

Small Cell Carcinoma

Question 17

What percentage of patients already have mets upon dx of small cell CA?

Answer 17

2/3

Question 18

In small cell CA, are the tumors usually central or peripheral?

Answer 18

central

Question 19

What are the key microscopic features for small cell carcinoma?

Answer 19

Small oval or fusiform cells with very high NC ratio, very little cytoplasm. Cell of origin probably the Kulchitsky cell, a neuroendocrine cell

Features of neuroendocrine differentiation apparent by electron microscopy and immunocytochemistry (neurosecretory granules and neurosecretory granule proteins)

Question 20

Identify. Positive for TTF-1, CD56, synaptophysin,chromogranin. Negative for CK34BE12 (cytokeratins).

Answer 20

Small cell CA.

Top left, the dark dots are the lymphocytes to compare to.

Bottom: strings and broken up cells due to dmamge when removing the needle is called crush artifact: characteristic of small cell CA.

Question 21

Staging Chart.

Answer 21

T: tumor size (most important)

N: Node

M: Mets (determined by CT)

Question 22

Staging Chart with given criteria.

Answer 22

Stage IIIa is important. Most common.

Question 23

You have found a tumor in your 4 year old patient who has never been exposed to cigarette smoke. What is the most likely type of tumor?

Lab results show that it is typical, and you let the parents know that it is most likely (benign or malignant)?

Answer 23

Carcinoid Tumor. (C for children)

About 2% of primary lung tumors and have been reported and account for up to 80- 85% of primary malignant lung tumors in children.

No relation to cigarette smoking or other causative factors.

TYPICAL.

Typical carcinoid is benign (90% of total, 1% mortality) vs. atypical carcinoids.

Atypical carcinoids (10% of total); 30% mortality.

Question 24

Which tumor is a neuroepithelial tumor with biogenic amine and polypeptide production (ACTH)? Most likely seen in?

Answer 24

Carcinoid; children.

Question 25

85% of carcinoid tumors are located where?

Answer 25

centrally within main-stem and lobar bronchi but are submucosal lesion, therefore not often diagnosed by brush or washing cytology

(patient will usually come in with a CC of cough, and the tumor will be discovered upon xray).

Question 26

Identify. This tends to obstruct the bronchus and EM and immunocytochemistry are similar to that of small cell carcinoma with neurosecretory granules.

Answer 26

Carcinoid.

Question 27

Identify. Tumor cells have separated from their stroma (“shrinkage artifact”). This type of tumor cells are fastened together by desmosomes.

Answer 27

Carcinoid.

Question 28

Identify. “Endocrine pattern” (nests, trabeculae, or spindled cells separated by thin-walled vessels) with less than 2 mitoses/10 HPF. Uniformity of cells and nuclei, normal nuclear/cytoplasmic ratio, small nucleoli, stippled chromatin. No necrosis.

Answer 28

ATYPICAL Carcinoid.

Question 29

Identify. Necrosis in this tumor is described as punctate, usually occurring in the center of tumor nests.

Answer 29

Atypical Carcinoid.

Question 30

Identify. This tumor is often attached to the _____________________by a pedicle.

Can this be due to asbestos exposure?

Answer 30

Solitary FIbrous Tumor; pleural surface. No relationship to asbestos.

The tumor cells are CD34+ and keratin-negative by immunostaining. This feature can be diagnostically useful in distinguishing these lesions from malignant mesotheliomas (which show the opposite phenotype).

Question 31

Mesothelioma is mostly located in the _____________. Majority of cases are due to exposure to _____________.

Answer 31

Pleura; asbestos.

(Small asbestos fibers go deep into lung tissue and produce fibrosis of lungs and pleura. Shipbuilding the major offender historically)

Question 32

What is one of the first findings of mesothelioma?

Answer 32

Pleural effusion. FU.

Question 33

Identify.

Answer 33

Mesothelioma. (epithelial type on left; mixed type on right).

Question 34

Identify.

Answer 34

Mesothelioma.

Question 35

Identify.

Answer 35

Mesothelioma. 3D blue balls.

Question 36

Identify.

Answer 36

Mesothelioma.