Pathoma- Chapter 9: Lung Cancer – Flashcards
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What is the most common cause of cancer mortality in the US (high-yield)?
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-Lung Cancer
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What are the most common cancers by incidence?
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1.) Breast (women); Prostate (men) 2.) Lung cancer 3.) Colorectal carcinoma
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What is the average of presentation for lung cancer?
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-60 y.o.
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What are the key risk factors for lung cancer?
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-Smoking (85% of lung cancers occur in smokers)
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What is the key carcinogen in cigarette smoke? (very high-yield)
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-Polycyclic Aromatic Hydrocarbons -Arsenic
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What does arsenic increase the risk of?
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-Squamous cell carcinoma of the lung
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How is the risk of lung cancer related to smoking?
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-Cancer risk is directly related to the duration and amount of smoking ('pack years')
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Risk Factors for Lung Cancer Where does radon come from?
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-Radon is formed from the radioactive decay of uranium- which is present in the soil all around us -Can accumulate in closed spaces such as basements- as a colorless, odorless gas -It can go into the lung cancer
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What is the 2nd most frequent cause of lung carcinoma in the US?
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-Radon exposure -It is responsible for most of the public exposure to ionizing radiation, too
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Radon exposure is the cause of increased risk of lung cancer in what profession?
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-Uranium miners
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Patients who are exposed to asbestos are much more likely to develop what form of lung neoplasm?
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-Lung cancer rather than mesothelioma
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How do pts. who have lung cancer present?
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-They present with non-specific symptoms, i.e., cough, weight loss, hemoptysis, post-obstructive pneumonia
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What will CXR classically reveal in a pt. with lung cancer?
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-A 'coin lesion' or a solitary nodule
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What is the next step after you have identified a solitary nodule in a pt. (very high-yield)?
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-Go back and compare this x-ray to a prior x-ray -If the coin lesion has been there for quite sometime and has been stable- much morel likely that it represents something benign -If the coin lesion is new or has been growing- it would require a biopsy in order to ascertain the diagnosis of cancer
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What are some benign lesions that could present as coin lesions?
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-Granuloma -Bronchial hamartoma; often calcified on imaging -A young pt. with a coin lesion- say less than the age of 40 is much more likely to have a benign lesion than they are to have cancer
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What would the granuloma that presented as a coin lesion be due to?
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-TB or a fungus
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In the midwest, which fungus would you think about as the cause of a coin lesion (very high-yield)?
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-Histoplasma
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What is a hamartoma?
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-A benign mass comprised of tissue that normally belongs in that location, but it is disorganized
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What do bronchial hamartomas contain (very high-yield)?
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-Lung tissue and cartilage
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How will a bronchial hamartoma appear on imaging?
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-It is often calcified on imaging
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What are the classic division of lung carcinoma?
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-Small-cell carcinoma (15%) -Non-small cell carcinoma (85%) -This distinction is made by the pathologist when looking at the cells under the microscope
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How is small cell carcinoma treated?
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-It is usually not amenable to surgical resection (treated with chemotherapy and radiation instead) "cells of small cell carcinoma are so small that the surgeon can't see them"
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How is non-small carcinoma treated?
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-Treated upfront with surgical resection and is usually not amenable to chemotherapy
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What are the major subtypes of non-small cell carcinoma?
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-Adenocarcinma (40%) -Squamous cell carcinoma (30%) -Large cell carcinoma (10%) -Carcinoid tumor (5%)
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What are the 2 key features of an adenocarcinoma of the lung (very high-yield)?
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-Glands and mucus production
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What are the key features of a squamous cell carcinoma of the lung (very high-yield)?
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-Keratin pearls and intracellular bridges
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If we don't see glands, mucus production, keratin pearls, or intracellular bridges, what kind of non-small cell carcinoma is it?
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-Large cell carcinoma
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What is the characteristic histology of small cell carcinoma?
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-Poorly-differentiated small cells -The tumor is mitotically-active and exhibits necrosis
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Small Cell Lung cancer is highly associated with what risk factor?
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-Male smokers
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Where will the small cell lung cancer be located in the lung?
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-Central tumor
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What are the paraneoplastic syndromes seen in small cell lung cancers?
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-SIADH (+ hyponatremia) -Ectopic ACTH production -Lambert-Eaton Syndrome
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Small Cell Lung Cancer: Paraneoplastic Syndromes What is Lambert-Eaton Syndrome?
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-Pts. develop antibodies against presynaptic Ca2+ channels causing muscle weakness
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Mnemonic for Small Cell Lung Cancer
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-Small Cell -(male) Smokers -Central -Paraneoplastic Syndromes (small, smoke, ssentral, syndromes)
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Histology of Small Cell Carcinoma
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-Relatively small cells that mimic lymphocytes in their size -There is also a significant degree of mitotic activity
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Small Cell Carcinomas arise from what cells (very high-yield)?
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-Arise from neuroendocrine (Kulchitsky) cells
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What stain is positive in small cell carcinomas (very high-yield)?
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-Chromogranin positive
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What two tumors will be chromogranin +?
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small cell carcinoma carcinoid tumor (non-small cell)
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How is squamous cell carcinoma defined on histology?
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-Have to see keratin pearls or intercellular bridges
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Intercellular Bridges in Squamous Cell Carcinoma
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-These lines represent the desmosomal connections between the squamous cells -This is because squamous cells are normally connected to each other via desmosomes
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What is the most common tumor seen in male smokers?
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-Squamous cell carcinoma
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Where will squamous cell carcinoma tumors be located in the lungs?
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-Central tumor
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What is the paraneoplastic syndrome associated with squamous cell carcinoma (very high-yield)?
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-May produce Parathyroid-related peptide- resulting in hypercalcemia
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How is an Adenocarcinoma defined?
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-The presence of glands or mucin production
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What is the most common lung cancer in nonsmokers and female smokers (high-yield)?
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-Adenocarcinoma
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Where is adenocarcinoma classically located in the lung?
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-Peripheral tumor
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Gross Image of an Adenocarcinoma of the Lung
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-Notice that the tumor is way out at the edge of the lung- up against the pleura- it is peripherally located
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How is a large cell carcinoma defined?
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-Poorly-differentiated large cells (no keratin pearls, no intercellular bridges, no glands, and no mucin production)
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Characteristics of Large Cell Carcinoma?
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-Not related to smoking -Can be central or peripheral -Hs a poor prognosis
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What is bronchioloalveolar carcinoma (Adenocarcinoma in-situ)?
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-Columnar cells that grow along preexisting bronchioles and alveoli
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Bronchioloalveolar carcinoma arises from what cells (very high-yield)?
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-Clara cells
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Bronchioloalveolar carcinomas are located where in the lung?
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-Peripheral tumors
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How can Bronchioloalveolar carcinomas present on imaging (very high-yield)?
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-Can present with pneumonia-like consolidation on imaging (very high-yield)
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What is the prognosis of Bronchioloalveolar carcinoma?
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-It has an excellent prognosis
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What is a carcinoid tumor?
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-A tumor of well-differentiated neuroendocrine cells -Will see nests of cells
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The cells in a carcinoid tumor will be positive for what markers (very high-yield)?
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-Chromogranin positive (very high-yield) -Neuroendocrine cells will contain neurosecretory granules within their cytoplasm- those neurosecretory granules will stain chromogranin positive on IHC
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Where can carcinoid tumors be located?
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-Can be either central or peripherally located
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What is the classic tumor seen with a carcinoid tumor (very high-yield)?
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-A polyp-like mass in the bronchus -This is how it shows up on examinations!!!!
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What is the prognosis of a carcinoid tumor?
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-Low-grade malignancy -Rarely can cause carcinoid syndrome
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What are the most common sources of metastasis to the lung?
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-Breast and colon carcinoma -Will appear as multiple 'cannon ball' nodules on imaging
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Which form of cancer is more common in the lungs: metastasis or primary tumors?
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-Metastasis is more common than primary tumors
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TNM Staging What is the T?
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-T- size and local extension of the tumor -N- spread to regional lymph nodes (hilar and mediastinal) -M- unique site of distant spread is the adrenal gland
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What is a unique site for lung metastasis (very high-yield)?
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-The adrenal gland -Very high-yield!!!!!
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What is the overall 5-year survival for lung cancer?
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-15% (fairly poor) -This is because it presents so late in the course of the disease
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Local Complications of Lung Carcinoma Which type of lung cancer will involve the pleura?
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-Adenocarcinoma- because adenocarcinoma is usually peripheral -Adenocarcinoma is the most common tumor seen in non-smokers and female smokers
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Local Complications of Lung Carcinoma What is SVC Syndrome?
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-This is when pts. have distended head and neck veins with edema and blue discoloration of the arms and face
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Involvement of recurrent laryngeal or phrenic nerve would present as?
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Recurrent laryngeal: This would result in hoarseness Phrenic - Diaphragmatic paralysis
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Local Complications of Lung Carcinoma What happens if the tumor compresses the sympathetic chain?
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-This happens when a tumor is located in the apex of the lung, i.e., a pancoast tumor -It results in ptosis, pinpoint pupil, and anhidrosis aka: Horner's syndrome
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Large Cell Carcinoma IHC for Adenocarcinoma
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-TTF-1
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Large Cell Carcinoma IHC for Squamous Cell Carcinoma
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-p40
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Large Cell Carcinoma IHC for Neuroendocrine tumors?
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-Chromogranin (Small Cell and Carcinoid tumors)
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What is the recommended screening for patients with long smoking history?
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-Screening by low-dose CT recommended for pts. with long smoking history
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Lung Cancer and Driver Mutation Testing What mutations are particularly common in adenocarcinoma?
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-EGFR mutation -ALK translocation
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Lung Cancer and Driver Mutation Testing What drug is used to treat adenocarcinomas with EGFR mutations?
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-Erlotinib
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Lung Cancer and Driver Mutation Testing What drug is used to treat adenocarcinomas with ALK translocations?
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-Crizotinib
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Lung Cancer and Driver Mutation Testing What mutation can be seen in any non-small cell lung cancer?
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-PD-L1 expression
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Lung Cancer and Driver Mutation Testing What drug is used to treat lung cancers with PD-L1 expression?
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-Pembrolizumab
