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36 Cards in this Set
- Front
- Back
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Lung cancer: clinical features
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Cough, weight loss, chest pain, dyspnea, cough, hemoptysis, etc.
Paraneoplastic syndromes Apical tumors may present with ulnar pain and ipsilateral Horner’s syndrome (Pancoast tumor). Superior vena caval syndrome |
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Lung cancer: Patterns of involvement
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Most arise near hilum
About 75% arise in first, second, or third order bronchi Locally may result in -Intraluminal mass -Peribronchial spread to carina or mediastinum -Intraparenchymal mass -Involvement of pleura |
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Lung cancer: Patterns of spread
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Nodal metastases are common-e.g. peribronchial, hilar, mediastinal
-Present in more than 50% of cases Distant metastases, most common sites are: -Adrenals -Liver -Brain -Bone |
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Carcinomas and lung cancer
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>95% of primary lung cancers are carcinomas
Review: Carcinomas are malignant neoplasms derived from epithelium -Carcinomas are classified based on the type of epithelium that they resemble (e.g., carcinomas that exhibit glandular architecture are adenocarcinomas) |
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Lung cancer classification
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For clinical management, the most important distinction is non-small cell carcinoma vs. small cell carcinoma
Recently introduced chemotherapeutic agents have necessitated accurate subclassification of non-small cell carcinomas (especially adenocarcinoma and squamous cell carcinoma) |
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Squamous cell carcinoma: definition
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A malignant epithelial tumor showing keratinization and/or intercellular bridges that arises from bronchial epithelium
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Squamous cell carcinoma: smoking, M vs F, paraneoplastic, location, characteristics, and metastasizes
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Closely related to smoking (>90%)
Most common in men Paraneoplastic syndromes-especially associated with hypercalcemia Usually central (two thirds) but may be peripheral The type of lung cancer most likely to cavitate Tends to be locally aggressive Metastasizes to distant organs less frequently than adenocarcinoma |
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Squamous cell carcinoma: histology
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Eosinophilic, hyaline cytoplasm
Intercellular bridges Keratin pearls |
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Bevacizumab and squamous cell carcinoma
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Bevacizumab (Avastin) is associated with a high risk of bleeding in squamous cell carcinoma of lung and has only been approved for “non-squamous” non-small cell carcinomas
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Small cell carcinoma: definition
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Definition: A malignant epithelial tumor consisting of small cells with scant cytoplasm, ill-defined cell borders, finely granular chromatin, and absent or inconspicuous nucleoli. The cells are round oval or spindle-shaped. Nuclear molding is prominent. Necrosis is typically extensive and the mitotic count is high.
Includes combined small cell carcinoma: small cell carcinoma combined with any of the histologic types of non-small cell carcinoma |
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Small cell carcinoma: smoking, signs and symptoms, location, progression, treatment
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Very closely correlated with smoking
Signs and symptoms may be related to: 1) local spread {e.g., superior venal caval syndrome secondary to extensive mediastinal lymphadenopathy}, 2) metastases or 3) paraneoplastic syndromes, especially ACTH, ADH Usually central Highly aggressive Rarely surgical candidates |
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Small cell carcinoma: histology
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2-4 x size of a lymphocyte nucleus
very high nuclear-to-cytoplasmic ratio “salt and pepper” chromatin nuclear molding crush artifact Neuroendocrine differentiation by electron microscopy or immunohistochemistry |
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Large cell carcinoma: definition and variants
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An undifferentiated non-small cell carcinoma that lacks the cytologic and architectural features of small cell carcinoma and glandular or squamous differentiation.
Variants -large cell neuroendocrine carcinoma -basaloid carcinoma -lymphoepithelioma-like carcinoma -clear cell carcinoma -large cell carcinoma with rhabdoid phenotype |
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Large cell carcinoma: location, tumor characteristics
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Often peripheral, but may be central
Tumor is often large, necrotic |
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Large cell neuroendocrine carcinoma: grade, histology, prognosis
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High-grade non-small cell carcinoma
Histologic criteria -neuroendocrine morphology (organoid, palisading, trabecular or rosettes) -non-small cell cytologic features -high mitotic rate (≥11 per 10 hpf) -Necrosis (frequently zonal) -at least one + ipx neuroendocrine marker (synaptophysin) Poor prognosis |
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Adenosquamous carcinoma: definition, epidemiology
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Definition: A carcinoma showing components of both squamous cell carcinoma and adenocarcinoma with each comprising at least 10% of the tumor.
0.4-4% of all lung cancers Behavior similar to adenocarcinoma Most patients are smokers |
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Adenocarcinoma: definition, frequency
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Definition: A malignant epithelial tumor with glandular differentiation or mucin production.
The most common histologic type of lung cancer in most countries Adenocarcinoma accounts for almost half of lung cancers |
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Adenocarcinoma: macroscopic patterns
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PERIPHERAL, may have central fibrosis
-MOST COMMON PATTERN Central/endobronchial Diffuse, pneumonia-like (mucinous adenocarcinoma) Diffuse bilateral (e.g., multiple nodules, lymphangitic pattern) Invasion along pleura (mimics mesothelioma) In association with scar or fibrosis |
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Adenocarcinoma: smokers, location, cavitation, spread
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Seen more frequently in smokers; is the most common type of lung cancer in women and nonsmokers
Typically more peripheral Rarely cavitates Primarily spreads by lymphatic or hematogenous routes but may spread aerogenously (e.g., mucinous carcinoma) |
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Adenocarcinoma: why use multidisciplinary classification
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Multidisciplinary approach driven by two major areas of interaction
1) in patients with advanced NSCLC a) discovery that the presence of EGFR mutations is a predictor of response to tyrosine kinase inhibitors b) requirement to exclude a diagnosis of squamous cell carcinoma in order to determine patient eligibility for treatment with: -Pemetrexed (because of improved efficacy) -Bevacizumab (because of toxicity) 2) radiologic-pathologic correlations between ground glass vs solid or mixed opacities seen on CT |
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Adenocarcinoma: preinvasive lesion classification
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Atypical adenomatous hyperplasia
Adenocarcinoma in situ (≤ 3 cm, formerly BAC) along preexisting alveolar structures (lepidic growth), lacking stromal, vascular, or pleural invasion (100% survival if completely resected) -Nonmucinous -Mucinous -Mixed mucinous/nonmucinous |
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Adenocarcinoma: minimally invasive classification
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Minimally invasive adenocarcinoma (≤ 3 cm lepidic predominant tumor with ≤ 5 mm invasion)
-Usually nonmucinous but may be mucinous -Mixed mucinous/nonmucinous -Diagnosis is excluded if the tumor invades lymphatics, blood vessels, or pleura or contains necrosis -Near 100% survival if completely resected |
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Adenocarcinoma: invasive classification
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Lepidic (scales) predominant (formerly nonmucinous BAC pattern, with > 5 mm invasion)
Acinar predominant Papillary predominant Micropapillary predominant Solid predominant with mucin production Variants of invasive adenocarcinoma -Invasive mucinous adenocarcinoma (formerly mucinous BAC) -Colloid -Fetal -Enteric |
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Atypical adenomatous hyperplasia: definition
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A localized small (usually 0.5 cm or less) proliferation of mildly to moderately atypical type II pneumocytes and/or Clara cells lining alveolar walls and sometimes respiratory bronchioles
Continuum of morphologic changes between AAH and AIS |
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Stains favoring adenocarcinoma
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Positive TTF-1
Negative or focal p63 Help to differentiate between adenocarcinomas and squamous cell carcinomas |
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EGFR targeted therapy
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Epidermal growth factor receptor is a receptor tyrosine kinase (TK) of the ErbB family
Tumors responding to EGFR tyrosine kinase inhibitors (gefitinib and erlotinib) contain somatic mutations of the EGFR TK domain Screening for common EGFR mutations in lung adenocarcinomas can be performed to predict which patients will respond to EGFR TKIs Response rates of 65-90% |
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Carcinoid tumor: definition
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Definition: Tumors characterized by growth patterns (organoid, trabecular, insular, palisading, ribbon, rosette-like arrangements) that suggest neuroendocrine differentiation. Tumor cells have uniform cytologic features with moderate eosinophilic, finely granular cytoplasm and nuclei with a finely granular chromatin pattern.
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Carcinoid tumor: typical vs atypical
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Typical carcinoid
<2 mitotic figures per 2 mm2 and no necrosis Atypical carcinoid ≥2 mitotic figures per 2 mm2 and/or foci of necrosis |
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Typical carcinoid: epidemiology, distribution, metastases, prognosis
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1-2% of lung tumors
Most patients less than 40 years old Not associated with smoking Distributed throughout lung, but often central, projecting into lumen; mucosa-covered Low rate of metastasis (10-15% regional nodal metastasis at presentation; eventually 5-10% with distant metastasis) 90-98% 5 year survival rate; 82-95% 10 year survival |
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Atypical carconoid: location, metastasis, prognosis
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More often peripheral than typical carcinoid tumor
At presentation, 40-50% with regional nodal metastasis or beyond 5 year survival of about 61-73%; 10 year survival of approximately 35-59% |
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Pulmonary hamartoma
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Benign, non-neoplastic
Usually less than 3-4 cm Usually cartilagenous May simulate malignancy radiographically |
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Metastatic lung tumors
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Lung is common site of metastasis
Typically metastases are multiple, bilateral, peripheral May show lymphangitic pattern of spread Occasionally solitary May be carcinomas, sarcomas, melanomas, etc |
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Sputum collection advantages and disadvantages
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Advantages
-Easy to obtain, if spontaneous -Large area sampled -Relatively inexpensive Disadvantages -Does not localize the lesion -Does not stage -Not too good for peripheral lesions |
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Bronchial brushings/washings advantages and disadvantages
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Advantages
-Can localize disease -Can diagnose smaller lesions -Can potentially diagnose central and peripheral lesions Disadvantages -More uncomfortable, expensive -Limited area -Not too good for very peripheral lesions |
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Transbronchial needle aspiration: advantages and disadvantages
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Advantages
-Allows staging of mediastinal lymph nodes -Low morbidity Disadvantages -Increased discomfort, expense -Not too good for peripheral lesions |
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Transthoracic FNA: advantages and disadvantages
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Advantages
-Allows diagnosis of peripheral lesions -Can diagnose benign lesions more accurately Disadvantages -Increased morbidity (e.g., pneumothorax) -Does not stage disease |
