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122 Cards in this Set
- Front
- Back
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Microscopic appearance of alveoli in pulmonary edema
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Pink fluid in normally clear alveolar spaces, hyperemia. Septal edema can involve widening of the alveolar septum.
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General (3) causes of pulmonary thromboemboli
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1. Stasis
2. Immobility 3. Hypercoagulable states |
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Sources of pulmonary thromboemboli
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Deep leg veins, then pelvic veins
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Appearance of a thrombus with Lines of Zahn
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Gross appearance of a hemorrhagic infarct and pulmonary arterial thromboembolism
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Etiology of pulmonary hypertension
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Primary: lung vascular disease, chronic hypoxia, bad genes, abnormal mediators inflammation, unknown.
Secondary: cardiac, IV drug abusers, autoimmune diseases, herbs |
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Appearance of a highly constricted arteriole in pulmonary hypertension showing MARKED MEDIAL HYPERTROPHY.
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Pulmonary alveolar proteinosis
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Heavy edema due to either a congenital lack of surfactant or an acquired state due to silicosis, immunodeficiency, or cancer. PAS positive
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Histologic appearance of pulm. alveolar proteinosis
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The alveoli will be chock-a-block full of a protein-lipid-granular precipitate.
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Angiofibroma
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Benign tumor of sinonasal area -- a testosterone dependent highly vascularized tumor that can kill you if it expands into the cranial cavity. BLEEDS LIKE CRAZY.
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Histologic appearance of an allergic inflammatory polyp
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What you'd expect -- eosinophils red and mast cells blue.
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Names and classifications for benign nasal papillomas
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Schneiderian, transitional, squamous
1. Exophytic: septal 2. Endophytic: lateral |
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What virii are nasal papillomas associated with?
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HPV 6,11.
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Path lab list of malignant sinonasal tumors
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SCC, TCC, adenocarcinoma, undiff carcinoma, neuroblastoma and neuroendocrine (characteristics are in Robbins, and probably later in these notecards)
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Race and age distribution of nasopharyngeal carcinomas
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Asians, either 15-25 or 60-69. The survival rates at 5 years are good but the tumors are recurrent
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Can nasopharyngeal cancers lack lymphocytic infiltrates?
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Yes.
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Common viral and genetic associations with nasopharyngeal cancers.
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EBV-DNA, HLA-2, HLA-BW46
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Histologic appearance: small tumor cells in a sea of lymphocytes
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Undifferentiated nasopharyngeal carcinoma
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Children have many and adults, few. Benign are associated with HPV 6,11 ... and malignant 16,18. Are they cancerous?
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Squamous papillomas of the sinonasal tract. Potential carcinoma development in 15 years because they are difficult to get rid of.
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General precursors to SCC in respiratory system.
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Like other squamous cancers...either keratoses or squamous dysplasia.
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Predominant carcinoma of the larynx?
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Squamous
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Clinical presentation of laryngeal carcinoma
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Hoarseness, pain, dysphagia, hemoptysis, stridor . . . etc.
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What determines survival rates in laryngeal carcinoma?
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Where the cancer is and whether it hits the local lymph node. The common locations are supraglottic, glottic and subglottic. . .
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The rule of 95%.
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95% of lung neoplasms are malignant cancer. 95% of those metastasize. BAD NEWS.
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Accrding to the ancient chart in our notes . . .
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People develop lung cancer most frequently in their 7th decade of life, men more than women.
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Major characteristics of squamous cell carcinoma of the lung
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1. Smokers
2. Central bronchi 3. Very low 5-yr survival rate 4. Met to peribronchial lymph nodes and liver. |
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Gross appearance of lung leukoplakia
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Gross appearance of Lung SCC
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Keratin pearl appearance in keratinizing invasive SCC.
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Characteristics of adenocarcinoma
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1. Still mostly smokers
2. Glandular neoplastic elements with destructive fibrosis. KEY. 3. Early metastasis. |
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Glands glands glands of adenocarcinoma
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Characteristics of bronchioalveolar carcinoma
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1. 71% smokers
2. Peripheral, pneumonia-like appearance 3. Lepidic growth (crawls along the walls, not into them) with NO DESTRUCTIVE FIBROSIS |
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Bronchioalveolar carcinoma -- note the consolidated, pneumonia-like appearance. Will also appear on x-rays as hazy consolidation near periphery of lung.
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Characteristics of large cell undifferentiated carcinoma
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Like all undiff cancers, VERY HIGH STAGE AND BAD PROGNOSIS
1. Peripheral 2. Epitheloid, spindle, clear 3. Mets wherever the hell it wants to. |
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Undiff large cell carcinoma - note pleomorphic cells are no organization.
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General characteristics of carcinoid tumors
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More atypical cells, mitoses, necrosis.
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How do you tell the difference between a large-cell undiff carcinoma and large-cell neuroendocrine carcinoma
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Endocrine will palisade and be positive for neuroendocrine markers
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Characteristics of small-cell lung carcinoma
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1. Aggressive and metastatic
2. SMOKERS 3. Non-surgical 4. TTF-1, CD56, synaptophysin |
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Small cell lung carcinoma, ewww....
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Characteristics of solitary fibrous tumor of the pleura.
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1. Hyaline fibrosis, spindle cells
2. Unrelated to asbestosis |
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Characteristics of malignant mesothelioma
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1. More men than women, 6th-9th decade of life.
2. Non-pleuritic chest pain 3. Paraneoplastic hypoglycemia, ADH. |
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Gross appearance of malignant mesothelioma
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1. Occasionally hemorrhagic pleural effusions
2. Multiple pleural nodules that coalesce over time. |
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Microscopic indicators of malignant mesothelioma
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1. Mucin neg
2. WT-1, calretinin, CK 5/6 positive 3. BER EP4, CEA, TTF-1 negative |
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Two morphological appearances of mesothelioma
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1. Epitheloid
2. Spindle (Sarcamoid) |
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General risk factors for lung cancer (Markus lecture)
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Smoking, obstructive lung disease, passive smoke, relative, pulmonary fibrosis, air pollutants, radon
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When does risk for lung ca decrease? When does it return to 80-90% nonsmoking level?
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5 yrs. 15 yrs. It will never return to normal.
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Do you increase your risk of mesothelioma with asbestos and smoking? What about lung ca?
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No. The combination does not carry increased risk over asbestos exposure alone. For lung ca, the two are independent risk factors.
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Frequency of non small cell carcinomas
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Adeno - 30%
SCC - 25% LCC - 15% Bronchoalveolar - 5% (although technically this is an adeno carcinoma) |
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Frequency of small cell carcinoma
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25%
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Peripheral involvement, early mets, DIC, hypertrophic pulmonary osteoarthropathy
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Adenocarcinoma
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Central involvement, common hilar complications, obstructive, cavitation, late mets, superior sulcus, hypercalcemia (from PTH), clubbing
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SCC
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Hylar mass, widened mediastinum, early and terrible mets, SIADH (hyponatremia, fluid overload), Eaton-Lambert
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Small cell carcinoma
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Peripheral, ill-defined mass, common hilar complications, rapid growth, early mets, clubbing
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Large cell carcinoma (remember that ALL large cell cancers grow quickly, because they don't differentiate or organize)
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Multicentric, consolidatory, lepidic growth and pneumonic features
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Bronchoalveolar cancer
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Do adenocarcinomas respond well to chemo/radiation?
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No, it's better to catch them before met and surgically excise them, if possible. If you have symptoms, it's too late.
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Solitary nodule vs. diffuse
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Adenocarcinoma general vs. bronchoalveolar adenocarcinoma
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Best prognosis of all lung cancer if a solitary nodule
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Bronchoalveolar carcinoma
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1-yr survival rates of bronchoalveolar carcinoma
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80% if resected.
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Bronchorrhea
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Copious sputum production, a characteristic of bronchoalveolar (which is growing along the alveolar walls anyway)
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Tx for SCC
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Resect if at all possible, responds better to chemo/radiation than adenocarcinomas
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Cancers that show cavitations and necrosis
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SCC, Large Cell Carcinoma
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Where are you most likely to find small cell carcinomas?
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Perihilum/hilum (80%)
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Can you surgically resect small cell carcinoma?
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No.
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Paraneoplastic syndromes of small cell carcinoma
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SIADH, ACTH overproduction (Cushing's), and Eaton-Lambert
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Do small cell carcinomas respond to chemotherapy?
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Yes! But they recur, hence the worse prognosis.
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Symptoms of mesothelioma
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Dyspnea, chest wall pain, bloody effusion, spontaneous pneumothorax
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Thrombocytosis, clubbing
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Paraneoplastic findings of mesothelioma
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Tx of mesothelioma
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Pleurodectomy, with talc pleurodesis and the usual chemo/rad. You will still die within the year.
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Presents most commonly in adults < 40 yrs of age.
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Carcinoid tumor
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Sx of carcinoid tumor
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Hemoptysis and cough.
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Cushing's, HTN (due to incr. ACTH), hypercalcemia
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Carcinoid
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Can secrete neurotransmitters like serotonin and has other NE markers
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Carcinoid. (small cell carcinomas also frequently have secretory granules and systemic paraneoplastic effects)
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Palisading histology
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Carcinoid
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Octrotide scan, serum chromgranin A2 blood test
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Carcinoid
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Percentage symptoms at time of diagnosis:
1. Local 2. Regional 3. Systemic mets 4. Paraneoplastic and constitutional |
1. 70%
2. 15% 3. 10% 4. 10%, but 40% will have either weight loss or chest pain. |
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Number 1 symptom of lung cancer, followed by several other prominent ones
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#1: Cough
-Hemoptysis, Dyspnea, pneumonia, lymphangitic dissemination, wheezing |
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Regional effects of lung CA
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Pleural/pericardial effusions, hoarseness, SVC syndrome (small cell), brachial plexus involvement (Horner's syndrome, Pancoast tumor)
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Sx of Pancoast tumor
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Supraclavicular mass, shoulder pain, ulnar distribution pain, rib involvement and of course Horner's syndrome
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Horner's syndrome
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Miosis, Ptosis, Anhydrosis.
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SVC Syndrome Sx
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Facial edema, JVD, huge central mass on X-ray, emergent intervention
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SIADH, Increased ACTH leading to hypokalemia, calcitonin excess
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Small cell carcinoma (adenocarcinoma will also present with calcitonin excess)
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Hypercalcemia (due to PTH)
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SCC, carcinoid
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Gynecomastia (increased FSH)
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large cell, adenocarcinoma
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Anti-calcium channel antibody
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Eaton-Lambert: associate with small cell
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Cerebellar ataxia
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squamous
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Focal neurologic signs -- are they paraneoplastic or metastatic?
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Mets!
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When is a coin lesion benign?
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Young, no growth or only grows every 16 months, (popcorn, laminated, central, diffuse) calcifications, well-marginated, smaller than 2 cm
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When is a coin lesion malignant?
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Older, doubles in 6 mos, (eccentric, stippled) calcfication, irregular margins, larger than 3cm
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What is the TNM system? Who doesn't follow this rubric?
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(Tumor, Nodes, Metastases) -- T is size and location, N is location, M is either yes or no. Small cell carcinomas have a different system
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Small cell staging
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Is either limited or extensive.
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How do you stage a tumor?
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CT, or MRI for superior sulcus. Can tell you T and N
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How do you stage T, N, and M all at once?
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A PET scan. The accuracy is very high, but you can't see the brain or kidney (already high metabolic activity)
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How do you evaluate performance status?
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Karnofsky score: you can look this up on Wikipedia.
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Why would you want a head CT?
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10% of small cell tumors present with cranial mets
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Examples of surgical diagnostic techniques
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MEDIASTINOSCOPY, T Biopsy, bronchoscopy, transthoracic needle aspiration, thoracentesis
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Bronchoscopy sensitivity in endobronchial disease vs. peripheral
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88% vs. 69% with all procedures, and it helps the sensitivity if the tumor is larger than 2 cm.
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Sensitivity of Transthoracic Needle Aspiration
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90%, but not needed for single lesion, straight to surgery
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Satisfactory Pre-Op FEV. Questionable? Bad?
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> 2L! from 1-2 L requires a perfusion scan. < 1L is unacceptable.
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Other pre-op pulmonary measurements to consider
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CO2, DLCO, O2 saturation, exercise performance.
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General trend of Tx and TNM staging
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Early stages -- mix of surgery if possible with chemo and radiation. As the stages rise, surgery will not be possible, and radiation will no longer be effective.
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Tx for limited stage small cell carcinoma
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Chemo and XRT
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Tx for extensive stage small carcinoma
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Chemo
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Is screening useful for lung CA?
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Apparently not. Both a bias in screening and the lack of accurate met detection contribute to no apparent drop in mortality.
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Top met to lung
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Breast. Followed by other lung, renal cell, malignant melanoma
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Main head and neck cancer. Others?
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Squamous cell carcinoma. Adenocarcinoma of salivary glands, undiff muconasal carcinoma.
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5 basic areas of head and neck region.
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oral cavity, pharynx, larynx, tongue and paranasal sinuses, major salivary glands
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Risk factors for head and neck cancer
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Alcohol (dose dependent) and of course smoking/smokeless tobacco. Combined effect is multiplicative. Also, viral infections via interfering with tumor suppressor gene fxn.
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EBV
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Endemic nasopharyngeal cancer
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Virii associated with head and neck cancers
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EBV, HPV, HIV, HSV
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Early Sx for head and neck cancer
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Epistaxis, non-healing ulcers, nasal obstruction, jaw swelling, lymphadenopathy, dysphagia, hoarseness
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Staging criteria for head and neck cancer
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TNM
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Indications for postop radiation HNC therapy
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Involved surgical margins, perineural involvement, bone/cartilagenous invasion, advanced disease, extracap lymph node extension.
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Dominant oncogenes involved in lung CA
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c-MYC, K-RAS, EGFR, and HER-2/neu
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Inactivated tumor suppressor genes involved in lung ca
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p53, RB, p16INK4a, and multiple loci on chromosome 3p
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Different genetic alterations in small cell vs. non-small cell
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small cell cancers harbor more frequent alterations in c-MYC and RB, whereas non-small cell tumors are associated with mutations in RAS and p16INK4a
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highest frequency of p53 mutations of all histologic types of lung carcinoma
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SCC
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2 types of bronchoalveolar carcinoma
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Mucinous and nonmucinous. They do not usually manifest glandular elements.
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Why do small cell carcinomas appear angry?
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Basophilic staining of vascular walls due to encrustation by DNA from necrotic tumor cells
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Do small cell carcinomas evidence neuroendocrine features
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Yes! 2/3rds of presenting cases will have neurosecretory granules . . . and if you think about the paraneoplastic (SIADH and ACTH) of small cell, you can imagine this would be true.
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Neuroendocrine markers tested for in lung CA
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chromogranin, synaptophysin, and Leu-7
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What is a DNES tumor smaller than a carcinoid?
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Tumorlet.
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Typical carcinoids
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No p53 mutations or BCL2/BAX imbalance
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