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49 Cards in this Set
- Front
- Back
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Lung Cancer
Patterns of involvement |
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 |
Nodal metastases are common-e.g. peribronchial, hilar, mediastinal
Present in more than 50% of cases |
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What are the most common sites of distant metastases?
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Adrenals
Liver Brain Bone Lymph nodes |
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What information can Pathologists provide related to lung cancer?
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Diagnosis-tumor type
Grading: how close to normal does it look? - Incorporates “architecture” and nuclear atypia Staging: how far has it spread? - For NSCLC use TNM - For SCLC: use TNM; limited vs extensive |
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Carcinomas
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are malignant neoplasms derived from epithelium
are classified based on the type of epithelium that they resemble (e.g., carcinomas that exhibit glandular architecture are adenocarcinomas) |
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What is the most common cause of primary lung cancer?
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> 95% of primary lung cancers are Carcinomas
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Adenocarcinoma
Defintion |
A malignant epithelial tumor with glandular differentiation or mucin production showing acinar, papillary, bronchioloalveolar or solid with mucin production growth patterns or a mixture of these patterns.
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Acinar adenocarcinoma
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Forming glands
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Papillary adenocarcinoma
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Forming finger like projections that has a fibrovascular core covered by malignant epithelium
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Bronchioloalveolar carcinoma
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A tumor that grows along alveolar septa and does not invade parenchyma
can be nonmucinous, mucinous or mixed |
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Adenocarcinoma
Subtypes |
Adenocarcinoma, mixed subtype (most common)
Acinar adenocarcinoma Papillary adenocarcinoma Bronchioloalveolar carcinoma - nonmucinous - mucinous - mixed or indeterminate Solid adenocarcinoma with mucin production |
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Adenocarcinoma
Epidemiology and Spread |
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 bronchioloalveolar carcinoma) |
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Adenocarcinoma
Microscopic Patterns of Involvement |
1. PERIPHERAL, may have central fibrosis
MOST COMMON PATTERN 2. Central/endobronchial 3. Diffuse, pneumonia-like (mucinous bronchioloalveolar) 4. Difffuse bilateral (e.g., multiple nodules, lymphangitic pattern) 5. Invasion along pleura (mimicks mesothelioma) 6. In association with scar or fibrosis |
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Bronchioloalveolar carcinoma
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less than 3% of lung cancers
arise in region of terminal bronchioles/alveoli single or multiple nodules; may have a pneumonic appearance (ground glass opacity on CT/CXR) 5 year survival for localized resected BAC=100% |
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Bronchioloalveolar carcinoma
Histology |
neoplastic cells grow along alveolar septae WITHOUT EVIDENCE OF STROMAL, VASCULAR OR PLEURAL INVASION
may or may not contain abundant mucin usually well-differentiated |
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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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What is the prevalence of EGFR in lung adenocarcinomas?
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20%
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Pathologic correlations of EGFR mutations
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Among adenocarcinomas, EGFR mutations are more prevalent in adenocarcinoma with bronchioloalveolar carcinoma features (specinifically the NON-MUCINOUS type of BAC)
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Squamous cell carcinoma
Defintion |
A malignant epithelial tumor showing keratinization and/or intercellular bridges that arises from bronchial epithelium
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Squamous cell carcinoma
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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 Stage for stage has a BETTER SURVIVAL than adenocarcinoma |
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Squamous cell carcinoma
Histology |
Eosinophilic, hyaline cytoplasm (glassy appearance)
Intercellular bridges (desmosomes) Keratin pearls |
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Bevacizumab (Avastin)
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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 |
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
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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 |
2-4 x size of a lymphocyte nucleus
very high nuclear-to-cytoplasmic ratio “salt and pepper” chromatin nuclear molding crush artifact neuroendocrine by electron microscopy immunhochemistry |
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Large cell carcinoma
Defintion |
An undifferentiated non-small cell carcinoma that lacks the cytologic and architectural features of small cell carcinoma and glandular or squamous differentiation.
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Large cell carcinoma
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Many are probably very poorly differentiated squamous cell carcinomas or adenocarcinomas. No definite glandular or squamous differentiation
Often peripheral, but may be central Tumor is often large, necrotic |
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Large cell neuroendocrine carcinoma
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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 Poor prognosis |
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synaptophysin
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neuroendocrine marker (can be used to identify large cell neuroendocrine carcinoma
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Adenosquamous carcinoma
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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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Carcinoid tumor
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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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Types of Carcinoid tumors
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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 tumor
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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) |
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Typical carcinoid tumor
5 year survival rate |
90-98%
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Typical carcinoid tumor
10 year survival rate |
82-95%
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Atypical carcinoid tumor
5 year survival rate |
about 61-73%;
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Atypical carcinoid tumor
10 year survival rate |
approximately 35-59%
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Atypical carcinoid tumor
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More often peripheral than typical carcinoid tumor
At presentation, 40-50% with regional nodal metastasis or beyond |
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Neuroendocrine
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cells that release a hormone into the circulating blood in response to a neural stimulus
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Pulmonary neuroendocrine tumors
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Neuroendocrine tumors share morphologic, ultrastructural, immunohistochemical and molecular characteristics
Although all of these tumors show evidence of neuroendocrine differentiation, they have very different clinical behaviors and therapies and prognosis |
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Major Types of
Pulmonary neuroendocrine tumors |
Small cell carcinoma
Large cell neuroendocrine carcinoma Carcinoid tumor - Typical carcinoid - Atypical carcinoid |
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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 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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Cytology
Mechanisms for attaining cells |
Sputum
Bronchial brushing/washing Transbronchial needle aspiration (TBNA) Transthoracic fine needle aspiration (FNA) FNA of metastasis |
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Histology
Mechanisms for attaining cells |
Bronchial biopsy
- Provides tissue, but some morbidity, expense Thoracoscopic biopsy - As above, more morbidity, expense Wedge biopsy with frozen section - As above but requires thoracotomy-more morbidity, expense Biopsy of metastasis-not the preferable way Autopsy-really not the preferable way |
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Sputum
Advantages vs. Disadvantages |
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 vs. Disadvantages |
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
(TBNA) Advantages vs. Disadvantages |
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 vs. Disadvantages |
Advantages
- Allows diagnosis of peripheral lesions - Can diagnose benign lesions more accurately Disadvantages - Increased morbidity (e.g., pneumothorax) - Does not stage disease |
