Resp 08: Lung Tumors

Front 1

What are the most common types of tumors in the lung?

Back 1

- Bronchogenic Carcinoma (90-95%)
- Carcinoids (5%)
- Other tumors (2-5%)

Front 2

Where do Bronchogenic Carcinomas begin?

Back 2

Originate in the bronchial (or bronchiolar) epithelium

Front 3

What is "public enemy #1" in industrialized countries?

Back 3

Bronchogenic Carcinoma

Front 4

How does the Bronchogenic Carcinoma compare in men and women?

Back 4

- ↓ in men
- ↑ in women

Front 5

What is the most common visceral malignancy in males?

Back 5

Bronchogenic Carcinoma

Front 6

What percent of cancer deaths in males and in both sexes is Bronchogenic Carcinoma?

Back 6

- 33% of cancer deaths in males
- 7% of cancer deaths in both sexes

Front 7

Who gets Bronchogenic Carcinoma more, males or females?

Back 7

Males: 19.9 --> 74 / 100,000
Females: 4.5 --> 31 / 100,000

Front 8

Why is Bronchogenic Carcinoma increasing in incidence in women?

Back 8

Cigarette smoking increasing

Front 9

How does incidence of lung cancer compare to breast cancer in women?

Back 9

Lung cancer has surpassed breast cancer as cause of death in women

Front 10

What is the most frequent fatal malignancy in men and women

Back 10

Bronchogenic Carcinoma

Front 11

When does Bronchogenic Carcinoma occur in life?

Back 11

- Middle and late adult life
- Peak incidence: 50s-60s
- <2% below age 40

Front 12

What are the potential risks / causes for Bronchogenic Carcinoma?

Back 12

- Tobacco smoking
- Industrial hazards
- Air pollution
- Molecular genetics
- Scarring

Front 13

What considerations about tobacco smoking is associated with an increased risk of Bronchogenic Carcinoma?

Back 13

- Amount of daily smoking
- Tendency to inhale
- Duration of smoking habit ("pack years")

Front 14

How does the amount of daily smoking change your risk of lung cancer?

Back 14

- Smokers: 10-fold greater risk
- Heavy smokers: 20-fold greater risk
- Stop smoking for 10 years, reduces risk to control level

Front 15

How do you calculate the "pack years"?

Back 15

- Multiply the number of packs of cigarettes smoked / day by number of years person has smoked

- E.g., 10 pack years = smoking 1 pack / day for 10 years or 10 packs / day for 1 year

Front 16

Where else besides lung does smoking cause increased risk of cancer?

Back 16

- Lip
- Tongue
- Mouth
- Pharynx
- Larynx
- Esophagus
- UB
- Pancreas
- Kidney

Front 17

What do 97% of smokers have regarding their bronchial epithelium? How does this compare to control subjects?

Back 17

- Atypical changes
- Only 0.9% of non-smokers have these changes

Front 18

What are the potential carcinogens in tobacco smoking?

Back 18

- Initiators: Benzopyrene
- Promoters: Phenol derivatives

Front 19

What are the radioactive elements in tobacco smoking?

Back 19

- Carbon-14
- Potassium-40

Front 20

What are the contaminants in tobacco smoking?

Back 20

- Arsenic
- Nickel
- Moldes
- Additives

Front 21

What are the industrial hazards associated with Bronchogenic Carcinoma?

Back 21

- Radiation (Hiroshima/Nagasaki survivors)
- Uranium (miners)
- Asbestos
- Other: nickel, chromates, coal, mustard gas, arsenic, beryllium, iron

Front 22

How can air pollution contribute to Bronchogenic Carcinoma?

Back 22

- Indoor air pollution
- Radon exposure
- Ubiquitous radioactive gas

Front 23

What can lung cancer in non-smokers be attributed to?

Back 23

Usually d/t radon exposure

Front 24

What oncogenes are involved in Bronchogenic Carcinoma?

Back 24

- C-myc: small cell carcinoma
- K-ras, EGFR, EML4-ALK: adenocarcinoma

Front 25

What tumor suppressor genes are involved in Bronchogenic Carcinoma?

Back 25

- p53
- Retinoblastoma
- Other genes on short arm of Chromosome 3

Front 26

What are the effects of Benzopyrene?

Back 26

Causes DNA damage at same codons of p53 gene as seen in mutations seen in clinical lung cancers

Front 27

What is the genetic relationship in Bronchogenic Carcinoma?

Back 27

Familial clustering and variable risk among heavy smokers suggests genetic predisposition

Front 28

What are "scar cancers"?

Back 28

- Cancers occurring in the vicinity of pulmonary scars
- Usually adenocarcinoma
- Usually the scar is a response to the tumor
- Sometimes the scar precedes the cancer (old infarct, wound, granulomatous infection)

Front 29

When does Bronchogenic Carcinoma occur? Duration of symptoms?

Back 29

- Usually presents in 50s
- Avg duration of symptoms: 7 months

Front 30

What are the major presenting complaints of Bronchogenic Carcinoma?

Back 30

- Cough (75%)
- Weight loss (40%)
- Chest pain (40%)
- Dyspnea (20%)
- Increased sputum production

Front 31

How is Bronchogenic Carcinoma sometimes diagnosed?

Back 31

Secondary spread

Front 32

What clinical features may cause tumor obstruction of airway?

Back 32

- Pneumonia
- Abscess
- Lobar collapse

Front 33

What clinical features may cause tumor obstruction of airway d/t cellular lipid accumulation in foamy macrophages?

Back 33

Lipid Pneumonia

Front 34

What can cause pleural effusion in lung tumor?

Back 34

Tumor spreads into pleura

Front 35

What clinical features may cause hoarseness in lung cancer?

Back 35

Recurrent laryngeal nerve invasion

Front 36

What clinical features may cause dysphagia in lung cancer?

Back 36

Esophageal invasion

Front 37

What clinical features may cause diaphragm paralysis in lung cancer?

Back 37

Phrenic nerve invasion

Front 38

What clinical features may cause SVC Syndrome in lung cancer?

Back 38

SVC compression by tumor

Front 39

What clinical features may cause Horner Syndrome in lung cancer?

Back 39

Sympathetic ganglion invasion

Front 40

What clinical features may cause Pericarditis or Tamponade in lung cancer?

Back 40

Pericardial involvement

Front 41

What is a lung tumor at the extreme apex of the lung called?

Back 41

Pancoast Tumor

Front 42

What features are common with Pancoast Tumors?

Back 42

- Tumor at extreme apex of lung
- Involvement of superior cervical sympathetic ganglion leads to Horner's Syndrome
- Horner's Syndrome: ipsilateral lid lag, miosis, ipsilateral anhydrosis

Front 43

How can you classify the types of Bronchogenic Carcinoma?

Back 43

- Small cell carcinoma
- Non-small cell carcinoma

Front 44

What are the types of Small Cell Carcinoma?

Back 44

- Oat cell (lymphocyte like)
- Intermediate cell (polygonal)
- Combined (usually w/ squamous)

Front 45

What are the types of Non-Small Cell Carcinoma?

Back 45

- Squamous cell (epidermoid) carcinoma
- Adenocarcinoma (glandular [acinar] w/ mucin; papillary; solid; Lepidic / Bronchioloalveolar)
- Large cell carcinoma (neuroendocrine, undifferentiated, giant cell, clear cell)
- Adenosquamous Carcinoma

Front 46

How do you classify Bronchogenic Carcinoma?

Back 46

Historically:
- Used to be based on response to chemotherapy (wasn't important because of similar tx strategy)

Recent advances
- Shift in emphasis on accurate sub-typing to get best treatment strategy for patient

Front 47

What is the most common type of Bronchogenic Carcinoma in males?

Back 47

Squamous Cell Carcinoma (25-40%)

Front 48

What kind of patient gets Squamous Cell Carcinoma?

Back 48

- Most common type in males
- Cigarette smokers

Front 49

What is the characteristic feature of Squamous Cell Carcinoma?

Back 49

**** Central Cavitary Necrosis
- Usually arises centrally (main or lobar bronchi); usually endobronchial, polypoid growth

Front 50

What are the histological features of Squamous Cell Carcinoma?

Back 50

- Keratin formation
- Intercellular bridges
- Atypia and invasion
- Well / moderately / poorly differentiated subtypes depending on degree of squamous differentiation

Front 51

What kind of lung cancer is associated with this image?

Back 51

Squamous Cell Carcinoma

Front 52

What kind of lung cancer is associated with this image?

Back 52

Squamous Cell Carcinoma

Front 53

What is the most common type of Bronchogenic Carcinoma in women?

Back 53

Adenocarcinoma

Front 54

What is the most common type of Bronchogenic Carcinoma in non-smokers?

Back 54

Adenocarcinoma (although most patients w/ this ARE smokers)

Front 55

What is the most common form of lung carcinoma in USA?

Back 55

Adenocarcinoma (25-40%)

Front 56

What are the morphological features of Adenocarcinoma?

Back 56

- Usually peripheral w/ pleural retraction or puckering
- Associated w/ scarring

Front 57

How fast does Adenocarcinoma grow? Metastasize?

Back 57

- Grows more slowly
- Metastasizes more frequently than squamous cell carcinoma

Front 58

What are the symptoms of Adenocarcinoma? How does this affect diagnosis?

Back 58

- Usually asymptomatic (peripheral tumor)
- Causes late diagnosis

Front 59

What are the histological features of Adenocarcinoma?

Back 59

** Glandular (acinar) w/ mucin
- Papillary
- Solid
- Lepidic (bronchioloalveolar)

Front 60

What kind of lung cancer is associated with this image?

Back 60

Adenocarcinoma

Front 61

What subset of Adenocarcinoma is responsible for 1-9% of lung carcinomas?

Back 61

Bronchioloalveolar Carcinoma

Front 62

What are the morphological features of Bronchioloalveolar Carcinoma?

Back 62

- Single peripheral nodule
- Multiple nodules (several lobes / bilateral) - multifocal / aerogenous spread
- Diffuse pneumonia-like infiltrate

Front 63

What are the histological features of Bronchioloalveolar Carcinoma?

Back 63

- LEPIDIC spread (tumor cells spread along alveolar septa)
- Nonmucinous (Clara cells, type 2 pneumocytes) - 2/3 of cases
- Mucinous (tall columnar mucinous cells) - worse prognosis

Front 64

What are the types of Bronchioloalveolar Carcinoma? How common? Prognosis?

Back 64

- Nonmucinous (Clara cells, type 2 pneumocytes) - 2/3 of cases
- Mucinous (tall columnar mucinous cells) - worse prognosis

Front 65

What kind of lung cancer is associated with this image?

Back 65

Bronchioloalveolar Carcinoma (type of Adenocarcinoma)

Front 66

What kind of lung cancer is associated with this image?

Back 66

What kind of lung cancer is associated with this image?

Front 67

Who is most likely to get Small Cell Carcinoma? How common?

Back 67

Predominantly in:
- Males
- Smokers
- 20-25% of lung cancers

Front 68

What is the prognosis of Small Cell Carcinoma?

Back 68

Highly malignant, median survival ~4 months
- Most have metastasized by the time of diagnosis
- 70% seen at advanced stage

Front 69

What are the features of Small Cell Carcinoma?

Back 69

- Submucosal / circumferential infiltration
- Rare endobronchial polypoid growth
- Extensive necrosis, crush artifact
- Secretory granules of neuroendocrine type

Front 70

What are the subclassifications of Small Cell Carcinoma?

Back 70

- Oat cell
- Intermediate cell
- Mixed (small cell / large cell)
- Combined (small cell / adeno or squamous)

Front 71

How does Small Cell Carcinoma respond to chemotherapy?

Back 71

Excellent responses (but still median survival ~4 months)

Front 72

What is paraneoplastic syndrome? What is it associated with?

Back 72

- Consequence of the presence of cancer in the body, but is not due to the local presence of cancer cells
- These phenomena are mediated by humoral factors (by hormones or cytokines) excreted by tumor cells or by an immune response against the tumor

* Small Cell Carcinoma has Ectopic Hormone Production (= Paraneoplastic Syndrome)

Front 73

What kind of Bronchogenic Carcinoma is associated with pleomorphic, large cells without differentiation? How common are these?

Back 73

Large Cell Carcinoma (10-15% of Bronchogenic Carcinomas)

Front 74

What does Large Cell Carcinoma look like?

Back 74

- Pleomorophic, large cells without differentiation
- Ultrastructural evidence of glandular or squamous differentiation

Front 75

What is the prognosis of Large Cell Carcinoma?

Back 75

5-year survival 6%

Front 76

What are the features of Giant Cell Carcinoma?

Back 76

- Highly malignant
- Mostly peripheral
- <10 month survival

Front 77

What kind of Bronchogenic Carcinoma has evidence of cell carcinoma and adneocarcinoma in the same neoplasm? How common?

Back 77

Adenosquamous Carcinoma
1-3% of Bronchogenic Carcinomas

Front 78

What are the features of Adenosquamous Carcinoma?

Back 78

- Evidence of squamous cell carcinoma and adenocarcinoma in same neoplasm
- Peripheral tumor associated w/ scar
- Presents similarly to adenocarcinoma
- Majority of patients are smokers

Front 79

Where does Bronchogenic Carcinoma metastasize to? Lymph nodes affected?

Back 79

- Adrenal gland (50%)
- Liver (30%)
- Brain (20%)
- Bone

- Hilar lymph nodes

Front 80

How do you determine survival and choice of therapy for Bronchogenic Carcinoma?

Back 80

Histologic type and tumor staging and the most important factors

Front 81

What classification scheme is used for staging Bronchogenic Carcinoma?

Back 81

TNM classification:
- T: size of the original primary Tumor and whether it has invaded nearby tissue
- N: nearby regional lymph Nodes that are involved
- M: distant Metastases

Front 82

What are the features of a "Stage Ia or Ib" lung cancer?

Back 82

Stage Ia:
- T1: Tumor 3 cm w/o pleural or main stem bronchus involvement
- N0: No metastasis to lymph nodes
- M0: No distant metastasis

Stage Ib:
- T2: Tumor 3cm or involvement of main stem bronchus 2cm from carina, visceral, pleural, or lobar alectasis
- N0: No metastasis to lymph nodes
- M0: No distant metastasis

Front 83

What are the features of a "Stage IIa or IIb" lung cancer?

Back 83

Stage IIa:
- T1: Tumor 3 cm w/o pleural or main stem bronchus involvement
- N1: ipsilateral hilar or peribronchial nodal involvement
- M0: No distant metastasis

Stage IIb:
- T2: Tumor 3cm or involvement of main stem bronchus 2cm from carina, visceral, pleural, or lobar alectasis
- N1: ipsilateral hilar or peribronchial nodal involvement
- M0: No distant metastasis

Front 84

What are the features of a "Stage IIIa" lung cancer?

Back 84

T1-3, N2, M0
- T1: Tumor 3 cm w/o pleural or main stem bronchus involvement
- T2: tumor 3cm or involvement of main stem bronchus 2 cm from carina, visceral, pleural, or lobar atelectasis
- T3: tumor w/ involvement of chest wall, diaphragm, mediastinal pleura, pericardium, main stem bronchus 2 cm from carina, or entire lung atelectasis
- N2: metastasis to ipsilateral mediastinal or subcarinal lymph nodes
- M0: No distant metastasis

OR

T3, N1, M0:
- T3: tumor w/ involvement of chest wall, diaphragm, mediastinal pleura, pericardium, main stem bronchus 2 cm from carina, or entire lung atelectasis
- N1: ipsilateral hilar or peribronchial nodal involvement
- M0: No distant metastasis

Front 85

What are the features of a "Stage IIIb" lung cancer?

Back 85

Any T, N3, M0:
- N3: metastasis to contralateral mediastinal or hilar lymph nodes, ipsilateral or contralateral scalene, or supraclavicular lymph nodes
- M0: No distant metastasis

T3, N2, M0:
- T3: tumor w/ involvement of chest wall, diaphragm, mediastinal pleura, pericardium, main stem bronchus 2 cm from carina, or entire lung atelectasis
- N2: metastasis to ipsilateral mediastinal or subcarinal lymph nodes
- M0: No distant metastasis


T4, Any N, M0:
- T4: tumor w/ invasion of mediastinum, heart, great vessels, trachea, esophagus, vertebral body, or carina or w/ malignant pleural effusion
- M0: No distant metastasis

Front 86

What are the features of a "Stage IV" lung cancer?

Back 86

Any T, Any N, M1
- M1: distant metastasis present

Front 87

What is a paraneoplastic syndrome?

Back 87

Symptom complexes that occur in patients w/ cancer that cannot be readily explained by local or distant spread; or by elaboration of hormones by tumor cells

Front 88

What are paraneoplastic syndromes important?

Back 88

- Earliest manifestation of occult neoplasm
- Significant clinical problems (may be lethal)
- May mimic metastases and be difficult to treat

Front 89

What are some examples of paraneoplastic syndrome in lung cancer? Which kind of lung cancer is associated with these?

Back 89

Small Cell Carcinoma:
- Cushing's Syndrome (ACTH)
- Hyponatremia (inappropriate ADH)
- Carcinoid Syndrome (serotonin)
- Myasthenic Syndrome (Eaton-Lambert Syndrome)

Squamous Cell Carcinoma:
- Hypercalcemia (parathormone)

Front 90

What is the overall outlook for Bronchogenic Carcinoma in general? 5-year survival?

Back 90

Poor outlook; 9% 5-year survival

Front 91

What is the 5-year survival for Squamous Cell Carcinoma? Adenocarcinoma? Small Cell Carcinoma?

Back 91

- Squamous Cell Carcinoma: 10%
- Adenocarcinoma: 10%
- Small Cell Carcinoma: 3%

Front 92

Which Bronchigenic Carcinoma has the worst outlook?

Back 92

3% 5-year survival: Small Cell Carcinoma

Front 93

How common are Carcinoid Tumors? Who gets them?

Back 93

- 1-5% of all lung tumors
- Most patients <40 yo (M=F)
- 20-40% are non-smokers

Front 94

What kind of neoplasms are Carcinoid Tumors?

Back 94

Low-grade Malignant Neoplasms

Front 95

What are the microscopic features of Carcinoid Tumors?

Back 95

- Nests / cords / masses
- Uniform cells w/ round nuclei
- Salt and pepper chromatin

Front 96

What would Immunohistochemistry show for Carcinoid Tumors?

Back 96

NSE, Chromogranin, Synaptophysin +

Front 97

What are the clinical symptoms of Carcinoid Tumors?

Back 97

- Hemoptysis
- Cough
- Obstructive symptoms (d/t intraluminal growth)
- Infections
- Bronchiectasis
- Atelectasis
- Emphysema

Front 98

What are the features of Carcinoid Syndrome?

Back 98

- Intermittent diarrhea
- Flushing
- Cyanosis

Front 99

What is the prognosis for Carcinoid Tumors?

Back 99

- Metastases occur rarely (1-5%)
- Usually benign for long periods and are amenable to resection
- 5 and 10 year survival is 87%