Term
1) True or False:
The FDA currently recommends CT screening for all smokers. |
|
Definition
False.
The evidence is there, but has not been implemented |
|
|
Term
| What are the 2 major types of lung cancer. |
|
Definition
2 types of Bronchogenic carcinoma
1) Non-small cell carcinoma (NSCLC)
- Adenocarcinoma (35% of all), squamous carcinoma, large cell, undifferentiated carcinoma (most common)
2) Small cell lung carcinoma
- Agressive with early metastasis and poor prognosis |
|
|
Term
| What are the most common exposures that lead to lung cancer? |
|
Definition
1) Tobacco smoke
2) Radon (uranium miners)
3) Asbestos (the worst!)
4) Wood smoke/air pollution |
|
|
Term
Which of the following is not a known risk factor for lung cancer.
1) Tobacco smoke exposure
2) Radon exposure
3) Asbestos exposure
4) Age
5) Wood smoke exposure |
|
Definition
|
|
Term
What kinds of cancer are each of the following associated with?
1) N-nitrosamines
2) PAH |
|
Definition
1) Adenocarcinoma
2) Squamous cell tumors |
|
|
Term
| What are the 3 best described oncogenes in human lung cancer? |
|
Definition
1) c-myc in small cell lung cancer (alters transcription)
2) K-ras in cell:cell signal transduction (proto-oncogene becomes oncogene with SNPs)
3) c-erbB2 is TK that regulates EGFR |
|
|
Term
| What gene deletion is associated with lung cancer? |
|
Definition
|
|
Term
| What tumor suppressor genes are known to malfunction in lung cancer? |
|
Definition
Rb and P53
- P53 replacement may slow tumor growth. |
|
|
Term
| What proto-oncogenes are most commonly mutated in pulmonary adenocarcinoma and how do these mutations contribute to the pathobiology of cancer? |
|
Definition
K-ras and EGFR
Mutation prevents auto-inhibition of TK on EGRF and leads to constitutive activation, leading to proliferation, invasion and metastasis |
|
|
Term
What pathological findings define each of the following?
1) Adenocarcinoma
2) Bronchioloalaveolar Cell Carcinoma (BAC)
3) Squamous cell carcinoma
4) Large cell, undifferentiated
5) Small cell |
|
Definition
1) Peripheral nodule or mass with pseudo-gland formation and intracytoplasmic mucin
2) subtype of 1 with alveolar septal growth, presenting as nodule or alveolar infiltrate (BRONCHORRHEA)
3) Bronchogenic tumor of central airways leading to obstruction. Look for "Keratin "earls" on H & E
4) Large, bulky mass with necrosis
5) central chest with early LN involvement and metastasis to brain, liver, bone marrow.
- Pleomorphic population of small cells with hyperchromatic nuclei and dispersed chromatin. |
|
|
Term
What kind of lung cancer matches each of the following pathological descriptions?
1) Peripheral nodule or mass with pseudo-gland formation and intracytoplasmic mucin
2) Bronchorrhea
3) "Keratin Pearls" on H & E
4) Large, bulky mass with necrosis
5) Pleomorphic population of small cells with hyperchromatic nuclei and dispersed chromatin. |
|
Definition
1) Adenocarcinoma
2) Bronchioloalveolar cell carcinoma (BAC)
3) Squamous cell carcinoma
4) Large cell carcinoma
5) Small cell carcinoma |
|
|
Term
| What is the basic diagnostic strategy for lung cancer? |
|
Definition
Diagnose early and remove surgically (most are not candidates).
1) Sputum cytology (high false negative)
2) Bronchoscopy (Safe and effective)
3) Image-guided needle biopsy (peripheral nodules that are hard to find on bronchoscopy)
4) Surgical biopsy (most invasive but most definitive). |
|
|
Term
| How are lung cancer tumors staged in small-cell carcinoma? |
|
Definition
1. Evaluation of the primary tumor
- Primary tumors are staged from T0 (no evidence of tumor) to T4 (extensive tumor)
2) Evaluation of regional lymph node metastases
- Regional lymph nodes are staged from N0 (no metastases) to N3 (contralateral metastases)
3) Evaluation of distant metastases
- M0 - no metastases; M1 - distant metastases present
The three parameters are combined together to establish pathologic stage of the disease (from I to IV). |
|
|
Term
| Why might lung cancer rates in non-smoking women be higher than in non-smoking men? |
|
Definition
Hormonal factors- estrogen
Endocrine factors may also speed up malignant transformation. |
|
|
Term
What medical therapies are suggested for each of the following NSMC?
1) Stage 1 A/B and II A/B
2) Stage IIIA
3) Stage IIIB
4) Stage IV |
|
Definition
1) Lobectomy
2) Surgery + chemo is superior to surgery alone
3) Thoracic radiation and chemotherapy only.
4) Palliation (chemotherapy to be 3-9 months extra) |
|
|
Term
| How does the therapy for small cell lung carcinoma differ from that for NSCC? |
|
Definition
Medical rather than surgery.
Chemo with thoracic radiation or chemo alone in extensive disease.
50% remission and 70% relapse! |
|
|
Term
| What are the important paraneoplastic syndromes to be aware of with lung cancers? |
|
Definition
1) Hypertrophic Pulmonary Osteoarthropathy (HPO)
- Clubbing and painful arthropathy of knees, ankles and wrists.
2) Hypercalcemia
- PTH-related peptide causes bone turnover and increases calcium reabsorption and sodium wasting through kidney.
3) SIADH
- Euvolemic hyponatremia
4) Cushing's
- Small cell cancers leading to ectopic ACTH production |
|
|
Term
| Why do patients with small cell lung cancer sometimes present with HTN, moon facies and abdominal striae? |
|
Definition
Cushing's syndrome with ectopic ACTH production.
Too much cortisol. |
|
|
Term
| What neurological disorders are associated with small cell carcinoma? |
|
Definition
1) Neuropathy
- anti-neuronal antibodies
2) Limbic encephalitis
- decreased cognitive ability and easy confusion (looks like dementia)
3) Lambert-Eaton Syndrome
- Proximal muscle weakness and hyporeflexia
- partial blockage of ACh release from NMJ by antibodies against Ca channels.
**decreases with remission** |
|
|
Term
A 75 year old man who is a non-smoker presents with localized chest pain. He was previously asymptomatic.
You order an CXR and see a peripheral sub-pleural mass that has spread to the hilar and peribronchial lymph nodes.
What do you see on gross examination and histological analysis of his lungs? |
|
Definition
This is Adenocarcinoma, the most common cause of lung cancer in non-smokers.
The asymptomatic history and older age fits well.
1) Gross
- Usually a peripheral, sub-pleural mass
2) Histology
- Infiltrating "pseudo" glands in cribriform, tubular or papillary configuration (80% of mucus)
- Desmoplastic stroma. |
|
|
Term
| What types of lung cancers are close to the mediastinum, deriving from the mucosa of the main, lobar or segmental bronchi? |
|
Definition
These are Central Lesion and often arise in areas of squamous metaplasia.
Carcinomas are Squamous Cell or Small Cell and are prone to distal atalectasis, necrosis/cavitation and microorganism colonization. |
|
|
Term
A 69 year old male with a 80 pack year h/x of smoking presents with chest pain. He is hypercalcemic. You order a CXR are discover a mediastinal mass.
What do you see on gross/histological analysis of the mass? |
|
Definition
This is squamous cell carcinoma. Age and smoking h/x fit, as well as central lesion (vs. peripheral lesion in adenocarcinoma) and hypercalcemia.
**Squamous pearls wrapping keratin plug like an ONION**
1) Gross
- Central lesion
2) Histological
- Squamous metaplasia/dysplasia, which may progress to carcinoma in situ and invasive squamous carcinoma.
- Intercellular bridges desmosomes.
- Intracytoplasmic keratinization. |
|
|
Term
A 72 year old female with a 30 pack year history of smoking presents presents with a bloody cough.
You order a chest X-ray and see a Central mass with metastases.
What do you see on gross/histological analysis of the mass? |
|
Definition
1) Grossly
- Central lesion with or w/o cavitation
2) Histology
- Sheet-like arrangement of malignant cells with vesicular nuclei, prominent nucleoli, and abundant cytoplasm.
- No keratin pearls, intercellular bridges, or mucin production |
|
|
Term
A 82 year old male presents with a bloody cough, HTN, moon face and abdominal striae. He is also hypokalemic.
You order a CXR and see a central tumor mass with small primary and extensive nodal disease.
What are the gross/histological findings? |
|
Definition
Older individual with bloody cough and paraneoplastic syndromes (Cushing's and SIADH described here), as well as central mass with small primary lesion means SMALL CELL CARCINOMA.
1) Gross
- Centrally located / mediastinal mass
- Frequently necrotic
- Mediastinal lymphadenopathy
2) Histological
- Small cells with dense hyperchromatic nuclei, scant cytoplasm, nuclear molding
- Extensive necrosis
- Lymphatic invasion
- Presence of neurosecretory granules (neuroendocrine differentiation |
|
|
Term
A 74 year old male roof-worker presents with pleuritic chest pain and a bloody pleural effusion.
On CXR you see diffuse pleural thickening.
What are the gross/histological findings? |
|
Definition
Asbestos exposure in older individual with pleural effusion and pain indicates Mesothelioma.
**look for ferruginous body!**
1) Gross
- White nodules and plaques covering the parietal and visceral surfaces (initially unilateral)
2) Histological
- Epithelial variant (papillary or tubular structures resembling adenocarcinoma)
- Spindle (sarcomatoid) variant (elongated spindle cells in fascicles)
- Mixed type (Epithelial and spindle cells) |
|
|
Term
| What is the drawback of using sputum cytology for lung cancer diagnosis? |
|
Definition
| Gets 70% of central masses (small cell and large cell), but only 50% of peripheral (adenocarcinoma) |
|
|
Term
| What is the diagnostic test of choice for central tumors? |
|
Definition
Flexible Bronchoscopy
1) detects 90% of central (endobrochial) tumors
2) two main ways of sampling:
- forceps biopsy of visible lesions
- bronchial brushing |
|
|
Term
| What is the diagnostic test of choice for patients with peripheral tumors (Adenocarcinoma)? |
|
Definition
Transthoracic Needle Biopsy
- Done under guidance by ultrasound or computed tomography (CT scan). |
|
|
Term
| What is the diagnostic test of choice for patients with small peripheral tumors or pleural tumors? |
|
Definition
Video-assisted thoracoscopy
- Thorascope is passed through a small incision in the chest to remove a sample of lung tissue. |
|
|
Term
| What 5 elements are usually contained in a lung cancer pathology report? |
|
Definition
1. Presence of malignant cells (positive for malignancy)
2. Type of cancer (i.e. Adenocarcinoma)
3. Grade of tumor (i.e. poorly differentiated)
4. Stage of tumor (if possible)
5. Special tests (proteonomics, gene expression, gene mutations) |
|
|
Term
| In which type of lung cancer do neoplastic cells recapitulate Clara cells, goblet cells or Type 1 and II pneumocytes? |
|
Definition
Bronchioloalveolar adenocarcioma (Adenocarcinoma varient), which is commonly seen in non-smokers and young individuals.
Cells grow along septa. |
|
|
Term
| What are the 2 types of tumors formed in Large cell carcinoma? |
|
Definition
1) Anaplastic
- undifferentiated squamous or adenocarcinomas
2) Neuroendocrine
- uniform, medium-size cells that grow in clusters (express neuroendocrine peptides and you may see neuroendocrine granules on EM). |
|
|
