Pulmonary Neoplasms - MedPath

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49 Terms

1
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What does this refer to

  • ______ : are abnormal tissue growths; may be benign or malignant

Neoplasms

2
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What does this refer to

  • Primary vs. metastatic lung tumors

  • Lung cancer is the leading cause of cancer-related deaths worldwide

Pulmonary neoplasms

3
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What does this refer to

  • Benign vs. Malignant

  • Primary vs. Secondary (metastatic)

  • Non-small cell lung cancer (NSCLC) vs. Small cell lung cancer (SCLC)

Classification of Pulmonary Tumors

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What does this refer to

  • Tobacco smoke: primary risk factor

  • Environmental exposures: radon, asbestos, pollution

  • Genetic predispositions

Etiologic factors

5
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What does this refer to

  • Most common: Hamartomas (contain cartilage, fat, connective tissue)

  • Usually peripheral and asymptomatic

  • Detected incidentally on imaging

  • Slow growing

Benign Pulmonary Tumors

6
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What does this refer to

  • They consist of a mixture of normal lung tissue elements, including cartilage, fat, connective tissue, and smooth muscle, with entrapped respiratory epithelium.

Composition of Hamartomas

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What does this refer to

  • They often appear as well-defined, coin-shaped nodules on imaging, sometimes with characteristic "popcorn-like" calcification or fat.

Appearance of Hamartomas

<p>Appearance of Hamartomas</p>
8
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What does this refer to

  • Non-Small Cell Lung Cancer (NSCLC) ~85%

  • Small Cell Lung Cancer (SCLC) ~15%

  • Other: carcinoid tumors, mesothelioma, lymphomas

Malignant Pulmonary Tumors

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What does this refer to

  • Smoking: responsible for ~90% of lung cancer cases

    • Heavy smokers have 20 times’ greater chance of lung cancer than nonsmokers

    • Smoking is related to cancers of the larynx, oral cavity, esophagus, and urinary bladder

  • Environmental or occupational exposures: radon, asbestos, air pollution

  • Genetic mutations: inherited or acquired

Etiologic factors

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What Non small cell lung cancer (NSCLC) subtype does this refer to

  • peripheral, most common in non-smokers

Adenocarcinoma

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What Non small cell lung cancer (NSCLC) subtype does this refer to

  • : central, associated with smoking

Squamous cell carcinoma

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What Non small cell lung cancer (NSCLC) subtype does this refer to

  • : undifferentiated, poor prognosis

Large cell carcinoma

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What does this refer to

  • Accounts for ~15% of cases

  • Highly aggressive and rapidly growing

  • Strongly associated with smoking

Small cell lung cancer (SCLC)

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What does this refer to

  • Driver mutations: EGFR, KRAS, ALK, BRAF (NSCLC); TP53, RB1 (SCLC)

  • Promote proliferation, evade apoptosis, enhance survival

  • Targetable mutations guide therapy decisions

Molecular Pathogenesis

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What does this refer to

  • ______ mutation → increased tyrosine kinase activity

  • Downstream signaling: RAS-RAF-MEK, PI3K-AKT pathways

  • Targeted by _______ inhibitors: erlotinib, osimertinib

EGFR Pathway in NSCLC

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What mutation is the following

  • _______ : associated with poor response to therapy

  • Found in younger, non-smoking populations

KRAS

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What mutation is the following

  • _______ rearrangement: targetable with crizotinib, alectinib

  • Found in younger, non-smoking populations

ALK

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What does this refer to

  • Initiation: DNA damage (carcinogens)

  • Promotion: clonal expansion

  • Progression: acquisition of malignant phenotype

Multistep Carcinogenesis

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What does this refer to

  • Metaplasia → Dysplasia → Carcinoma in situ → Invasive cancer

  • Loss of differentiation and architecture

  • Increased mitotic activity and pleomorphism

Histopathological Changes

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What does this refer to

  • Composed of stromal cells, immune cells, extracellular matrix

  • Supports tumor growth, angiogenesis, immune evasion

  • Dynamic and interactive system

Tumor Microenvironment

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What does this refer to

  • Tumors secrete vascular endothelial growth factor (VEGF) to promote blood vessel formation

  • New vessels are leaky and irregular

  • Targeted by anti-VEGF therapies (e.g., bevacizumab)

Angiogenesis in lung cancer

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What does this refer to

  • PD-L1 (Programmed Death-Ligand1) expression on tumor cells binds PD-1 on T cells

  • Suppresses immune response

  • Checkpoint inhibitors restore T-cell activity

Immune evasion mechanisms

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What does this refer to

  • Tumor cells degrade extracellular matrix via proteases

  • Enter blood/lymphatic vessels

  • Seed distant organs: brain, bone, liver, adrenals

Invasion and Metastasis

24
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What does this refer to

  • Occur due to ectopic hormone/cytokine production

  • SCLC: SIADH, ectopic ACTH (Cushing), neurologic syndromes

  • NSCLC: hypercalcemia (parathyroid hormone related protein-PTHrP), hypertrophic osteoarthropathy

Paraneoplastic syndrome

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What paraneoplastic syndrome is associated with SCLC

SIADH, ectopic ACTH (Cushing), neurologic syndromes

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What paraneoplastic syndrome is associated with NSCLC

NSCLC

27
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What does this refer to

  • Cough, hemoptysis, wheezing, chest pain, weight loss

  • Recurrent pneumonia, hoarseness (recurrent laryngeal nerve)

  • Superior vena cava syndrome in central tumors

Symptoms of Lung Cancer

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What does this refer to

  • CXR: mass, atelectasis, pleural effusion

  • CT: defines size, lymph node involvement, metastases

  • PET: identifies metabolically active disease

Radiologic Appearance

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What does this refer to

  • Bronchoscopy: visual and biopsy of central lesions

  • Endobronchial ultrasound (EBUS): guides lymph node sampling

  • Transthoracic needle biopsy for peripheral nodules

Bronchoscopy and Biopsy

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What radiology technique tells you “: mass, atelectasis, pleural effusion”

CXR

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What radiology technique tells you “: defines size, lymph node involvement, metastases”

CT

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What radiology technique tells you “: identifies metabolically active disease”

PET

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What is used to “visual and biopsy of central lesions”?

Bronchoscopy

34
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What is used to “guides lymph node sampling”

Endobronchial ultrasound (EBUS)

35
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What is used for for peripheral nodules

Transthoracic needle biopsy

36
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Given the cytologic and histologic information below, what would you diagnose the patient with

  • “glandular structures, mucin production”

Adenocarcinoma

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Given the cytologic and histologic information below, what would you diagnose the patient with

  • “keratin pearls, intercellular bridges”

Squamous

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Given the cytologic and histologic information below, what would you diagnose the patient with

  • “small blue cells, nuclear molding, necrosis”

SCLC

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What does this refer to

  • T: tumor size and local invasion

  • N: nodal involvement

  • M: presence of distant metastases

Stage guides prognosis and treatment

40
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What does this refer to

  • Surgical resection (stages I-IIIA)

  • Adjuvant chemotherapy, radiation

  • Targeted therapies and immunotherapies for advanced stages

NSCLC Treatment Strategies

41
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What does this refer to

  • Chemo-radiotherapy mainstay of treatment

  • Limited stage: curative intent

  • Extensive stage: palliative, often rapid relapse

SCLC Treatment Strategies

42
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What does this refer to

  • EGFR, ALK, ROS1 inhibitors for mutation-positive tumors

  • Improved survival and reduced toxicity

  • Resistance mutations (e.g., T790M) can develop

Targeted Therapy in NSCLC

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What does this refer to

  • Checkpoint inhibitors (PD-1/PD-L1 blockers)

  • Effective in high PD-L1 expression

  • Improves overall survival in NSCLC

Role of Immunotherapy

44
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What does this refer to

  • Checkpoint inhibitors (PD-1/PD-L1 blockers)

  • Effective in high PD-L1 expression

  • Improves overall survival in NSCLC

Surveillance and Follow-Up

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What does this refer to

  • 5-year survival depends on stage and histology

  • Early-stage NSCLC: ~60-70%

  • SCLC and late-stage NSCLC: <15%

Prognosis

46
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What does this refer to

  • Rare, aggressive cancer of pleura

  • Strongly linked to asbestos exposure

  • Long latency period (20–50 years)

  • More common in men and older individuals

  • Asbestos fibers cause chronic inflammation

  • DNA damage leads to mesothelial cell mutation

  • Tumor spreads along pleural surfaces

  • Invades chest wall, diaphragm, and pericardium

Mesothelioma

47
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What does this refer to

  • Neuroendocrine tumors (NETs) of the lung

  • Classified as typical or atypical

  • Less aggressive than small cell carcinoma

  • May secrete hormones (e.g., serotonin)

  • Origin from neuroendocrine Kulchitsky cells

  • Uncontrolled proliferation due to mutations (e.g., MEN1)

  • Tumor may produce bioactive amines

  • Can cause carcinoid syndrome if metastasized

Carcinoid tumors

48
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What does this refer to

  • : asbestos-related, pleural origin, aggressive

  • Importance of early recognition and pathology

  • Both require multidisciplinary management

Mesothelioma

49
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What does this refer to

  • “neuroendocrine tumors, variable behavior, hormone-secreting”

  • Importance of early recognition and pathology

  • Both require multidisciplinary management

Carcinoid Tumors