Pathology of Pulmonary Neoplasia

Question 1

What is the most common death by cancer worldwide?

Answer 1

Lung cancer

Question 2

What is the biggest cause of lung cancer?

Answer 2

Tobacco

Question 3

What are causes of lung cancer apart from tobacco?

Answer 3

• Asbestos
• Environmental radon
• Occupational exposure
• Air pollution and urban environment
• Other radiation
• Pulmonary fibrosis

Question 4

What is the increased risk of lung cancer caused by smoking in males and females?

Answer 4

RISK of cancer INCREASED 22 times in males and 12 times in females

Question 5

How does passive smoking increase risk of lung cancer?

Answer 5

-50-100% increased risk
- Causes at least 25% of so-called non-smoking
lung cancers

Question 6

Does stopping smoking stop your risk of lung cancer?

Answer 6

NO

- Risk reduces with abstinence but only slowly.

Question 7

What is the main carcinogen in tobacco likely to give you Adenocarnomas?

Answer 7

N-nitrosamines

Question 8

What is the main carcinogen in tobacco likely to give you Squamous SCLC?

Answer 8

Polycyclic aromatic hydrocarbons (PAH)

Question 9

What are the 2 main pathways of carcinogenesis in the lung?

Answer 9

In the lung periphery and in the central lung airways

Question 10

How does carcinogenesis occur in the lung periphery?

Answer 10

Bronchioalveolar epithelial stem cells transform causing Adenocarcinoma.

Question 11

How does carcinogenesis occur in the central lung airways?

Answer 11

Bronchial epithelial stem cells transform causing Squamous cell carcinoma.

Question 12

What kind of cancer is most lung cancers?

Answer 12

They are an adenocarcinoma in the peripheral of the lung

Question 13

What is the carcinoma sequence of peripheral lung adenocarcinogenesis?

Answer 13

Atypical adenomatous hyperplasia (AAH) > Adenocarcinoma in situ > Invasive adenocarcinoma

Question 14

What oncogene is mainly smoking induced?

Answer 14

KRAS

Question 15

Which oncogenes are not related to tobacco carcinogenesis?

Answer 15

• EGFR
• BRAF, HER2
• ALK rearrangements
• ROS1 gene rearrangements

Question 16

What are the different types of tumours of the lung?

Answer 16

• Benign causes of mass lesion
• Carcinoid tumour
• Tumours of bronchial glands: very rare
• Lymphoma
• Sarcoma
• METASTASES to lung are common

Question 17

What are the 4 main types of carcinoma?

Answer 17

• Squamous cell
• Adenocarcinoma (most likely)
• Small cell carcinoma
• Large cell carcinoma

Question 18

Which carcinomas are non-small cell carcinomas (NSCLC)?

Answer 18

• Adenocarcinoma
• Squamous cell carcinoma
• Large cell carcinomas
• Others

Question 19

Which carcinoma has increased in number of cases in Scotland?

Answer 19

Adenocarcinoma

Question 20

Features of primary lung cancer

Answer 20

• Probably grows ‘clinically silent’ for many years
• Presents late in its natural history
• Generally speaking, symptomatic lung cancer is fatal.

Question 21

Small cell carcinoma

Answer 21

• Comprises about 10-15% of lung cancers.
• This type is the most aggressive and rapidly growing.
• It is strongly related to cigarette smoking.

Question 22

Local effects of lung cancer

Answer 22

• Bronchial Obstruction
• Pleural
• Direct Invasion
• Lymph node metastases

Question 23

Features of bronchial obstruction local effects

Answer 23

• Collapse
• Endogenous lipoid pneumonia
• Infection/abscess
• Bronchiectasis

Question 24

Features of pleural local effects

Answer 24

• Inflammatory

- Malignant

Question 25

Features of direct invasion local effects

Answer 25

- Chest wall - Nerves: Phrenic-diaphragmatic paralysis L recurrent laryngeal -hoarse, bovine cough Brachial plexus-pancoast T1 damage Cervical Sympathetic-horner's syndrome -Mediastinum (SVS, Pericardium)

Question 26

Features of lymph node metastases local effects

Answer 26

- Mass effect | - Lymphangitis carcinomatosa

Question 27

Distant effects of lung cancer

Answer 27

- Distant metastases: liver, adrenals, bone, brain, skin. - Secondary to local effects: Neural, vascular. - Non-metastatic effects

Question 28

Non-Metastatic Paraneoplastic Effects of small cell carcinoma

Answer 28

- ACTH, SIADH

Question 29

Non-Metastatic Paraneoplastic Effects of squamous cell carcinoma

Answer 29

- PTH

Question 30

Non-metastatic effects of lung cancer

Answer 30

Finger clubbing and Hypertrophic pulmonary osteoartgropathy (HPOA)

Question 31

Investigation techniques for lung cancer

Answer 31

- Chest X-ray - Sputum Cytology rarely used - Bronchoscopy - Trans-thoracic Fine Needle Aspiration - Trans-thoracic Core Biopsy - Pleural effusion cytology and Biopsy - Advanced imaging techniques e.g. CT scan

Question 32

What can prognostic markers be used for?

Answer 32

TO select patients for ADJUVANT therapy

Question 33

What is the PD1/PD-L1 axis immune checkpoint in NSCLC?

Answer 33

- A therapeutic target | - An important biomarker

Question 34

What are predictive biomarkers used for after diagnosis?

Answer 34

They will increasingly be used to select patients for therapy - Adenocarcinoma e.g. EGFR, KRAS, HER2, BRAF mutations, ALK translocations etc. - Squamous cell - Immunotherapy in NSCLC has transformed practice.

Question 35

What are the immune checkpoints adopted by tumours to avoid immune destruction?

Answer 35

PD1 PD-L1 CTLA4