Pulm Path Pt 3 Flashcards by Elizabeth Mazza

Atypical adenomatous hyperplasia (AAH)

small! <5mm

- dysplastic pneumocytes present along alveoli with some interstitial fibrosis

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Adenocarcinoma in Situ (AIS)

formerly bronchioalveolar carcinoma (BAC)
<3Cm
dysplastic pneumocytes confluently growing along alveoli

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What is the most common lung malignancy in smokers and non-smokers?

pulmonary adenocarcinoma

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What malignancy shows glands invading the lung tissue?

pulmonary adenocarcinoma

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Why is mucinous adenocarcinoma so dangerous?

because it’s presentation can mimic pneumonia or other lung infection (with bilateral infiltrates), so diagnosis is often missed

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What is the progression of squamous carcinoma? (4 stages)

normal bronchial epithelium
squamous metaplasia
squamous carcinoma in situ
invasive squamous carcinoma

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What malignancy is more common in men, has a strong association with smoking, and often occurs centrally?

squamous carcinoma

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What malignancy are Keratin pearls the hallmark of?

squamous carcinoma

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What should you think of if you see orange cytoplasm on cytology slide?

Keratin => squamous carcinoma

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What is small cell neuroendocrine carcinoma almost always associated with?

smoking!

has a high rate of metastasis (very mitotically active)
likely to necrose

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Which is small cell neuroendocrine carcinoma important to ID for treatment?

surgical excision not recommended if metastatic to LN
requires specific chemotherapy
chemo/radiation-responsive, but high rate of recurrence

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What does small cell carcinoma look like histologically?

small cells with fine blue nuclear chromatic, scant cytoplasm, nuclear “molding”, and characteristic necrosis

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What molecular testing is used to diagnose adenocarcinoma?

EGFR
ALK
PDL-1

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When would a Tyrosine Kinase Inhibitor be used to treat adenocarcinoma?

If genetic tests a positive for EGFR mutation

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What chemotherapy treatment would be used if patient tested negative for EGFR mutation?

If positive for ALK rearrangement -> Crizontinib

If negative for ALK rearrangement -> chemotherapy with or without Bevacizumab

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What is another implication of squamous carcinoma?

hypercalcemia (PTH-related peptide)

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What are other implications of small cell carcinoma?

SIADH
Cushing’s syndrome

NOTE: might not be adrenal in origin, always a possibility that tumors originated in lungs and metastasized

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What is Trosseau’s syndrome? What can it lead to?

vessel inflammation due to a blood clot

- can lead to migratory thrombophlebitis

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What is DIPNECH?

diffuse interstitial pulmonary neuroendocrine cell hyperplasia
- very small, less than 5mm “tumorlets”

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How is DIPNECH diagnosed?

high resolution CT

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How can you tell DIPNECH apart from a carcinoid tumor?

size: carcinoid tumor is larger (>5mm), while DIPNECH is <5mm

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What is it important to accurately diagnose a carcinoid tumor?

because they can metastasize! (though they are slow growing)

- they are considered a low grade carcinoma (not benign)

What is considered a neuroendocrine carcinoma grade 1?

carcinoid tumor

What is different about an atypical carcinoid tumor?

increased mitotic activity
necrosis
disordered growth
increased rate of metastasis
lower survival (still better than small cell carcinoma)

What are the survival rates for: - carcinoid tumors (grade 1) - atypical carcinoid tumors (grade 2) - small cell carcinoma (grade 3)

- carcinoid tumors: 95% - atypical carcinoid tumors: 70% - small cell carcinoma: 5%

What looks like "cauliflower" cartilage on a low mag histo slide? What does it look like on high mag?

pulmonary hamartoma | - fibrous tissue with benign glandular epithelium around hyaline cartilage

What does a hamartoma look like on CT scan?

"coin" lesion

What loss of function is associated with lymphangioleiomyomatosis (LAM)?

TSC2 tumor supressor

What population is most likely to present with LAM?

young women (extremely uncommon in men) NOTE: may present with pneumothorax

What is the MOA of LAM?

proliferation of cells creating cystic spaces | - cells are modified smooth muscle cells

What markers are LAM cells positive for?

- HMB-45 (melanoma marker) | - perivascular epithelioid cells (PEC-oma)

What is the major cause of a transudate pleural effusion?

heart failure

What are the major causes of exudate pleural effusion?

- infection (Tb, bacterial pneumonia) | - malignancy

When would a serous transudative effusion be seen?

patient with heart failure

When would a milky chylous effusion be seen?

patient with bronchogenic carcinoma | - one in example was obstructing the thoracic duct

When would a blood effusion be seen?

metastatic carcinoma involving the pleura

What is empyema?

inflammatory exudate with accumulation of pus in the pleural space - typically a bacterial infection

What is notorious for creating "loculations" (web-like traps for fluid)

empyema | - CT shows interconnected webbing that traps pus inside

What will the exudate of an empyema be like?

fluid will be thick, yellow, smear will show neutrophils and often bacteria

What is a primary (idiopathic) pneumothorax?

rupture of subpleural blebs | - typically seen in younger patients

What is a secondary pneumothorax caused by?

- cystic infections - cystic tumors - rupture of subpleural blebs - positive-pressure ventilation - trauma

What is a tension pneumothorax?

injury to the chest wall resulting in a one-way valve (vacuum), that allows air INto the pleural space, but not out

What is the concept behind a tension pneumothorax?

it is the expansion of the chest wall (not the lungs per se) that is responsible for inspiration

What does a tension pneumothorax look like on CXR?

**mediastinal shift** pushes all midline structures aside

What type of pneumothorax has pleural cavity pressure less than atmospheric pressure?

primary pneumothorax

What type of pneumothorax has pleural cavity pressure greater than atmospheric pressure?

tension pneumothorax

What is a solitary fibrous tumor?

- benign when small and pedunculated | - larger ones may behave like sarcoma

What is a typical stain used to diagnose benign tumors?

CD34 stain

What is a solitary fibrous tumor?

a circumscribed pleural-based mass | - on excision, it is pedunculated from the neighboring lung tissue (it is minimally attached => easy to excise)

What is mesothelioma associated with?

asbestos exposure

What stain is used to diagnose mesothelioma?

calretinin NOTE: also look for ferruginous bodies***

What are the variants of mesothelioma?

- epithelioid - sarcomatoid - mixed

Why is mesothelioma difficult to treat?

- can't be easily excised | - limited responsiveness to chemotherapy and radiation