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NEOPLASMS OF LUNG, PLEURA, AND MEDIASTINUM

By Jeffrey Martinez,2014-06-26 20:49
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NEOPLASMS OF LUNG, PLEURA, AND MEDIASTINUM ...

    NEOPLASMS OF LUNG, PLEURA, AND MEDIASTINUM

    Classification Disease Etiology Epidemiology Pathology Clinical Hamartoma Not discussed Not discussed Radiology: Starts in adolescence ? adulthood

     Solitary nodule +/- popcorn None in newborns (not

     calcification; congenital)

     Peripheral > central

    Gross: solitary, lobulated, cartilaginous Benign

    Micro: normal tissues in Epithelial

    excess/disarray (=def. of hamartoma) Neoplasms

    Squamous Assoc w/ human papilloma Not discussed Radiology: Children > adults papillomatosis virus (HPV; Study w/ in situ Slow growing nodules (cauliflower Larynx > trachea > bronchi

    hybrdization) like on bronchoscopy)

     Micro: Squamous papillomas

    Squamous cell Model of Pathogenesis of 1) Smokers (98%) Radiology: 1) May secrete PTH like cmpd (? carcinoma Bronchogenic Squamous 2) 20-30% of Central > peripheral patient may have hypercalcemia)

    Carcinoma: Resp mucosa ? common Gross: 2) Will metastisize to regional

    squamous metaplasia ? carcinomas Bronchi>Larynx>trachea (rare) nodes

    squamous dysplasia ? Micro:

    carcinoma in situ ? invasive +/- Desmosomes

    squamous carcinoma +/- Keratin production (keratin pearls) Adenocarcinoma Not discussed 1) 30-40% of common Radiology: Not discussed

    carcinomas Peripheral > Central

    2) Most common Micro:

    carcinoma in non- +/- Glands;

    smokers, but 80% occur +/- Mucin Malignant in smokers Bronchio-alveolar carcinoma subset Epithelial Bronchioalveolar Not assoc w/ smoking or virus Rising incidence Radiology: Not discussed Neoplasms carcinoma (presently 20-25%) Peripheral (can be multifocal and (non-small cell (subset of bilateral) carcinoma) adenocarcinoma) Micro: Lepidic (butterfly-like) growth

     pattern ? architecture retained, but

     epithelium replaced by malignant

     cells

     +/- mucin

     Unifocal or Multifocal (must

     distinguish multifocal primary form

     metastases)

    Large cell undiff Not discussed 10% of common Radiology: Non-specific Differentiate from squamous cell carcinoma carcinomas Micro: H&E undiff; favor b/c no desmosomes/keratin; from

    adenocarcinoma (by EM) adenocarcinoma b/c no

    glands/mucin

    Classification Disease Etiology Epidemiology Pathology Clinical

    Mature Not discussed NOT assoc w/ smoking Radiology: 1) Bronchial submucosal mass is

    Carcinoid (<5% of pulm neoplasms) Central > peripheral typical

    Tumor Micro: 2) Rare mets to regional nodes (5%),

     Bland neuroendocrine neoplasm surgical resection ? 100% cure

     Salt & Pepper chromatin

     Synaptophysin/chromogranin positive (by IHC)

     No mitotic figures or necrosis

    Atypical Not discussed Radiology: Non-specific

    Carcinoid Peripheral > central Capable of metastisis

    Tumor Micro:

    Neuroendocrine Bland neuroendocrine neoplasm

    Neoplasms Rare mitotic figures

     Focal necrosis

     Prominent nucleoli

    Small Cell Not discussed Radiology: Ectopic ACTH, ADH, Eaton- Common in smokers, ? rad

    Carcinoma Central in > 90% Lambert, carcinoid syndrome exposure

     Freq. mets to LN & distant sites Commonly high stage @ presentation 20% of common neoplasms

    Micro: ? surgery not indicated b/c tumor

     Malignant cytology (salt&pepper has likely metastasized

     chromatin) Responds well to chemo/RT, but low

     No nucleoli 5 yr survival b/c relapses quickly

     High mitotic activity & necrosis

Prognostic Variables:

     1) Non-Small Cell Lung Carcinoma (NSCLC)

     a. Definitely: Stage, performance status, weight loss

     b. Possibly: Gender, ploidy, k-ras mutation, p53 protein accumulation

     c. Not: age, histology

     2) Small Cell Lung Carcinoms (SCLC)

     a. Definitely: State, performance status

     b. Probably: Gender (male worse than female), age, # of metastatic sites

     Primary Lung Radiology: Mean age = 52 Classification Disease Etiology Epidemiology Pathology Clinical Melanoma High Res CT may detect M=F

     bronchial wall mass Must be distinguished from solitary met

    Gross: 5-10% of pts have unknown primary (b/c

     Endobronchial mass (tracheal or bronchial) some primarys regress)

    Micro:

     Highly variable architecture and cytology

     May be unpigmented (amelanotic)

     Mesothelioma Asbestos? Assoc w/ asbestos Radiology:

    exposure Diffuse pleural involvement

     May have assoc effusion

    Micro:

     Malignant

     Deeply invasive growth pattern

     Epithelial, spindle cell, or biphasic

     EM shows long microvilli

     Keratin + by IHC

     Pulmonary Most common Multiple nodules favor mets vs primary

    Metastases neoplasms neoplasms (except BAC)

    involving the lung Can involve pleura and have assoc pleural

     effusion

    Morphology, histology, and physical usually

     identify the primary site, butt assignment of

     primary may require IHC

    Carcinoma Breast, GI, Renal (can metastisize

    anywhere), Head/neck squamous cell

    carcinoma Sarcoma Osteosarcoma

    Soft tissue sarcoma

    (both can involve lung; more common in

    Metastatic Disease kids) Melanoma Radiology: Extrapulmonary primary melanoma much

     Multiple nodules favor mets, but mets can be more common than pulmonary primary

     Solitary melanoma

    Micro: No known primary in 5-10% of cases

     Variable architecture & cytology

     S100 +/- HMB45 reactive

     Neural and Nerve Schwannoma Neoplasms of the Mediastinum Posterior Sheath Neoplasms Neurofibroma Classification Disease Etiology Epidemiology Pathology Clinical Mediastinum Lymphomas Hodgkin’s disease

    Non-Hodgkin’s lymphoma

    Bronchogenic Cysts Non-neoplastic lung Middle Lymphomas Hodgkin’s disease Medastinum Non-Hodgkin’s lymphoma

    Lymphomas Hodgkin’s disease

    Non-Hodgkin’s lymphoma

    Thymoma Assoc w/ Most common tumor in Radiology: 2/3 of MG have/will have a thymoma

    Myasthenia the mediastinum Variable involvement of adjacent organs 1/3 of thymoma pts have/will have MG

    Gravis (MG) (invasive thymomas breach the pleura) Anterior/Superior Micro:

    Mediastinum Thymoma: bland, non-invasive

     Invasive Thymoma: bland but invasive (4 T’s)

     (Thymoma and Invasive Thymoma are

     neoplasms of thymic epithelium)

     Thymic carcinoma; malignant carcinoma

    Teratoma Pediatric

    Thyroid/Parathyroid Endocrine

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