Difference between revisions of "Lung tumours"

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Lung tumours (view source)

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→‎Adenocarcinoma of the lung: split-out
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=Malignant tumours=
=Malignant tumours=
==Adenocarcinoma of the lung==
==Adenocarcinoma of the lung==
*AKA ''lung adenocarcinoma''.
*[[AKA]] ''lung adenocarcinoma''.
===General===
{{Main|Adenocarcinoma of the lung}}
Treatment:
*Lung adenocarcinoma may be treated with [[EGFR inhibitors]] (e.g. gefitinib (Iressa), erlotinib (Tarceva)).<ref name=pmid20855837>{{cite journal |author=Sun Y, Ren Y, Fang Z, ''et al.'' |title=Lung adenocarcinoma from East Asian never-smokers is a disease largely defined by targetable oncogenic mutant kinases |journal=J. Clin. Oncol. |volume=28 |issue=30 |pages=4616–20 |year=2010 |month=October |pmid=20855837 |doi=10.1200/JCO.2010.29.6038 |url=}}</ref>
 
Patients that receive EGFR inhibitors classically are:<ref name=pmid21151896>{{cite journal |author=Job B, Bernheim A, Beau-Faller M, ''et al.'' |title=Genomic Aberrations in Lung Adenocarcinoma in Never Smokers |journal=PLoS One |volume=5 |issue=12 |pages=e15145 |year=2010 |pmid=21151896 |pmc=2997777 |doi=10.1371/journal.pone.0015145 |url=}}</ref>
*Non-smokers.
*Female.
*Asian.
**Caucasians also benefit.<ref name=pmid20973798>{{Cite journal  | last1 = Rosell | first1 = R. | last2 = Moran | first2 = T. | last3 = Cardenal | first3 = F. | last4 = Porta | first4 = R. | last5 = Viteri | first5 = S. | last6 = Molina | first6 = MA. | last7 = Benlloch | first7 = S. | last8 = Taron | first8 = M. | title = Predictive biomarkers in the management of EGFR mutant lung cancer. | journal = Ann N Y Acad Sci | volume = 1210 | issue =  | pages = 45-52 | month = Oct | year = 2010 | doi = 10.1111/j.1749-6632.2010.05775.x | PMID = 20973798 }}</ref>
 
===Gross===
*Classically peripheral lesions.
*May be multifocal.
 
===Microscopic===
Features:
*Nuclear atypia.
*Eccentrically placed nuclei.
*Abundant cytoplasm - classically with mucin vacuoles.
 
Negatives:
*Lack of intercellular bridges.
 
Patterns:<ref name=pmid21252716>{{cite journal |author=Travis WD, Brambilla E, Noguchi M, ''et al.'' |title=International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma |journal=J Thorac Oncol |volume=6 |issue=2 |pages=244–85 |year=2011 |month=February |pmid=21252716 |doi=10.1097/JTO.0b013e318206a221 |url=}}</ref>
*Lepidic - tumour grows long the alveolar wall; means ''scaly covering''.<ref>URL: [http://medical-dictionary.thefreedictionary.com/lepidic http://medical-dictionary.thefreedictionary.com/lepidic]. Accessed on: 8 August 2013.</ref>
*Acinar - berry-shaped glands.
*Papillary - fibrovascular cores.
*Micropapillary - nipple shaped projections without fibrovascular cores.
*Solid - sheet of cells.
 
Notes:
*[[Lymphovascular invasion]] is common.
*Micropapillary predominant pattern and tumours with any amount of the lepidic pattern are associated with EGFR mutations.<ref name=pmid21970488>{{Cite journal  | last1 = Shim | first1 = HS. | last2 = Lee | first2 = da H. | last3 = Park | first3 = EJ. | last4 = Kim | first4 = SH. | title = Histopathologic characteristics of lung adenocarcinomas with epidermal growth factor receptor mutations in the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society lung adenocarcinoma classification. | journal = Arch Pathol Lab Med | volume = 135 | issue = 10 | pages = 1329-34 | month = Oct | year = 2011 | doi = 10.5858/arpa.2010-0493-OA | PMID = 21970488 }}</ref>
 
DDx:
*[[Metastasis|Metastatic]] adenocarcinoma.
**[[Colorectal adenocarcinoma]].
**Breast adenocarcinoma.
***[[Invasive ductal carcinoma of the breast]].
***[[Invasive lobular carcinoma]].
*[[Squamous cell carcinoma of the lung]].
*[[Non-small cell lung carcinoma]] - diagnosis should be avoid if possible.
*[[Malignant mesothelioma]].
*[[Small cell carcinoma of the lung]].
*Adenocarcinoma in situ.
 
====Images====
<gallery>
Image:Bronchioloalveolar carcinoma, mucinous type 2.jpg |BAC - mucinous type - low mag. (WC/Yale Rosen)
Image:Bronchioloalveolar carcinoma, mucinous type.jpg | BAC - mucinous type - high mag. (WC/Yale Rosen)
</gallery>
www:
*[http://www.pathpedia.com/education/eatlas/histopathology/lung_and_bronchi/bronchioloalveolar_carcinoma_mucinous.aspx BAC mucinous type adjacent to benign (pathpedia.com)].
*[http://cancergrace.org/wp-content/uploads/2007/05/mucinous-vs-nonmucinous-bac-histology.jpg BAC mucinous and nonmucinous (cancergrace.org)].<ref>URL: [http://cancergrace.org/lung/2007/05/14/bac-mucinous-and-non-mucinous/ http://cancergrace.org/lung/2007/05/14/bac-mucinous-and-non-mucinous/]. Accessed on: 8 August 2013.</ref>
 
====Classification====
Classification based on extent:<ref name=pmid21252716>{{cite journal |author=Travis WD, Brambilla E, Noguchi M, ''et al.'' |title=International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma |journal=J Thorac Oncol |volume=6 |issue=2 |pages=244–85 |year=2011 |month=February |pmid=21252716 |doi=10.1097/JTO.0b013e318206a221 |url=}}</ref>
#Adenocarcinoma in situ (AIS) - previously known as [[BAC]].
#*Subtypes: nonmucinous, mucinous, mixed mucinous/nonmucinous.
#Minimally invasive adenocarcinoma (MIA).
#*Lepidic growth with upto 5 mm of invasion.
#*Subtypes: nonmucinous (most common), mucinous, mixed mucinous/nonmucinous.
#Invasive adenocarcinoma:
#*Subtypes: micropapillary, mucinous (previously ''mucinous BAC''), colloid, fetal, enteric.
 
===IHC===
Primary versus metastatic:
*CK7 +ve.
*TTF-1 +ve.
*CK20 -ve.
 
Adenocarcinoma versus SCC:
*TTF-1 +ve.
*p40 -ve.<ref name=pmid22056955>{{Cite journal  | last1 = Bishop | first1 = JA. | last2 = Teruya-Feldstein | first2 = J. | last3 = Westra | first3 = WH. | last4 = Pelosi | first4 = G. | last5 = Travis | first5 = WD. | last6 = Rekhtman | first6 = N. | title = p40 (ΔNp63) is superior to p63 for the diagnosis of pulmonary squamous cell carcinoma. | journal = Mod Pathol | volume = 25 | issue = 3 | pages = 405-15 | month = Mar | year = 2012 | doi = 10.1038/modpathol.2011.173 | PMID = 22056955 }}</ref>
*p63 -ve -- occasionally +ve.
 
===Molecular===
*EGFR mutations (typically assessed by PCR) - respond to [[TKI]]s (e.g. [[gefitinib]], [[erlotinib]]) if:<ref name=pmid19680292>{{Cite journal  | last1 = John | first1 = T. | last2 = Liu | first2 = G. | last3 = Tsao | first3 = MS. | title = Overview of molecular testing in non-small-cell lung cancer: mutational analysis, gene copy number, protein expression and other biomarkers of EGFR for the prediction of response to tyrosine kinase inhibitors. | journal = Oncogene | volume = 28 Suppl 1 | issue =  | pages = S14-23 | month = Aug | year = 2009 | doi = 10.1038/onc.2009.197 | PMID = 19680292 }}</ref>
**Exon 19 deletion.
**Exon 21 L858R.
***Natural history of mutation is suspected to have a better prognosis vs. wild-type.<ref>URL: [http://www.mycancergenome.org/mutation.php?dz=nsclc&gene=egfr&code=l858r http://www.mycancergenome.org/mutation.php?dz=nsclc&gene=egfr&code=l858r]. Accessed on: 27 April 2012.</ref>
**KRAS mutations are absent, i.e. ''wild-type KRAS''.<ref>{{Cite journal  | last1 = Pao | first1 = W. | last2 = Wang | first2 = TY. | last3 = Riely | first3 = GJ. | last4 = Miller | first4 = VA. | last5 = Pan | first5 = Q. | last6 = Ladanyi | first6 = M. | last7 = Zakowski | first7 = MF. | last8 = Heelan | first8 = RT. | last9 = Kris | first9 = MG. | title = KRAS mutations and primary resistance of lung adenocarcinomas to gefitinib or erlotinib. | journal = PLoS Med | volume = 2 | issue = 1 | pages = e17 | month = Jan | year = 2005 | doi = 10.1371/journal.pmed.0020017 | PMID = 15696205 }}</ref>
 
*ALK [[chromosomal translocation]] (inv(2)(p21p23) -- EML4-ALK fusion).<ref name=pmid21245935>{{Cite journal  | last1 = Li | first1 = Y. | last2 = Ye | first2 = X. | last3 = Liu | first3 = J. | last4 = Zha | first4 = J. | last5 = Pei | first5 = L. | title = Evaluation of EML4-ALK fusion proteins in non-small cell lung cancer using small molecule inhibitors. | journal = Neoplasia | volume = 13 | issue = 1 | pages = 1-11 | month = Jan | year = 2011 | doi =  | PMID = 21245935 }}</ref>
**Associated with a poor prognosis.<ref name=pmid22134072>{{Cite journal  | last1 = Yang | first1 = P. | last2 = Kulig | first2 = K. | last3 = Boland | first3 = JM. | last4 = Erickson-Johnson | first4 = MR. | last5 = Oliveira | first5 = AM. | last6 = Wampfler | first6 = J. | last7 = Jatoi | first7 = A. | last8 = Deschamps | first8 = C. | last9 = Marks | first9 = R. | title = Worse disease-free survival in never-smokers with ALK+ lung adenocarcinoma. | journal = J Thorac Oncol | volume = 7 | issue = 1 | pages = 90-7 | month = Jan | year = 2012 | doi = 10.1097/JTO.0b013e31823c5c32 | PMID = 22134072 }}</ref>
**Amenable to treatment with TKI.
**See ''[[lung carcinoma with ALK rearrangement]].
 
===Sign out===
====Biopsy====
<pre>
LUNG, LEFT, BIOPSY:
- ADENOCARCINOMA, LEPIDIC GROWTH; INVASION CANNOT BE EXCLUDED IN THIS SMALL SPECIMEN.
</pre>
 
====Resection====
<pre>
LUNG, LEFT UPPER LOBE, LOBECTOMY:
- ADENOCARCINOMA WITH AN ACINAR PATTERN, SOLID PATTERN, MICROPAPILLARY PATTERN
  AND LEPIDIC PATTERN -- PATTERNS IN ORDER OF PREVALENCE.
- MARGINS NEGATIVE FOR MALIGNANCY.
- THREE LYMPH NODES NEGATIVE FOR MALIGNANCY (3 POSITIVE/4).
- PLEASE SEE TUMOUR SUMMARY.
</pre>
 
<pre>
LUNG, RIGHT UPPER LOBE, LOBECTOMY:
- MULTIPLE ADENOCARCINOMAS (x2) WITH AN ACINAR PATTERN, SOLID PATTERN, MICROPAPILLARY PATTERN
  AND LEPIDIC PATTERN -- PATTERNS IN ORDER OF PREVALENCE.
- MARGINS NEGATIVE FOR MALIGNANCY.
- FOUR LYMPH NODES NEGATIVE FOR MALIGNANCY (0 POSITIVE/4).
- LYMPHOVASCULAR INVASION PRESENT.
- PLEASE SEE TUMOUR SUMMARY AND COMMENT.
 
COMMENT:
The histology of the two adenocarcinomas resemble one another and lymphovascular
invasion is present.  These findings favour that the smaller tumor is a metastasis, rather
than a synchronous primary.
</pre>
 
====Micro====
<pre>
Adequacy: scant tissue (<0.5 cm).
Gland formation: focal, poorly formed.
Cell size: large.
Cytoplasm: moderate-to-abundant, grey-eosinophilic.
Nucleus location: eccentric.
Nuclear pleomorphism: moderate.
Nuclear moulding: absent.
Nucleoli: present, prominent.
Nuclear pseudoinclusions: present.
</pre>
 
<pre>
Number of cores: 3.
Length of cores (total): 2.0 cm.
 
Gland formation: present.
Cell size: large.
Cytoplasm: moderate, grey-eosinophilic.
Necrosis: none apparent.
Mucin: none.
 
Nucleus location: eccentric.
Nuclear pleomorphism: moderate.
Nuclear moulding: absent.
Nuclear pseudoinclusions: absent.
Nuclear shape/arrangment: cigar-like/pseudostratified.
Nucleoli: present.
</pre>
 
====Staging note====
*Two small tumours in one lobe is pT3.
*Visceral pleural involvement upgrades small tumours.


==Bronchioloalveolar carcinoma==
==Bronchioloalveolar carcinoma==
Michael
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