Difference between revisions of "Non-small cell lung carcinoma"

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'''Non-small cell [[lung]] carcinoma''', abbreviated '''NSCLC''', is a malignant epithelial neoplasm that is ''not'' [[small cell carcinoma of the lung]].   
{{ Infobox diagnosis
| Name      = {{PAGENAME}}
| Image      = Non-small cell lung carcinoma -- high mag.jpg
| Width      =
| Caption    = Non-small cell lung carcinoma. [[H&E stain]].
| Synonyms  = large cell carcinoma (term discouraged in the context of biopsies & FNAs)
| Micro      =
| Subtypes  = NSCC favour adenocarcinoma, NSCC favour squamous cell carcinoma, NSCC-not otherwise specified
| LMDDx      = [[lung adenocarcinoma]], [[squamous cell carcinoma of the lung|lung squamous carcinoma]], [[lung small cell carcinoma]], poorly differentiated metastatic [[carcinoma]], other poorly differentiated neoplasms
| Stains    =
| IHC        = pankeratin +ve, [[CD56]] -ve, chromogranin A -ve, synaptophysin -ve, [[TTF-1]] +ve/-ve, [[p63]] +ve/-ve
| EM        =
| Molecular  =
| IF        =
| Gross      =
| Grossing  =
| Staging    = [[lung cancer staging]]
| Site      = [[lung]] - see ''[[lung tumours]]''
| Assdx      =
| Syndromes  =
| Clinicalhx = no history of malignancy or no suspicion of recurrence
| Signs      =
| Symptoms  = +/-hemopytsis, +/-dyspnea
| Prevalence = uncommon
| Bloodwork  =
| Rads      = not suggestive of metastatic disease
| Endoscopy  =
| Prognosis  = usually poor
| Other      =
| ClinDDx    = other [[lung tumours]]
| Tx        = surgery if feasible
}}
'''Non-small cell lung carcinoma''', abbreviated '''NSCLC''', is a [[carcinoma|malignant epithelial neoplasm]] of the [[lung]] that is ''not'' [[small cell carcinoma of the lung]].   


It can be understood as a synonym for ''large cell carcinoma'' which is umbrella term that includes [[squamous cell carcinoma of lung]] and [[adenocarcinoma of the lung]].
It is umbrella term that includes [[squamous cell carcinoma of lung]], [[adenocarcinoma of the lung]] and [[adenosquamous carcinoma of the lung]].<ref>{{Cite journal  | last1 = Song | first1 = Z. | last2 = Lin | first2 = B. | last3 = Shao | first3 = L. | last4 = Zhang | first4 = Y. | title = Therapeutic efficacy of gefitinib and erlotinib in patients with advanced lung adenosquamous carcinoma. | journal = J Chin Med Assoc | volume = 76 | issue = 9 | pages = 481-5 | month = Sep | year = 2013 | doi = 10.1016/j.jcma.2013.05.007 | PMID = 23769878 }}</ref>
 
It is also known as '''large cell carcinoma'''; however, usage of ''large cell carcinoma'' is discouraged in the context of lung biopsies and [[pulmonary cytopathology|lung cytopathology]] specimens.<ref name=pmid22970842>{{Cite journal  | last1 = Travis | first1 = WD. | last2 = Brambilla | first2 = E. | last3 = Noguchi | first3 = M. | last4 = Nicholson | first4 = AG. | last5 = Geisinger | first5 = K. | last6 = Yatabe | first6 = Y. | last7 = Ishikawa | first7 = Y. | last8 = Wistuba | first8 = I. | last9 = Flieder | first9 = DB. | title = Diagnosis of lung cancer in small biopsies and cytology: implications of the 2011 International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society classification. | journal = Arch Pathol Lab Med | volume = 137 | issue = 5 | pages = 668-84 | month = May | year = 2013 | doi = 10.5858/arpa.2012-0263-RA | PMID = 22970842 }}</ref>
 
In the clinical context, it is often referred to as '''non-small cell lung cancer'''; this ignores the fact that not all non-small cell lung cancer fits into the [[carcinoma]] category.
 
''Poorly differentiated carcinoma of the lung'', ''non-small cell carcinoma'' and ''poorly differentiated lung carcinoma'' redirect to this article.
 
==General==
*''Non-small cell lung carcinoma'' can be considered a [[waffle diagnosis]] and as such its use should be limited.
**It is preferable to be more specific if this is possible, i.e. call ''adenocarcinoma'' or ''squamous cell carcinoma''.
*Historically, it was sufficient to differentiate between [[small cell carcinoma of the lung|small cell]] and non-small cell carcinomas, as the treatment for all non-small cell lung carcinomas was the same.
*''Small cell carcinoma'' is typically considered non-surgical disease; thus, ''non-small cell carcinoma'' or ''poorly differentiated carcinoma'', as a diagnosis, is less likely to exclude surgery as an option.
 
Clinical:
*Radiologic findings should not be suggestive of a metastasis.
*No history of malignancy or no suspicion of recurrence.
*+/-Hemopytsis.
*+/-Dyspnea.
 
==Microscopic==
Features:
*Typically large cells with abundant cytoplasm.
*+/-[[Nucleoli]].
*No stippled chromatin.
 
DDx:
*[[Squamous cell carcinoma of the lung]].
*[[Adenocarcinoma of the lung]].
*[[Small cell carcinoma of the lung]].
*Large cell variant of [[small cell carcinoma of the lung]].
*[[Lung metastasis]] - imaging suggestive of a metastasis or a history of malignancy.
*[[Malignant melanoma]].
*Other poorly differentiated neoplasms
 
===Grading===
*''NSCC-NOS'', ''NSCC favour adenocarcinoma'', ''NSCC favour SCC'' are grade 4.
 
Note:
*In a large series of patients, there is no statistical difference in survival been grade 3 and grade 4.<ref name=pmid16678584>{{Cite journal  | last1 = Sun | first1 = Z. | last2 = Aubry | first2 = MC. | last3 = Deschamps | first3 = C. | last4 = Marks | first4 = RS. | last5 = Okuno | first5 = SH. | last6 = Williams | first6 = BA. | last7 = Sugimura | first7 = H. | last8 = Pankratz | first8 = VS. | last9 = Yang | first9 = P. | title = Histologic grade is an independent prognostic factor for survival in non-small cell lung cancer: an analysis of 5018 hospital- and 712 population-based cases. | journal = J Thorac Cardiovasc Surg | volume = 131 | issue = 5 | pages = 1014-20 | month = May | year = 2006 | doi = 10.1016/j.jtcvs.2005.12.057 | PMID = 16678584 }}</ref>
 
===Images===
<gallery>
Image: Non-small cell lung carcinoma -- low mag.jpg | NSCLC - low mag. (WC)
Image: Non-small cell lung carcinoma -- intermed mag.jpg | NSCLC - intermed mag. (WC)
Image: Non-small cell lung carcinoma -- high mag.jpg | NSCLC - high mag. (WC)
Image: Non-small cell lung carcinoma -- very high mag.jpg | NSCLC - very high mag. (WC)
Image: Non-small cell lung carcinoma - alt -- very high mag.jpg | NSCLC - very high mag. (WC)
</gallery>
 
==IHC==
Features:
*Lack of staining with [[neuroendocrine markers]] (chromogranin A -ve, synaptophysin -ve, CD56 -ve).
*Keratins +ve.
 
Note:
*If immunostains favour adenocarcinoma or squamous cell carcinoma, the case should be sign as ''favour adenocarcinoma'' or ''favour squamous cell carcinoma'', see ''Sloan-Kettering algorithm'' below and ''Sign out'' section.
 
===Adenocarcinoma versus squamous carcinoma===
Memorial Sloan-Kettering algorithm - Rekhtman ''et al.'':<ref name=pmid21623384>{{Cite journal  | last1 = Rekhtman | first1 = N. | last2 = Ang | first2 = DC. | last3 = Sima | first3 = CS. | last4 = Travis | first4 = WD. | last5 = Moreira | first5 = AL. | title = Immunohistochemical algorithm for differentiation of lung adenocarcinoma and squamous cell carcinoma based on large series of whole-tissue sections with validation in small specimens. | journal = Mod Pathol | volume = 24 | issue = 10 | pages = 1348-59 | month = Oct | year = 2011 | doi = 10.1038/modpathol.2011.92 | PMID = 21623384 }}</ref>
{| class="wikitable sortable"
! TTF-1\p63
! p63 -ve (0% of cells)
! p63 +ve <50% of cells
! p63 +ve >=50% of cells
|-
| TTF-1 +ve >=50% of cells
| [[adenocarcinoma of the lung|Adenocarcinoma]]
| Adenocarcinoma
| Adenocarcinoma
|-
| TTF-1 +ve <50% of cells
| Adenocarcinoma
| Adenocarcinoma
| [[Lung SCC|Squamous carcinoma]]
|-
| TTF-1 -ve (0% of cells)
| Adenocarcinoma
| CK5/6 to determine
| Squamous carcinoma
|}
 
==Sign out==
International consensus terminology - Travis ''et al''.:<ref name=pmid22970842>{{Cite journal  | last1 = Travis | first1 = WD. | last2 = Brambilla | first2 = E. | last3 = Noguchi | first3 = M. | last4 = Nicholson | first4 = AG. | last5 = Geisinger | first5 = K. | last6 = Yatabe | first6 = Y. | last7 = Ishikawa | first7 = Y. | last8 = Wistuba | first8 = I. | last9 = Flieder | first9 = DB. | title = Diagnosis of lung cancer in small biopsies and cytology: implications of the 2011 International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society classification. | journal = Arch Pathol Lab Med | volume = 137 | issue = 5 | pages = 668-84 | month = May | year = 2013 | doi = 10.5858/arpa.2012-0263-RA | PMID = 22970842 }}</ref>
{| class="wikitable sortable"
! Diagnosis
! Stains
|-
| Non-small cell carcinoma, favour adenocarcinoma
| [[TTF-1]] or napsin +ve
|-
| Non-small cell carcinoma, favour squamous cell carcinoma
| [[p40]] or [[p63]] +ve
|-
| Non-small cell carcinoma-not otherwise specified
| -ve NE stains, -ve SCC stains, -ve adenoca stains
|}
 
===Not otherwise specified===
<pre>
Lung, Left Lower Lobe, Core Biopsy:
- NON-SMALL CELL CARCINOMA-NOT OTHERWISE SPECIFIED, see comment.
 
COMMENT:
The tumour stains as follows:
POSITIVE: EMA, AE1/AE3.
NEGATIVE: TTF-1, chromogranin A, synaptophysin, CD56, CD45, CK5/6, p63.
 
The morphology would be compatible with small cell carcinoma or basaloid
squamous cell carcinoma. 
 
The neuroendocrine markers (chromogranin A, synaptophysin, CD56) and the squamous
markers (p63, CK5/6) are negative; thus, the tumour is not further classified.
</pre>
 
===Favour squamous===
<pre>
Lung, Left Upper Lobe, Core Biopsy:
- NON-SMALL CELL CARCINOMA, favour squamous cell carcinoma, see comment.
 
Comment:
The tumour stains as follows:
POSITIVE: AE1/AE3, CK5/6, CK7.
NEGATIVE: TTF-1, napsin A, p63, CDX2, CK20, S-100.
 
EGFR/ALK testing has been ordered.
 
The immunostains favour squamous cell carcinoma.
</pre>
 
==See also==
*[[Lung tumours]].
*[[SUV]].
*[[Sarcomatoid carcinoma of the lung]].
 
==References==
{{Reflist|1}}


[[Category:Pulmonary pathology]]
[[Category:Pulmonary pathology]]
[[Category:Diagnosis]]
Michael
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