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Small Cell Carcinoma Histology
- Neuroendocrine
- Salt and pepper chromatid and nuclear moulding
- Central
- Little to no cytoplasm
- High mitotic rate (most aggressive)
- Frequent necrosis
- Stains for neurosecretory granules
- Absent or faint nucleolus
- Derived from pluripotent bronchial stem cell or neuroendocrine cell of bronchus
- BCL2 (antiapoptotic) in IHC
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Small Cell Carcinoma Patients
- Smoking
- Metastases at presentation often
- Paraneoplastic syndromes (neurosecretory)
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Small Cell Carcinoma Treatment
- Cannot do surgery
- Initially highly sensitive to chemotherapy and radiation (Limited stage)
- Limited stage is when all masses encompassable in one radiographic port
- Extensive stage (everything else) only chemotherapy
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Non Small Cell Lung Cancer Treatment
- Stage 1 is surgery
- Stage 2 surgery/chemotherapy
- Don’t do surgery if hypercapnic, cor pulmonale, or predicted post surgery FEV1<1.2 L
- Stage 3 radiation and chemotherapy
- Stage 4 chemotherapy and paliative
- Treatment of advanced depends on performance status (PS) give 2 drugs 4-6 cycles
- Adjuvant therapy is post surgical chemotherapy (but is it good?)
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Adenocarcinoma Histology
- Pattern can be acinar, papillary, lepidic or solid (thus solid areas or ground glass areas)
- Gross pleural puckering with solid yellow necrosis, due to peripheral locus with fibrosis retracting (most common)
- Can also be central, difuse pneumonia like or pleural, or peripheral base
- Derived from Clara cell, so mucin producing
- Also can be derived from type 2 pneumocyte
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Adenocarcinoma Patients
- Women more than men
- non smokers (somatic mutation)
- or smokers
- 100% 5 year survival if completely resected
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Squamous Histology
- Kertain producing, intracellular bridges and solid pattern
- Central, involving major bronchi
- Hypercalcemia
- Certain protein targets for immunohistochemistry
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Squamous Patients
Smoking
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Large Cell
- Neuroendocrine
- Prominent nucleoli with lots of cytoplasm
- Can be multinucleate
- Central or peripheral
- Really just an “other” category
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Carcinoid
- Often nested
- Neuroendocrine
- Usually asymptomatic so found incidentally
- Hemoptysis or cough
- Cushing’s syndrome only when metastatic
- MEN1 is rare syndrome
- Typical has no mitosis
- Atypical has some mitosis
- If more than 10 mitoses it’s large cell
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Lung cancer Screening
- Don’t do sputum
- Don’t do CXR
- Do low dose CT if 30 pack years recent/current smoker over 55-80
- Reduced lung cancer mortality 20%, all cause 7%
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Erlotinib
- Inhibits tyrosin kinase associated with EGFR
- Don’t know the mechanism
- 33% improvement in overall survival
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Gefitinib
- Study showed better than other chemodrugs in progression free survival at the one year mark
- Use with EGFR M+ patients
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Crizotinib
- Shrinks tumors in ALK patients
- Adenocarcinoma
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Pancoast’s Tumor
- Superior sulcus (apex)
- Usually squamous cell
- Pain/upper extremity weakness
- Invades brachial plexus
- Horner’s Syndrome: ptosis, miosis, anhidrosis
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Superior Vena Cava Syndrome
- Facial fullness, edema, dilated veins over anterior chest wall
- Usually goes away when you treat cancer
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Paraneoplastic Syndromes
- 20% of patients
- SIADH (too much ADH)
- Cushing (ACTH)
- Hypocalcemia (calcitonin)
- Hypercalcemia (PTH-like factor)
- Lambert-Eaton (similar to myasthenia gravis)
- Hypertrophic Osteoarthopathy pain and clubbing, most common with adenocarcinoma
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Thymoma
- Men and women in their 50s and 60s
- Most asymptomatic
- 1/3 have chest pain, cough, dyspnea, SVC syndrome
- Up to half associated with myasthenia gravis (make sure this is under control before you treat)
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Thymoma Histology
- Grossly lobular and anterior and superior mediastinum
- Epithelial, spindle, and lymphocytes
- Spindle is good prognosis (even with epithelial)
- As you get more epithelial and less lymphocytic, the prognosis gets worse
- Thymic carcinoma epithelial resembling other tissue types
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Thymoma Staging
- WHO Type A Spindle-Good
- AB Spindle and epithelial/lymphocytes-Good
- B1 Lymphocytes and scattered epithelial-Good
- B2 Lymphocytes and epithelial-Fair
- B3 Scattered lymphocytes and epithelial rich-Fair
- C Thymic Carcinoma-Poor
- Masaoka Stage 1 non invasive of capsule of thymus (macro/microscopically)
- Stage 2 invasive of fatty tissue outside thymus or microscopically invades capsule of thymus
- Stage 3 macroscopically invades neighboring organs
- Stage 4 metastases or hematologic spread
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Thymoma treatment
- Surgery for non invasive
- Surgery and radiation with or without chemo for invasive
- Treat thymic carcinoma like carcinoma (aggresively)
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Hodgkins Lymphoma patients and treatment
- Young females
- Often asymptomatic
- B cell symptoms (fever, night sweats, weight loss)
- Low stage is chemo readiation
- High stage is chemotherapy
- Excellent prognosis if early stage
- Acute lymphoblastic leukemia
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Hodgkins lymphoma histology
- Primarily B cells
- Reed sternberg (looks back at you)
- Grossly nodular and sclerosing
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Acute lymphoblastic leukemia patients and treatment
- Most common non-hodgkins lymphoma
- Boys and adolescent males
- Respiratory distress
- SVC syndrome
- Rapidly progressive to leukemic phase
- Intense chemotherapy with or without bone marrow has improved dismal prognosis
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Acute lymphoblastic luekemia histology
- Starry sky appearance
- Mostly T cell
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Teratoma
- Anterior for children and young adults
- Bening or cystic
- Asymptomatic
- Mature can be calcified like teeth and incidental on CXR
- Immature occur mostly in children, presenting with chest pain, cough dyspnea
- Good prognosis mature and immature
- Worse prognosis if other germ cell elements or immature elements or somatic malignancy
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Seminoma (germinoma)
- Males 20s through 40s
- Radiosensitive
- Good prognosis
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True thymic hyperplasia
- Weight of organ higher than expected for age
- Rebound after stressful event (burns, surgery, illness)
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Follicular thymic hyperplasia
- B, T, and lymphoid follicles
- 75% with myasthenia gravis
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Light’s criteria
- pleural protein/serum protein>.5
- pleural LDH/serum LDH>.6
- pleural LDH>2/3 normal serum
- Any of these means exudate
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Parapneumonic pleural effusion criteria
- Complicated if pH <7.1
- LDH>1,000 IU/L
- Glucose<40 mg/dl
- New loculations
- Uncomplicated: pH>7.3
- if pH 7.1-7.3 take serial effusions
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