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Oncology - Lung CA (dropped image link (*NSCLC = NON small cell carcinoma
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Oncology - Lung CA
*Pancoast Tumours
- in the apex of the lungs
- involve the brachial plexus
- cervical sympathetic chain = Horners
--> PAM triad = ptosis, anhydrosis, myosis (pinpoint pupils)
- scapula and axilla pain
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*Cervical Gangliona nd Pancoast tumors
- note the 3 neuron pathway for sympathetic to the face and eyes that is affected in Pancoast tumors
- first order neuron = descends to c8-T1
- second order ascends to cervical ganglion to synapse with 3rd order
- 3rd order neuron then ascends with the internal carotid and joins into a bundle with opthalmic divion = v1 of CN 5 to go to the eye and face
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*NSCLC = NON small cell carcinoma
- includes all other types of lung cancer other than SCLC
- adenocarcinoma is the most common of all primary lung cancers and is actually NOT caused by smoking
*Adenocarcinoma
- adenocarcinoma is the most common of all primary lung cancers and is actually NOT caused by smoking
- "ADENOCARCINOMA = HADDA NO SMOKES... but had EATEN ALK or peripheral smoke"
--> women non-smokers
--> EGFR and ALK gene mutations are the cause of adenocarcinoma
--> PPPs = peripheral tumours with prolactinemia
- "KRAS smokers can get ADENOCARCINOMA"
--> these are the exception to the rule of smokers lung CA
--> KRAS mutation in smokers gives Adenocarcinoma
Notes:
- NEVER rule out Adenocarcinoma as a lung CA causes
--> even if they are a smoker
--> smoking still increases the chance of this CA
- ALWAYS remember adenocarcinoma makes up half = 50% of cases of lung CAs
Histopathology of Lung Adenocarcinoma
- glandular cells
- large cytoplasm with irregularly placed nuclei
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*Sqamous cell carcinoma
- SCLC and Sqamous CLC go together
- both are Sentral and caused by smoking
-- squamus has poor prognosis
- "SQCCCuamous QC = QUAD C of SQCCCuamous cell lung CA"
--> calcemia high, cigarettes, cavitation, CENTRAL
*squamous Cell metaplasia
- precursor to squamous cell carcinoma
- normal bronchial pseudostratisfied ciliated columnar cells line the bronchioles
--> have goblet cells and ciliated cells for mucus production and mucociliary escalaotr
- with chronic irritants like smoke
--> sqaumous cell metaplasia is protective at first since the cells can shed and are more resistant to damage from the smoke
--> this is reversible
- but later leads to squamous CLA if don't stop smoking
- SC metaplasia is the exact same process as Barret's esophagus (= squamous --> columnar gastric metaplasia) and esophageal cancer
-
*SCC = small cell carcinoma
- SCLC and Sqamous CLC go together
- both are Sentral and caused by smoking
--> note also that large cell is caused by smoking as well and is the worst prognosis
- SMALL cell carcinomas = SCA + SMALL --> SMOKING, SSENTRAL and AGGRESSIVE / SECRETE ALL the As
- neuroendocrine markers = neural celld adhesion molecule
- SIADH = ADH, ACTH (Cushing), Chromagramin A
- SMALL = small MYCky mouse + ALL = Lambert-Eaton Myasthenia syndrome
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SMALL cell carcinomas = SCA + SMALL --> SMOKING, SSENTRAL and AGGRESSIVE / SECRETE ALL the As
- SCLC and sqamous are SENTRAL and caused by SMOKING
- neuroendocrine As
--> ACTH = Cushing's syndrome
--> CHromogranin A
--> ADH (SIADH)
SMALL MYCy Mouse
--> Amplification of MYC oncogene
- LAAAAmbert-Eaton Myasthenia Antibodies to calcium channels
--> hypocalcemia
LAb markers for SC CA with ADH neuroendocrine = SIADH
- SIADH triad
--> serum osmolarity low
-->urine osmolarity high > 100 mOs
--> hyponatremia = low Na
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*Carcinoid Syndrome / Tumors
- see notes in Oncology
- best prognosis out of all lung cancers
- CARCINOID is in the name
Clinical Cases
Carcinoid Tumors
- can be either typical = benign (most = 90%) or atypical = malignant
-
Notes:
- Carcinoid tumors are a more rare type of tumor
- they can present anywhere in the body, but are most commonly in the lungs or GI tract (usually stomach or intestines)
- they develop from uncontrolled growth of neuroendocrine cells so they have many secretions
--> mostly secrete serotonin 5 -ht
--> excess serotonin 5 -ht leads to carcinoid syndrome
- note that most carcinoid tumors are typical = meaning they are slow growing and do not invade other tissues or metastasize
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Carcinoid Syndrome
- includes flushing and diarrhea, and less frequently, heart failure, emesis and bronchoconstriction
- note that the patient in the clinical case has no signs of flushing, emesis or diarrhea
--> are these from GI carcinoids?
--> he presented with hematemesis, and Hx of pneumonia from bronchoconstriction
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Lung Cancers are SPHERES in the lungs that
--> "cause a SPHERE of blockages and problems"
- S = SVC Syndrome compression
- P = pancoast tumor (compress brachial plexus)
--> present with hoarseness of the voice
- H = Horner Sydrome (CN 7 = facial nerve compression)
- E = Endocrine (Carcinoid, smAALL A CA markers)
- R = recurrent laryngeal compression
- E = effusions (general)
*Mesothelioma
- CA of the lung pleura
- caused almost always by asbestos exposure
- positive labs for cytokeratin and calretinin
- "asbestos is in the middle = MESO of work CYTES (nobody Kares...) and CALL centres"
- mesothelioma from asbestos
- work CYTES = cytokeratin
- CALL centres = calretinin
Mesothelioma Signs and presenting complaint
- exudative and HEMORRHAGIC constant pleural effusions
- present with a PROGRESSIVE dyspnea, NON-productive cough, chest pain
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CT - mesothelioma unilateral pleural thickenning
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Organ *Transplant Rejection
- Hyperacute Rejection
- Acute Rejection
- Chronic Rejection
Acute Transplant Rejection
- .>= 6 months post transplant
-
Hyperacute Transplant Rejection
- minutes to hours post transplant
- "white graft rejection" in the lungs
Chronic Transplant Rejection
- .>= 6 months post trasnplant
- within 5 years of LUNG transplants 50% will have chronic rejection
- starts with lymphocyte infiltration of the small airways
- then fibrosis and scarring of the bronchioles
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Lung CA *Differential Map
Smoker?
NON-smoker with lung CA
NON-small cell lung CA
- Adenocarcinoma = most common lung CA in BOTH NON-smokers and also OVERALL
--> so even smokers can have Adenocarcinoma
get XRAY
SENTRAL or Peripheral?
CENTRAL lung CA in NON-smoker
- this would be rare to have a central lung CA in NON-smoker
- but is still possible
PERIPHERAL lung CA in a NON-smoker
- most likely adenocarcinoma since most common in NON-smokers
--> plus OVERALL
--> can still happen in smokers
- need to do biopsy to rule out
--> adenocarcinoma? ------ subtype?
--> Bronchiole Alveolar?
--> Bronchiole Carcinoid?
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SMOKER with lung CA
- SENTRAL / CENTRAL
- +/- Syndrome
-
get XRAY
SENTRAL or Peripheral?
PERIPHERAL lung CA in a smoker
- most likely adenocarcinoma since most common overal
- can still happen in smokers
-
CENTRAL lung CA in a SMOKER
- SENTRAL / CENTRAL
- +/- Syndrome
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Secreting something?
Serotonin = 5-ht
- 5-HIAA metaabolite in the urine
Carcinoid ---- Non-small cell lung CA
- gives carcinoid syndrome
- high 5-ht and 5-HIAA metaabolite in the urine
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