Practice question answers Lung and pleural tumors

Practice question answers
Lung and pleural tumors

© Jun Wang, MD, PhD

1. E. Presence of intercellular bridges is consistent with squamous cell differentiation. Irregular contours of the nests and marked pleomorphism are consistent with malignancy. Malignant tumor with squamous cell differentiation in lung is squamous cell carcinoma. Abscess is by definition a collection of pus, but should not have cytological atypia. Adenocarcinomas, including those from lung and colon, have glandular differentiation but not intercellular bridges. Pulmonary small cell carcinoma has solid nests of cells with round to oval molding nuclei and scant cytoplasm.

2. D. p63 is marker for squamous cell differentiation. Calretinin is positive for mesothelioma. Chromogranin is a neuroendocrine marker that is expressed in neuroendocrine tumors, including carcinoid, small cell carcinoma, and olfactory neuroblastoma. CK20 is usually positive for colon adenocarcinoma. TTF-1 is usually positive in adenocarcinomas of lungs.

3. E. Presence of intercellular bridges is consistent with squamous cell differentiation. Any epithelial cells in lymph nodes are highly suggestive of metastasis. None of Hodgkin lymphoma, acute lymphadenitis and chronic lymphadenitis has epithelial cells in the lymph nodes. Adenocarcinomas, including metastatic cancers, have glandular differentiation but not intercellular bridges.

4. E. See discussion in question 1.

5. C. p63 is marker for squamous cell differentiation. CD30 is expressed by Hodgkin lymphoma. Chromogranin is a neuroendocrine marker that is expressed in neuroendocrine tumors, including carcinoid, small cell carcinoma, and olfactory neuroblastoma. TTF-1 is usually positive in adenocarcinomas of lungs. WT-1 is positive for mesothelioma.

6. B. This is a paraneoplastic syndrome presented with hypercalcemia. Absence of malignant changes in bone ruled out bone metastasis. The primary tumor is a squamous cell carcinoma. Hypercalcemia in a lung squamous cell carcinoma is usually caused by cancer production of parathyroid hormone-related protein.

7. A. Malignant tumor with glandular differentiation is adenocarcinoma. Hodgkin lymphoma has no glandular components. Metastatic renal cell carcinoma does not have glandular pattern and is negative for TTF-1. Small cell carcinoma has solid nests of cells with round to oval molding nuclei and scant cytoplasm. Squamous cell carcinoma has squamous differentiation characterized by intercellular bridges and keratin pearls.

8. D. EGFR testing is important for adenocarcinoma for therapeutic purpose. Chromogranin is a neuroendocrine marker that is expressed in neuroendocrine tumors, including carcinoid, small cell carcinoma, and olfactory neuroblastoma. Colloid iron is positive in chromophobe type renal cell carcinoma. EB virus is associated with nasopharyngeal carcinoma, primary effusion lymphoma, extranodal NK/T cell lymphoma, nasal type, and Burkitt lymphoma, etc, but not adenocarcinoma of lung. Sputum microbiology studies are used for infectious process.

9. C. This is a case of Horner syndrome that can be seen in malignant neoplasms of lungs.
It is caused by irritation of sympathetic nerve supply by tumor. Autoantibody against postsynaptic acetylcholine receptor is seen in myasthenia gravis. Autoantibody against presynaptic voltage-gated calcium channels is seen in Lambert-Eaton myasthenic syndrome, a paraneoplastic syndrome associated with small cell carcinoma. Disruption of cranial nerve III and metastatic tumor to right orbit will likely cause abnormal eye movement.

10. B. EGFR mutation can be seen in adenocarcinoma of lungs. BHD mutation is associated with renal oncocytoma and chromophobe type renal cell carcinoma. NF1 is associated with neurofibromatosis. VHL is associated with von Hippel-Lindau syndrome and clear cell type renal cell carcinoma. Abnormality of WT-1 is seen in Wilms tumor.

11. B. Marked pleomorphism is more consistent with large cell carcinoma. Diffuse large B cell lymphoma and Hodgkin lymphoma are negative for cytokeratin. Small cell carcinoma has solid nests of cells with round to oval molding nuclei and scant cytoplasm. Squamous cell carcinoma has squamous differentiation characterized by intercellular bridges and keratin pearls.

12. C. See discussion in question 11.

13. B. Chromogranin is a neuroendocrine marker that is expressed in neuroendocrine tumors, including carcinoid, small cell carcinoma, and olfactory neuroblastoma. CD30 is expressed by Hodgkin lymphoma. Cyclin D1 is positive in mantle cell lymphoma. p63 is marker for squamous cell differentiation. WT-1 is positive in Wilms tumor and mesothelioma.

14. D. Any epithelial cells in lymph nodes are highly suggestive of metastasis. These tumor cells are positive for CK7 and TTF-1, consistent with adenocarcinoma of lungs. Acute lymphadenitis has neutrophilic infiltrate, but not epithelial cells in the lymph nodes. Diffuse large B cell lymphoma is negative for cytokeratin. CK20 positivity is commonly seen in colon cancer. Squamous cell carcinoma has squamous differentiation characterized by intercellular bridges and keratin pearls.

15. B. Distended veins, facial swelling are suggestive of superior vena cava syndrome that can be seen in malignant neoplasms of lungs. Obstruction of lymph may cause edema, as seen in inflammatory breast cancers, but usually not distended vessels. Congestive heart failure more likely have edema in lower instead of upper extremities.

16. D. Tumor of nests of small to intermediate sized cells with molding nuclei and scant cytoplasm is most consistent with small cell carcinoma, a malignant lung tumor highly associated with cigarette smoking. Carcinoid tumors express cytokeratin and neuroendocrine markers, but have decent amount cytoplasm. Hodgkin lymphoma have Reed Sternberg cells and are negative for cytokeratin. Myasthenia gravis usually have involvement of extraocular, bulbar muscles, besides proximal limbs. Squamous cell carcinoma has squamous differentiation characterized by intercellular bridges and keratin pearls.

17. B. Autoantibody against presynaptic voltage-gated calcium channels is seen in Lambert-Eaton myasthenic syndrome, a paraneoplastic syndrome associated with small cell carcinoma. Autoantibody against postsynaptic acetylcholine receptor is seen in myasthenia gravis. Local irritation of sympathetic nerve supply is seen in Horner syndrome. Anemia and hypercalcemia usually have more systemic presentations.

18. C. The morphological features and co-expression of cytokeratin and vimentin are consistent with metastatic clear cell renal cell carcinoma. Metastasis of renal cell carcinoma can occur at any time, anywhere. Adenocarcinoma of lung is positive for CK7 and TTF-1. Mesothelioma usually has pleural thickening. Squamous cell carcinoma has squamous differentiation characterized by intercellular bridges and keratin pearls.

19. B. Well differentiated tumor with neuroendocrine differentiation is consistent with carcinoid. Adenocarcinoma has glandular differentiation. Hodgkin lymphoma have Reed Sternberg cells and are negative for cytokeratin. Small cell carcinoma has solid nests of cells with round to oval molding nuclei and SCANT cytoplasm. Squamous cell carcinoma has squamous differentiation characterized by intercellular bridges and keratin pearls.

20. C. Pleural thickening and the presence of markedly atypical cells is highly suggestive of mesothelioma, as confirmed by positive reactivity to CK5/6 and WT-1. Adenocarcinoma of lung is positive for CK7 and TTF-1. Empyema is characterized by large amount of neutrophils, but not markedly atypical cells. Primary effusion lymphoma is a B cell lymphoma that is positive for CD20, but negative for cytokeratin. Squamous cell carcinoma of lung is usually centrally located and negative for calretinin.

21. A. The most important risk factor for mesothelioma is asbestosis exposure. Pay attention to history of shipyard working, construction, etc. EB virus is associated with nasopharyngeal carcinoma, primary effusion lymphoma, extranodal NK/T cell lymphoma, nasal type, and Burkitt lymphoma, etc, but not mesothelioma. HHV8 is associated with primary effusion lymphoma.

22. D. Pleural based spindle cell tumor with “staghorn” vessels, CD99 expression is most compatible with solitary fibrous tumor. Adenocarcinoma of lung is positive for cytokeratin and TTF-1. Mesothelioma can be sarcomatoid, but usually are positive for calretinin and WT-1. Small cell carcinoma has solid nests of cells with round to oval molding nuclei and scant cytoplasm. Squamous cell carcinoma has squamous differentiation characterized by intercellular bridges and keratin pearls. Both are commonly centrally located, and rarely pleural based.




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