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Procedure Advantages Disadvantages
Endobronchial ultrasound (EBUS)
  • Direct visualization of lymph node stations.
  • Complements EUS: covers lymph node stations 2R and 4R which are difficult to access by EUS
  • Lower false-negative rate than with blind transbronchial FNA and fewer complications
  • More invasive than EUS, few practitioners, but rapidly growing in popularity
Endoscopic ultrasound (EUS)
  • Least invasive modality
  • Uses the esophagus to access mediastinal lymph nodes
  • Excellent for staging lymph nodes
  • Useful for station 2L and 4L, L adrenal, celiac lymph node
  • Cannot reliably access right sided paratracheal lymph node stations 2 R and 4R
  • Accurate discrimination of primary hilar tumors and involved lymph nodes is important




Differential Diagnosis Similar Features Differentiating Features
Pulmonary tuberculosis Chronic cough, weight loss, hemoptysis, nocturnal diaphoresis, dyspnea In pulmonary tuberculosis, differentiating features include: increase in diameter despite optimal medical therapy, patients age is usually younger, hemoptisis is an early feature, and CXR anatomical predilection for upper lobes
Lung abscess Chronic cough, weight loss, hemoptysis, and dyspnea In lung abscess, differentiating features include: acute or subacute onset, CXR anatomical predilection for upper lobes, and usually resolve with antibiotic
Pneumonia Chronic cough, weight loss, hemoptysis, and dyspnea In pneumonia, differentiating features include: good response to antibiotics, acute onset, predilection on CXR is consolidation, laboratory markers indicate infection.
Fungal infection Chronic cough, weight loss, hemoptysis, and dyspnea In fungal infection, differentiating features include: CXR findings: air-cresecent sign, no response to antibioitcs, and mimcs tuberculosis.
Chronic eosinophilic pneumonia Chronic cough, weight loss, hemoptysis, and dyspnea In chronic eosinophilic pneumonia , differentiating features include: followed by a parasite infection or medication exposure, and increased serum IgE levels


Age-adjusted incidence of lung cancer by histological type
Adapted from Wikipedia [1]
All types 66.9
Adenocarcinoma 22.1
Squamous-cell carcinoma 14.4


Age-adjusted incidence of lung cancer by histological type
Adapted from Wikipedia [1]
Type Incidence per 100,000 per year
All types

66.9

Adenocarcinoma

22.1

Squamous-cell carcinoma

14.4



Classification: Mucoepidermoid Carcinomas
Adapted from Radiopedia [2]
Salivary gland-confined carcinomas
  • Major salivary glands (50%)
  • Parotid gland (40%)
  • Submandibular gland (7%)
  • Sublingual gland (3%)
  • Minor salivary glands (50%)
  • Palate (most common)
  • Retromolar area
  • Floor of the mouth
  • Buccal mucosa
  • Lip
  • Tongue
Other organ mucoepidermoid carcinomas
  • Thyroid
  • Lung



WHO histological classification system
Adapted from WHO/IARC (2006) [2]
Main types Subtypes Prevalence
Adenocarcinoma
  • Adenocarcinoma, mixed
  • Acinar adenocarcinoma
  • Papillary adenocarcinoma
  • Bronchioloalveolar carcinoma
  • Nonmucinous
  • Mucinous
  • Mixed nonmucinous and mucinous or indeterminate
  • Solid adenocarcinoma with mucin production
  • Fetal adenocarcinoma
  • Mucinous (“colloid”) carcinoma
  • Mucinous cystadenocarcinoma
  • Signet ring adenocarcinoma
  • Clear cell adenocarcinoma
  • 40% of lung cancers
Squamous cell carcinoma
  • Papillary
  • Clear cell
  • Small cell
  • Basaloid
  • 25% of lung cancers
Large cell carcinoma
  • Large cell neuroendocrine carcinoma
  • Basaloid carcinoma
  • Lymphoepithelioma-like carcinoma
  • Clear cell carcinoma
  • Large cell carcinoma with rhabdoid phenotype
  • 10% of lung cancer
Less common types
Adenosquamous carcinoma
  • No subtypes
  • Less than 5%
Sarcomatoid carcinoma
  • Pleomorphic carcinoma
  • Spindle cell carcinoma
  • Giant cell carcinoma
  • Carcinosarcoma
  • Pulmonary blastoma
  • Less than 5%
Carcinoid tumor
  • Typical carcinoid
  • Atypical carcinoid
  • Less than 5%
Salivary gland tumor
  • Mucoepidermoid carcinoma
  • Adenoid cystic carcinoma
  • Epithelial-myoepithelial carcinoma
  • Less than 5%



Genes Presence in non small cell-lung cancers
EGFR
  • EGFR mutations are present in approximately 10% to 15% of all non-small cell lung cancers
KRAS
  • Mutations are present in approximately 30% of pulmonary adenocarcinomas
  • Mutations are present in approximately 5% of pulmonary squamous cell carcinomas
  • Associated with carcinomas with mucinous histology
ALK
  • Mutations are present in approximately 5% of all non-small cell lung cancers
HER2
  • Mutations are present in approximately 4% of adenocarcinomas
BRAF
  • Mutations are present in less than 2% of adenocarcinomas
ROS-1
  • Mutations are present in less than 2% of adenocarcinomas


Classification
Adapted from Radiopedia [2]

Salivary gland-confined carcinomas
  • Major salivary glands (50%)
  • Parotid gland (40%)
  • Submandibular gland (7%)
  • Sublingual gland (3%)
  • Minor salivary glands (50%)
  • Palate (most common)
  • Retromolar area
  • Floor of the mouth
  • Buccal mucosa
  • Lip
  • Tongue
Other organ mucoepidermoid carcinomas
  • Thyroid
  • Lung




Mucoepidermoid carcinoma staging
Adapted from American Joint Committee on Cancer (AJCC). 1998 [3]

Tumor
  • T1 - 2cm or less w/o extraparenchymal extension
  • T2 - >2cm but not greater than 4cm; and w/o extraparenchymal extension
  • T3 - >4cm or with extraparenchymal extension
  • T4a - invades skin,mandible, ear canal or facial nerve
  • T4b - invades skull base, pterygoid plates or encases carotid
Nodes
  • NX - Cannot be assessed
  • N0 - No regional lymph nodes metastasis
  • N1 - Single ipsilateral lymph node, <= 3cm in greatest dimension
  • N2
  • N2a - Single ipsilateral lymph node, 3-6 cm in greatest dimension
  • N2b - Multiple ipsilateral lymph nodes, <= 6cm in greatest dimension
  • N2c - Bilateral or contralateral lymph nodes, <= 6cm in greatest dimension
  • N3 - Lymph node(s) >6 cm in greatest dimension
Overall stage
  • I - T1 N0
  • II - T2 N0
  • III - T3 N0-1, or T1-3 N1
  • IVA - T4a N0-2, or T1-4a
  • IVB - T4b N0-3, or T1-4b N3
  • IVC - M1


Differential Diagnosis Similar Features Differentiating Features
Benign mixed tumor Painless parotid swelling and facial deformity In benign mixed tumor , differentiating features include: histopathological findings
Warthin tumor Painless swelling and facial deformity In warthin tumor differentiating features include: multicentric presentation (20%) and are usually small (1-4 cm), highly associated with smoking
Adenoid cystic carcinoma Swelling on salivary gland and facial deformity In adenoid cystic carcinoma, differentiating features include: tendency for perineural extension, distribution, and mainly occur in relation to the airways
Metastasis Painless swelling and facial deformity In metastasis, differentiating features include: primary tumor origin, and histopathological findings.



Type of tumor Age Location Histological features Imaging features Origin Bone/Cartilage
Osteoma 40-50 years Skull bones Matured lamellar bone Sclerotic Benign Bone
Osteoid osteoma 10-20 years Short and long bone diaphysis Osteiod outlined by osteoblasts, incorporated in a fibrous stroma Sclerotic Benign Bone
Osteosarcoma 11-40 years Long bones metaphysis Osteoid and bone formed of malignant osteoblasts and fibroblasts Sclerotic Malignant Bone
Chondroma 30-60 years Small tubular bones of the hands and feet Maturated hyaline cartilage (enchondroma/ecchondroma), preserving lobulation Well-defined Malignant Cartilage
Chondrosarcoma 30-60 years Long bones metaphysic, axial skeleton Immature cartilage, no preserving lobulation, cells arranged in groups of two or four, with atypia and mitosis Well-defined Malignant Cartilage
Ewing sarcoma 5-25 years Long bones diaphysis Small, round, undifferentiated cells, no stroma, a lot of capillary arrangement. Ill-defined Malignant Bone
Giant cell tumor 20-40 years Knee Multinucleated giant cells, fusiform cells, mononuclear cells. Well-defined Malignant Bone
Metastases 50-90 years No site predilection Frequently adenocarcinomas. Metastases can be blastic or lytic depending on the tumor origin Sclerotic Malignant Bone





Stage Description
I
  • Inactive or static lesions
II
  • Actively growing lesions
  • Most osteochondromas occur in this stage.
III
  • Actively growing lesions that are locally destructive/aggressive
  • Deformity secondary to mass effect
  • Malignant degeneration
  • Low-grade chondrosarcoma


Differential Diagnosis Similar Features Differentiating Features
Enchondroma
  • Usually found in children, enchondromas are asymptomatic
  • These tumors arise from rests of growth plate
  • Located in the metaphyseal region
  • In enchondroma, differentiating features include:
  • Imaging features, such as endosteal scalloping, well circumscribed masses, and lytic lessions
Chondroblastoma
  • Benign cartilaginous neoplasm
  • Affects young patients
  • Located on long bones
  • In chondroblastoma, differentiating features include:
  • They arise in the epiphysis or apophysis of a long bone
  • Classical location is one-third of the tibia
Periosteal chondroma
  • Benign cartilaginous neoplasm
  • Commonly located on the proximal humerus and distal femur
  • Affects young patients
  • In periosteal chondroma, differentiating features include:
  • Symptomps are usually present for a long period of time
  • Imaging features include there is no stalk or peduncle as in an osteochondroma
Chondromyxoid fibroma
  • Benign cartilaginous neoplasm
  • Located in the metaphyseal region of long bones
  • In chondromyxoid fibroma, differentiating features include:
  • Occur in young adults (second and third decades)
  • Usually located in the tibia


Type of osteochondroma Features
Solitary osteochondroma
  • Non-hereditary
  • 85% of osteochondromas
  • No genetic mutations
  • Located in long bones, 85% of osteochondromas
  • Onset is in early adolescence
Multiple osteochondromas (hereditary)
  • Hereditary
  • Approximately 20% of osteochondromas
  • Related genetic mutations EXT-1 and EXT-2,
  • Early onset of disease (newborn or children)



Genes implicated in HNPCC Frequency of mutations in HNPCC families Locus
MSH2 approximately 60% 2p22
MLH1 approximately 30% 3p21
MSH6 7-10% 2p16
PMS2 relatively infrequent 7p22
PMS1 case report 2q31-q33
TGFBR2 case report 3p22
MLH3 disputed 14q24.3







Type of osteoid osteoma Characteristics
Intracortical Dense sclerosis around the nidus
Periosteal Periosteal reaction
Cancellous (medullary) Produces very little reactive bone
Subarticular Simulates arthritis as it produces synovial reactions



Differential Diagnosis Similar Features Differentiating Features
Osteoblastoma
  • Benign, male predilection, and also present in long bones
  • In osteoblastoma, differentiating features include: uncommon tumor, affect the axial skeleton more frequently and lesions are typically larger than 2 cm
Brodie abscess
  • Present in children, limb pain, and ocassionaly affects long bones
  • In brodie abscess differentiating features include: fever, subacute onset, and location is usually affects the metaphysis of tubular bones
Osteosarcoma
  • Affects same group of population (children and adolescents), patients usually present with bone pain, and the location is usually long bones
  • In osteosarcoma, differentiating features include: malignancy, infiltration to surrounding tissue, and elevation of serum alkaline phosphatase (ALP)
Enostosis
  • Affects same group of population (children and adolescents), small size, and the location is usually long bones
  • In enostosis, differentiating features,include: pathognomonic radiological appearance, incidental finding
Differential Diagnosis Similar Features Differentiating Features
Fibrous dysplasia
  • Benign, often an incidental finding, and affects the same group of patients.
  • In fibrous dysplasia, differentiating features include: More common presentation is on ribs: 28%, no gender predilection, and complete resection is usually not possible.
Osteoblastoma
  • Benign, incidental, and male predilection.
  • In osteoblastoma, differentiating features include: normally affect the axial skeleton, lesions are typically larger than 2 cm, and surgical excision is often the treatment of choice.
Adamantinomas
  • Benign, slow growing, similar clinical onset.
  • In adamantinomas , differentiating features include: locally aggressive tumor, common in the 3rd to 5th decades of life, location is usually confined to the jaw.
Chronic sinusitis
  • Affects same group of population (young to middle aged adults), clinical onset is similar.
  • In chronic sinusitis, differentiating features include: fever, previous history of acute sinusitis, and lack of facial deformation or imaging findings compatible with osteoma.




Differential Diagnosis Similar Features Differentiating Features
Cardiac tamponade
  • Elevated jugular venous pressure, reduced diastolic filling of the right ventricle, and hypotension.
  • In cardiac tamponade, differentiating features include: muffled heart sounds, pericardial rub, and electrocardiographic changes.
Chronic obstructive pulmonary disease
  • Elevated jugular venous pulse (JVP), shortness of breath, and tachypnea.
  • In cardiac tamponade, differentiating features include: history of chronic bronchitis, coarse crackles with inspiration, and spirometry with FEV1/FVC < 70%.
Mediastinitis
  • Elevated venous pressure, tachypnea and shortness of breath.
  • In mediastinitis, differentiating features include: fever, positive confirmation of organisms and elevated leukocytes.
Pneumonia
  • Hypotension, tachypnea,cough, and chest pain.
  • In pneumonia, differentiating features include: Bronchial breath sounds, leukocytosis with left shift, positive blood culture and altered laboratory findings (procalitonin).
Acute respiratory distress syndrome
  • Low blood pressure,hypotension, and shortness of breath.
  • In cardiac acute respiratory distress syndrome, differentiating features include: acute onset, bilateral infiltrates on chest radiograph sparing costophrenic angles and pulmonary wedge pressure < 18 mmHg.
Syphilis
  • Enlarged lymph nodes, hypotension and dysphagia.
  • In syphilis, differentiating features include: Positive treponemal tests, history of unprotected sex, and superficial mucosal patches.


Differential Diagnosis Similar Features Differentiating Features
Familial adenomatous polyposis (FAP)
  • Familial inheritance, increased risk of colorectal cancer, extra-colonic tumors.
  • Autosomal recessive, 100+ polyps and age under 40, centinel tumors are differently located than HNPCC, such as: Osteomas, dental anomalies, congenital hypertrophy of the retinal pigment epithelium (CHRPE)
Juvenile polyposis
  • Familial inheritance, autosomal dominant, high risk of GI and non GI cancer, also a germline mutation.
  • Gastrointestinal hamartomatous polyps, on physical exam lip pigmentation is common.
Cowden syndrome
  • Rare autosomal dominant inherited disorder, increased risk of colorectal cancer, also has gene mutations.
  • Intestinal hamartomatous polyps, physical exam may show macrocephaly, gene affected PTEN.
  1. 1.0 1.1 Lung Cancer Epidemiology. Wikipedia. https://en.wikipedia.org/wiki/Lung_cancer Accessed on February 17, 2016
  2. 2.0 2.1 2.2 Mucoepidermoid carcinoma. Radiopedia. Dr Frank Gailliard. http://radiopaedia.org/articles/mucoepidermoid-carcinoma-of-salivary-glands Accessed on February 17, 2016
  3. AJCC System for Staging of Benign and Malignant Salivary Gland Tumors. AJCC Accessed on February 18, 2016