This document discusses lung cancer, including its risk factors, presentation, diagnosis, staging, prognosis, and different types. It notes that cigarette smoking is the leading risk factor, accounting for 85% of lung cancers. Radon exposure and asbestos are also significant risk factors. The main types of lung cancer are small cell carcinoma and non-small cell carcinoma (which includes adenocarcinoma, squamous cell carcinoma, and large cell carcinoma). Diagnosis requires biopsy and imaging can reveal solitary pulmonary nodules. Prognosis is generally poor due to lack of effective screening.

1. Lung Cancer
W. P. Rivindu H. Wickramanayake
Group no. 04a
3rd Year 2nd Semester – 2017 October
Tbilisi State Medical University, Georgia

2. Key Risk Factors for Lung Cancer
- Risk directly linked to duration and amount of smoking (pack years)
1) Cigarette smoking (85% of lung cancer)
- Colorless, odorless gas
- Decay product of uranium
- Found in soil, accumulates in closed space (basement)
2) Radon (2nd most common cause) - most common
ionizing radiation exposure in USA
3) Asbestos

4. Carcinogenicity of Cigarette Smoking
 Contains > 60 carcinogens
 Polycyclic aromatic hydrocarbons and arsenic are particularly
carcinogenic
 Cancer risk directly increases with duration and amount of
smoking (pack years)

6. Presentation of Lung Cancer
Average age at presentation is 60.
Most common cause of cancer death in USA.
Nonspecific presentation
- Cough, weight loss, hemoptysis, post obstructive pneumonia

7. Diagnosing Lung Cancer
Diagnosis requires biopsy.
Imaging reveals solitary nodule (coin-lesion) - growing lesion concerning.
Coin lesions also seen in ;
- Granulomas - TB, fungus (ex - histoplasma in midwest)
- Bronchial hamartoma - benign tumor of lung tissue + cartilage; often
calcified in imaging.
- Harmartoma - disorganized mass that grows at same rate as
surrounding tissue; made of same cells that makes the tissue.

8. TNM Staging of Lung Cancer
1) T - tumor size
i. Pleural involvement classically seen in adenocarcinoma (adenocarcinoma is
peripheral)
ii. Obstruction of SVC (superior vena cava syndrome) - distended head and neck veins
with edema and blue discoloration of arms and face
iii. Involvement of recurrent laryngeal nerve (hoarseness) or phrenic nerve
(diaphragmatic paralysis)
iv. Horner's - compression of sympathetic chain (ptosis, anhydrosis - in skin, miosis) -
especially if tumor is at apex of lung (pancoast tumor)
2) N -
Spread to hilar and mediastinal lymph nodes
3) M -
Unique site of distant metastasis is adrenals (HY)
Others - brain, bone, liver

9. Prognosis of Lung Cancer
 Poor (no effective screening method) - 5 year survival rate is
15%

10. Two Main Categories of Lung Cancer
1) Small cell carcinoma (15% of all lung carcinoma)
- Usually no amenable to surgery (treat with chemotherapy and radiation)
2) Non-small cell carcinoma (85% of all lung carcinoma)
i. Adenocarcinoma (40%) - glands or mucus production
ii. Squamous cell carcinoma (30%) - keratin pearls or intercellular
bridges
iii. Large cell carcinoma (10%) - none of above features seen
iv. Carcinoid tumor (5%)
- Treat upfront with surgery (doesn't respond well to chemotherapy)

11. Different Types of Lung Cancer
1) Small Cell Carcinoma
- Treat with Chemotherapy
2) Non-small Cell Carcinoma
Subtypes;
i. Squamous cell carcinoma
ii. Adenocarcinoma
iii. Broncheoalveolar carcinoma (Adenocarcinoma in situ)
iv. Large cell carcinoma
v. (Bronchial) carcinoid tumor
3) Mesothelioma
- Related to asbestos
4) Metastasis
- Common origin of metastasis - breast, colon

12. Different Types of Lung Cancer
1) Neuroendocrine (NE) tumor
- Small cell carcinoma (poorly differentiated NE cells)
- (Bronchial) carcinoid tumor (well differentiated NE cells)
2) Adenocarcinoma
- Bronchioalveola r carcinoma (adenocarcinoma in situ)
3) Related to smoking - small, large, squamous, adeno
- Squamous cell carcinoma (most common in male smokers
- Small cell carcinoma (male smokers)
- Adenocarcinoma (most common in female smokers and non-
smokers) [broncheoalveolar carcinoma not associated with
smoking]
- Large cell carcinoma To Next Page

13. 5) Undifferentiated and poor prognosis
- Small cell carcinoma
- Large cell carcinoma
4) Paraneoplastic syndrome
- Squamous cell carcinoma (PTHrp)
- Small cell carcinoma (ADH, ACTH, Ab for Ca channel)
- Large cell carcinoma (BHCG)
6) Excellent prognosis
- Bronchoal veolar carcinoma
Continued;

14. Types of Cancer
1) Small cell carcinoma
 Poorly differentiated small cell and very aggressive
 Arise from neuroendocrine cells (Kulchitsky cells)
 Chromogranin +ve (less +ve than carcinoid tumor)
 Located Centrally
 Male smokers (99% of small cell carcinoma patients are
smokers)
 Associated with 5A and 1B
 Produces ACTH
 Produces ADH
 Produces Ab for Eaton - Lambert syndrome (presynaptic Ca channel
Ab) (paraneoplastic syndromes)
 Anti-neuronal antibody syndrome (limbic encephalitis, cerebellar
degeneration, opsoclonus, GI dysmotility, poly radiculopathy)
 Amplification of myc oncogene
 LOVES TO GO TO BRAIN - give prophylactic cranial irraditation
 MOST AGGRESSIVE TYPE OF LUNG CANCER

15. 2) Adenocarcinoma
 Glands or mucin
 Located peripherarily
 Most common tumor in nonsmokers and female smokers
Fig: glandular structure in
adenocarcinoma

16. 3) Squamous cell carcinoma
 Keratin pearls or intercellular bridges (by definition)
 Located centrally
 Most common tumor in male smokers
 May produce PTHrp (paraneoplastic syndrome)
 Hilar mass from bronchus
 Associated with double C
- HyperCalcemia- due to PTHrp
- Cavitation
Fig : keratin
pearl
Fig : intracellular
bridge

17. 4) Large cell carcinoma
Poorly differentiated and highly anaplastic cells (no keratin
pearls, intercellular bridges, glands or mucin)
Smoking associated
Located centrally or peripherarily
Poor prognosis
Poor response to chemotherapy; remove surgically
Paraneoplastic - may secrete B-HCG

18. 5) (Bronchial) Carcinoid tumor
 Well differentiated neuroendocrine cells; chromogranin positive
 Not related to smoking
 Central or peripheral (when central, makes polyp like mass in bronchus)
 MOST COMMON PRIMARY LUNG CANCER IN CHILDREN
 Low grade malignancy; rarely, can cause carcinoid syndrome
- caused due to release of vasoactive substance (mainly serotonin)
- flushing, diarrhea, restrictive cardiomyopathy due to endocardial fibrosis
Fig: chromogranin positivity

19. 6) Bronchioloalveolar carcinoma (adenocarcinoma in situ)
 Columnar cells that grow along preexisting bronchioles and alveoli; arise from clara cells
 Not related to smoking
 Located periphararily
 Excellent prognosis Pneumonia like consolidation on imaging
Fig: normal alveoli top right ; columnar cells on rest

20. 7) Metastasis
 Most common source are breast and colon carcinoma
 Canon-ball nodules on imaging
 More common than primary tumors

21. 8) Mesothelioma
 Can see psammoma bodies in biopsy (concentric calcifications
- other HY cancer - papillary thyroid, meningioma, papillary serous ovarian)
 Highly associated with asbestos exposure (lung cancer more common in asbestos
exposure)
 Malignant tumor of mesothelial cells (mesothelium is a membrane of simple squamous
cells that lines body cavities: pleura , peritoneum, mediastinum and pericardium)
 Tumor encases the lung

22. References ;
 Robbins Pathology – 10th Edition
 Pathoma Lecture Notes – 2017
 Board Review System – Pathology – 5th Edition
 https://library.med.utah.edu/WebPath/LUNGHT
ML/LUNGIDX.html#9