Lung tumors

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Lung tumors

  1. 1. LUNG TUMORS
  2. 2. LUNG TUMORS Primary : • 95 % are Bronchogenic Carcinoma – Extremely common – M:F = 2:1 , Age 55-65 • 5% are Bronchial carcinoids Mesenchymal malignancies Lymphomas Benign lesions: hamartoma Secondary : very common
  3. 3. Bronchogenic Carcinoma: • Commonest cause of cancer related deaths in males, and in the US in females as well • The rate of increase is declining in males but is accelerating in females • Majority are related to smoking • Bad prognosis ( 5 year survival for all stages of lung cancer combined < 15%) • If localized to lung 5 yr survival is 45%
  4. 4. Types of Lung carcinoma : • SMALL CELL LUNG CANCER (SCLC) – Small Cell Carcinoma • NON SMALL CELL LUNG CANCER : NSCLC – Squamous Cell Carcinoma – Adenocarcinoma – Large Cell Carcinoma • Note : Combined patterns are possible
  5. 5. - Squamous cell carcinoma was the most common type but has recently been replaced by adenocarcinoma - Adenocarcinoma most common type in females, nonsmokers and patients < 45 years
  6. 6. • Division is for therapeutic purposes • Virtually all SCLC have metastasized by time of diagnosis →→ treated by chemotherapy +/radiotherapy • NSCLC better treated by surgery • Genetic differences: SCLC : RB gene mutation NSCLC: p16/CDKN2A gene inactivation KRAS & EGFR oncogene mutation
  7. 7. Etiology 1- Cigarette smoking – ↑↑↑ risk – Contains numerous carcinogens – Up to 90% squamous & small cell CA occur in smokers – Correlation between smoking in pack years & lung CA : 60X increased risk in heavy habitual smokers – Passive smoking : 2X – Effect of carcinogen is genetically conditioned
  8. 8. 2 - Genetic Factors : • Stepwise accumulation of genetic mutations triggered by carcinogens • Earliest is inactivation of suppressor gene on chromosome 3P • Later mutations in P53 & K- RAS …etc : – Activating mutations in EGFR & K-RAS in adenocarcinoma – RB mutation in Small Cell Carcinoma – P 16/ CDKN2A inactivation in NSCLC
  9. 9. 3- Environmental Hazards : • • • • Asbestos workers Uranium workers Exposure to radiation Nickel , arsenic , chromate….etc 4- Scarring in lung tissue ( Scar Cancer ) usually adenocarcinoma
  10. 10. Diagnostic techniques for lung cancer : 1- Chest X ray, CT, …..etc 2- Sputum Cytology & bronchial wash 3- Bronchial biopsy : Biopsy taken by bronchoscope 4- Transbronchial biopsy : forceps down bronchoscope into lung parenchyma to take a biopsy. 5- Transcutaneous needle biopsy 6 -Open lung biopsy
  11. 11. A- Squamous cell CA B- Small Cell CA
  12. 12. Gross appearance of most types : Central • Thickening of mucosa • Later may show irregular whitish warty lesion→ ulceration • Infiltration of wall of bronchus into lung • Hemorrhage, necrosis & cavitation may be seen Peripheral: • Consolidated rounded lesion
  13. 13. Central Cancer
  14. 14. Peripheral Cancer
  15. 15. 1- SQUAMOUS CELL CA : • • • • Male> female, > 90% in smokers Usually central location, Warty ± cavitation May present with HYPERCALCEMIA Precursor Lesion: – Squamous metaplasia → Dysplasia → Carcinoma in Situ → Squamous cell CA • Histology :Various degrees of squamous differentiation ± Keratin formation • Prognosis better than Small Cell CA
  16. 16. Squamous metaplasia & Carcinoma in situ
  17. 17. 2- ADENOCARCINOMA : • • • • • Commonest in females Least associated with smoking Usually peripheral but may be central Growth is slower than squamous but widely metastasize Types include : A- Usual bronchial derived ( 80%) ±mucin. May be: – Acinar – Papillary – Solid
  18. 18. • B- Bronchioloalveolar CA : • • • • Multifocal diffuse or localized nodule . Peripheral location May present as pneumonic consolidation Growth along alveolar walls without destruction of walls (non-invasive) • Prognosis of better than usual adenocarcinoma.
  19. 19. Bronchioalveolar Carcinoma
  20. 20. Precursor Lesions in Adenocarcinoma: • ? Presence of Bronchioalveolar Alveolar Stem Cells (BASC) expansion after lung injury • Atypical Adenomatous Hyperplasia (AAH) → Bronchioalveolar CA → Adenocarcinoma • AAH has same 3P deletion & K-RAS mutation similar to CA
  21. 21. 3- LARGE CELL ANAPLASTIC CARCINOMA : • Poorly differentiated tumors • Difficult to type, may need special immunostains. • Incidence is about ( 10-15 % ) • Probably poorly differentiated Squamous Cell CA or Adenocarcinoma • Prognosis is poor
  22. 22. 4- SMALL CELL CARCINOMA (SCLC) • • • • • • • Male > Female , >90% in smokers Arise from neuroendocrine cells Central mass Most aggressive,necrosis, metastasize early Most frequent type with ectopic hormones Cytology: Crush artefact, nuclear molding Histology : Small blue cells (Oat Cell CA) mitosis+ +,necrosis++
  23. 23. A- Squamous cell CA B- Small Cell CA
  24. 24. Types of Bronchial Carcinoma
  25. 25. Spread of lung cancer : 1- Local extension pleura , pericardium & mediastinum , nerves & vessels 2- Lymph node metastases regional L.N. ,bronchial, tracheal and mediastinal 3-Distant metastases : Adrenal (> 50% ) , Liver , Brain , bone …
  26. 26. Staging of Lung CA • BASED ON TNM STAGING SYSTEM : • Stage I = T1 N0 M0 (tumor <3cm.) • Stage II = T2 N1 M0 ( tumor > 3cm.) • Stage III = T3 N1 M0 ( tumor involving chest wall, mediastinum, contralateral nodes….etc.) • Stage IV = Any T, any N, M1
  27. 27. Local & regional invasion : i- Lymphatic : carina, mediastinum & neck - Mediastinal invasion → – Recurrent laryngeal n. on left →vocal cord paralysis – Phrenic nerve → diaphragmatic paralysis – Esophagus → bronchoesophageal fistula – Cardiac & pericardial invasion – Chest wall invasion → Pain & pleural effusion
  28. 28. Late invasion of upper lobe tumors : • Right upper lobe tumors or LN’s compress SVC → Superior Vena Cava Syndrome • Apical tumors ‘Pancoast’tumor : – Brachial plexus → Pain in distribution of ulnar nerve – Destruction of 1st.&2nd.rib ± vertebrae – Sympathetic chain invasion→Horner’s Syndrome (ipsilateral enophthalmus,ptosis,miosis &anhydrosis )
  29. 29. Extrathoracic Metastases : adrenals → no symptoms bone → pain , fracture,↑Ca & alkaline phosphatase brain → headache, convulsions …. etc liver → incidental or hepatomegaly, ascitis…etc.
  30. 30. Paraneoplastic Syndrome : Present in 10% of tumors, most in SCLC • Ectopic hormone production : – – ADH , ACTH, Gonadotrophic H….in SCLC PTH relared peptide→↑ Calcium in Squamous cell CA • Migratory thrombophlebitis, DIC in AdenoCA • Digital clubbing,hypertrophic osteoarthropathy • Neuromuscular disorders …etc in SCLC
  31. 31. Carcinoid tumor (neuroendocrine cancer grade I) • Younger age than CA , 5% of lung tumors • Arise from neuroendocrine cells • Most arise in bronchial wall, fill lumen or extend into lung • Histology: Uniform cells , absent mitoses , arranged in nests, cords . • Atypical Carcinoid : Show mitoses , necrosis, atypia
  32. 32. Symptoms : • Obstruction & atelectasis • Infection • Most cases are hormonally inactive but few produce the Carcinoid syndrome • Surgery curative in most cases • About 30 % may metastasize to lymph nodes ± distant metastases
  33. 33. Carcinoid tumor
  34. 34. Metastatic tumors in lung • All types of carcinomas or sarcomas can metastasize to the lung • Reach lung by lymphatic or hematogenous route & may show : – Multiple discrete nodules , (Cannon Ball ) – Single nodule – Diffuse lymphatic dissemination called Lymphangitis Carcinomatosa • Pleural effusion is common in metastatic tumors
  35. 35. Tumor- like lesions of the lung : Lung Hamartoma : • Consists of cartilage,& clefts lined by respiratory epithelium surrounded by connective tissue • Usually peripheral , & incidental ( Coin Lesion ) • May simulate tumor radiologically
  36. 36. PLEURAL EFFUSION • Pleural effusion is a common manifestation of both primary and secondary pleural diseases. Normally, no more than 15 mL of serous, relatively acellular, clear fluid lubricates the pleural surface. • Pleural Effusion : Accumulation of fluid – Transudate – CHF, Liver failure ,Renal failure – Exudate - Pneumonias – Hemorrhagic- Cancer ,TB, Infarcts •
  37. 37. • Increased accumulation of pleural fluid occurs in the following settings: • Increased hydrostatic pressure, as in congestive heart failure • Increased vascular permeability, as in pneumonia • Decreased osmotic pressure, as in nephrotic syndrome • Increased intrapleural negative pressure, as in atelectasis • Decreased lymphatic drainage, as in mediastinal carcinomatosis
  38. 38. PLEURA • Hemothorax : Blood in pleural cavity – Trauma – Rupture of dissecting aneurysm • Pyothorax/Empyema : Pus in pleural cavity
  39. 39. • Chylothorax : – Accumulation of milky, lipid rich fluid due to lymphatic obstruction, usually be tumor • Pneumothorax : – Traumatic – Penetrating injury – Spontaneous : TB,emphysema , Asthma • Tension Pneumothorax : – Medical emergency with air entering under pressure → Atelectasis
  40. 40. • Clinical Picture : Chest pain – Ipsilateral shoulder pain – diaphragm – Non-productive cough • Compression Atelectasis
  41. 41. PLEURA Malignant Mesothelioma : • • • • Rare tumors of mesothelial cells Exposure to asbestos in >50% Long latent period Not related to smoking • Pathogenesis : – Inactivation of several tumor suppressor genes – Simian virus 40 viral DNA in 60-80% cases inactivates p53 & RB
  42. 42. Morphology : • Starts as pleural fibrosis & plaque • Later firm yellowish white tumor around the pleura • Microscopically : mixed pattern – Epithelial – Sarcomatoid – Biphasic • Prognosis : POOR
  43. 43. Tumors in Upper Respiratory Tract : • Nasopharyngeal Carcinoma : – EBV related – Squamous cell & Undifferentiated carcinoma – Numerous lymphocytes(Lymphoepithelioma) • Laryngeal Tumors : – Benign : Polyps & Papillomas – Malignant : Carcinoma
  44. 44. Laryngeal Carcinoma : • • • • Squamous cell CA Middle age , M>F Etiology : Smoking & Alcohol Mainly on vocal cords → hoarseness of voice • Carcinoma in situ → Invasive squamous cell carcinoma → Lymph nodes & neck • May be cured if early

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