Lecture notes for medical students

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2. Learning Objectives

3. Learning Objectives
1. Introduction & History
2. Relevant Anatomy, Physiology
3. Aetiology
4. Pathophysiology
5. Pathology
6. Classification
7. Clinical Features
8. Investigations
9. Management
10. Prevention
11. Guidelines
12. Take home messages

4. Introduction & History.
•

5. Introduction & History.
• A solitary pulmonary nodule is defined as
a discrete, well-marginated, rounded
opacity less than or equal to 3 cm in
diameter that is completely surrounded by
lung parenchyma, does not touch the hilum
or mediastinum, and is not associated with
adenopathy, atelectasis, or pleural effusion.
• Benign lung tumors can occur in the
periphery of the lung, but they can also
occur as endobronchial lesions within the
tracheobronchial tree.

6. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoning/ Toxins/ Drug induced

7. Aetiology

8. Aetiology
• Idiopathic
• Congenital/Genetic
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative
• Iatrogenic

9. Pathophysiology

10. Pathophysiology
• The cause and pathogenesis of benign lung
tumors are poorly understood. The
nomenclature of benign lung tumors is
based on histologic findings.

11. Classification

12. Classification
As per presumed origin:
• Unknown - Hamartoma, clear cell, and
teratoma
• Epithelial –Bronchial Adenoma, Papilloma
and polyps
• Mesodermal - Fibroma, lipoma, leiomyoma,
chondroma, granular cell tumor, and
sclerosing hemangioma
• Other - Myofibroblastic tumor, xanthoma,
amyloid, and mucosa-associated lymphoid
tumor

13. Classification
• Adenomas and hamartomas constitute
the largest group of benign lung tumors

14. Hamartoma

15. Hamartoma
• A Hamartoma is a mostly benign, focal
malformation that resembles a neoplasm in
the tissue of its origin.
– It grows at the same rate as the
surrounding tissue.
– It is composed of tissue elements
normally found at that site ( c/w teratoma
tissue elements NOT normally found at
that site)
– but they are growing in a disorganized
manner.

16. Hamartoma
• Hamartomas (chondroadenomas) are the
most common type of benign lung tumor.
• They occur primarily in adults, although
they do occasionally arise in children.
• Hamartomas are peripherally located.
• Grossly, they have a firm, marblelike
consistency.
.

17. Hamartoma
• Hamartomas consist of haphazardly
organized mature cells and tissues, mostly
of masses of hyaline cartilage with a
myxoid connective tissue, adipose cells,
smooth muscle cells, and clefts lined with
respiratory epithelium.
• Hamartomas can be easily enucleated, but
wedge resection is also appropriate.

18. Bronchial adenomas

19. Bronchial adenomas
• Bronchial adenomas make up 50% of all
benign pulmonary tumors.
• Aka Mucous gland adenomas/ bronchial
cystadenomas- arise in the main or local
bronchi.
• Histologically, they consist of columnar
cell–lined cystic spaces with a papillary
appearance.

20. Tracheobronchial tumors

21. Tracheobronchial tumors
• Multiple laryngeal papillomatosis
• Solitary papillomas
• Inflammatory papilloma
• Granular cell myoblastomas
• Leiomyoma
• Lipoma

22. Multiple laryngeal papillomatosis

23. Multiple laryngeal papillomatosis
• Multiple laryngeal papillomatosis is a viral
disease of the upper airway that primarily
affects children.
• This disorder has malignant potential and
may later spread to the tracheobronchial
tree.

24. Solitary papillomas
• Usually are less than 1.5 cm in
diameter.
• They usually are lobar or segmental in
location
• Histologically similar to viral
papillomatosis.

25. Inflammatory Papillomas
• Inflammatory papilloma is a solitary
polypoid mass of granulation tissue
that is associated with an underlying
pulmonary inflammatory condition.

26. Granular cell myoblastomas

27. Granular cell myoblastomas
• Granular cell myoblastomas are of
neural cell origin.
• A granular cell myoblastoma contains
polygonal or spindle cells with
granular cytoplasm.
• Granular cell myoblastomas tend to be
multiple in 10% of cases
• more common in men aged 30-50
years.

28. Other parenchymal tumors

29. Other parenchymal tumors
• Leiomyoma
• Lipoma
– occasionally occurr in the endobronchial
tree
– almost exclusively are found at an
endobronchial location.

30. Sclerosing hemangiomas

31. Sclerosing hemangiomas
• Sclerosing hemangioma is an uncommon tumor
derived from the epithelial cells of pneumocytes
(terminal bronchiolar cells).
• Sclerosing hemangiomas are most commonly
found in middle-aged women.
• This tumor consists of several elements, including
solid cellular areas, papillary structures, sclerotic
regions, and blood-filled spaces.
• Chest radiography demonstrates a well-defined
nodule that is less than 3 cm.

32. Other mesenchymal tumors

33. Other mesenchymal tumors
• Lipoma
• Leiomyoma
• Neural tumors
• Fibroma
• Benign clear-cell
tumor
• Plasma cell
granuloma,.
• bronchial glomus
tumors
• fibrous histiocytoma
• Xanthoma
• Pulmonary hyalinizing
granuloma,
• Pulmonary
endometrioma
• Pseudolymphoma
• Teratoma

34. Multiple tumors
• Many benign lung tumors occasionally
have multiple origins.
– hamartomas,
– hyalinizing granulomas
– Leiomyomas
– sclerosing hemangiomas.

35. The Carney triad
• The Carney triad is a syndrome of
1. gastric epithelioid leiomyosarcoma
2. Pulmonary chondroma
3. Extra-adrenal paragangliomas.
• The Carney triad mainly affects
women.

36. Pulmonary tumorlets
• Pulmonary tumorlets are minute collections
of neuroendocrine cells scattered
throughout the lung.
• Pulmonary tumorlets predominantly affect
older women.

37. Chemodectoma &Carcinoid

38. Chemodectoma &Carcinoid
• Chemodectoma is a rare tumor of the
neuroendocrinne tissue.
• Clinically significant intrapulmonary
chemodectomas are paragangliomas.
• Paraganglioma is a neoplasm that originates
from the paraganglion cells.
• They secrete vasoactive hormones/ACTH.
• They behave in a benign fashion.

39. Clinical Features
•

40. Clinical Features
• Demography
• Symptoms
• Signs
• Prognosis
• Complications

41. Demography

42. Demography
• Reported series suggest that benign lung
tumors affect men more frequently than
women.

43. Symptoms

44. Symptoms
• Asymptomatic.
• Discovered accidently on X-Ray/CT chest
ordered routinely. A solitary pulmonary
nodule .

47. A solitary pulmonary nodule
May be secondary to a wide differential of
causes. However, more than 95% are-
1. Malignancies (most likely primary)
2. Granulomas (most likely infectious)
3. Benign tumors

48. Signs

49. Signs
• Mostly None.
• (localized) wheezing
• Persistent coughing
• Hemoptysis
• Fever - Especially when associated pneumonia is
present
• Diminished breath sounds
• Dullness to percussion
• Rales
• Digital clubbing
• Autoimmune disease–associated skin and joint
abnormalities

50. Complications

51. Complications
• pneumonia
• atelectasis
• Hemoptysis
• hyperinflation
• malignancy

52. Investigations

53. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology
– Germ line Testing and Molecular Analysis
• Diagnostic Laparotomy.

54. Investigations
• Laboratory Studies
– Routine
– Special
Laboratory studies have a limited role
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology

55. Investigations in Malignancy
•

56. Investigations in Malignancy
• For diagnosis
• For staging
• For Screening
• For Monitoring

57. Diagnostic Studies
Imaging Studies

58. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT- HDCT
• Angiography
• MRI
• Endoscopy- Bronchoscopy.
• Nuclear scan- PET-CT

59. Benign Radiologic Characteristics
•

60. Benign Radiologic Characteristics
• Size- smaller than 8 mm
• Growth rate
• Presence of calcification
• Border characteristics
• Internal characteristics
• Location

61. Growth rate
Doubling times-
• less than 1 month suggest infections
• more than 18 months suggest benign
processes such as granuloma, hamartoma,
bronchial carcinoid, and rounded
atelectasis.
• If a nodule remains the same size for 2
years, it is very likely benign.

62. Clacification
•

63. Clacification
• The five patterns of calcification usually
observed in benign lesions are
• diffuse, central, laminar, concentric, and
popcorn.
• Stippled and eccentric patterns are more
suspicious for malignancy

64. Border characteristics
• Well-defined, smooth, nonlobulated edge

65. Internal characteristics
• fat within the lesion is specific for a
hamartoma,
• Ground-glass opacities
• presence of air bronchograms within the
solitary pulmonary nodule

66. Location
• Nodules that are attached to pleura, vessels,
or fissures are likely to be benign

67. Lung Reporting and Data System (Lung-
RADS)
• Categories 1 and 2 correspond to very low
risk
• Category 3 warrants an earlier low-dose CT
scan in 6 months’ time.
• Category 4a and 4b.
• 4a, a 3-month low-dose follow-up CT scan /
PET-CT if the solid component of the
nodule is 8 mm or wider.
• 4b-chest CT with or without contrast,
PET/CT, and/or tissue sampling .

68. Differential Diagnosis

69. Differential Diagnosis
• Malignancies (most
likely primary)
• Granulomas (most
likely infectious)
• Arteriovenous
Malformations
• Hydatid Cysts
• Lipoid pneumonia
• Lung Abscess
• Rheumatoid Arthritis
• Sarcoidosis
• Secondary Lung
Tumors
• Small Cell Lung
Cancer
• Tuberculosis (TB)
• Pulmonary Atelectasis
• Lymphoma

70. Management

71. Management guidelines
Depends on probability of malignancy
• Very low probability - Serial CT scanning
at 3-6 months, 9-12 months, and then at 18-
24 months
• Low-to-moderate probability - PET
imaging; if uptake is minimal, CT
surveillance or nonsurgical biopsy
• High probability (>65%) - Surgical
resection, ideally thoracoscopic wedge
resection;

72. Management
Difficult questions:
• Is the nodule benign or malignant
• Should it be investigated or observed
• Should it be surgically resected

73. benign or malignant?
• Malignancy may be curable when present
as a solitary pulmonary nodule .
• A comprehensive assessment generally
includes
– History
– physical examination
– evaluation of previous chest radiographs,
– CT scanning
– positron-emission tomography [PET] scanning)
– invasive diagnostic procedures.

74. benign or malignant?
Quantitative risk models
• Mayo Clinic Model
• Veterans Administration (VA) Cooperative
Model
• Brock University Risk Model

75. benign or malignant?
• History of malignancy
• History of smoking & pack-years smoked
• Occupational risk factors for lung cancer -
Exposure to asbestos, radon, nickel,
chromium, vinyl chloride, and polycyclic
hydrocarbons can lead to the development
of a solitary pulmonary nodule
• Areas with endemic mycosis or with a high
prevalence of TB.
• History of TB or pulmonary mycosis

76. Biopsy
• endobronchial ultrasonographically guided
transbronchial needle biopsy,
• CT-guided transthoracic needle aspiration
(TTNA).
• Video-assisted thoracoscopic surgery
(VATS) can be used to obtain a biopsy
specimen from a superficial, pleural-based
lesion, or the lesion can be resected using
this approach
• Open biopsy

77. Minimally invasive Therapy

78. Minimally invasive Therapy
• Bronchoscopic resection.
• VATS

79. Operative Therapy

80. Operative Therapy
• thoracotomy with bronchotomy/local
excision,
• segmental resection,
• lobectomy,
• sleeve resection
• pneumonectomy.

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