This document summarizes the classification, epidemiology, risk factors, imaging appearance and staging of lung cancer. It describes the major histologic types including adenocarcinoma, squamous cell carcinoma, small cell carcinoma and large cell carcinoma. The most common type is adenocarcinoma, strongly linked to smoking. On CT, adenocarcinoma may appear as a solid nodule, part solid nodule or ground glass nodule. Squamous cell carcinoma often causes central obstruction and atelectasis. Small cell carcinoma widely metastasizes and commonly causes superior vena cava syndrome. Staging involves the TNM system considering tumor size, node involvement and metastases.

1. LUNG MALIGNANCY

2. • The most common cause of cancer in men, and the 6th most
frequent cancer in women worldwide.
• It is the leading cause of cancer mortality worldwide in both men
and women and accounts for approximately 20% of all cancer
deaths

3. Epidemiology
The major risk factor is
CIGARETTE SMOKING
• implicated in 90% of cases
• increase the risk of lung cancer 20-30 times.
• Strongly associated with squamous cell carcinoma(SCC), small cell
carcinoma, large cell carcinoma (LCC), and to a lesser extent
adenocarcinoma

4. • Other risk factors:
• asbestos: 5x increased risk
• occupational exposure:10%
uranium, radon, arsenic, chromium
• diffuse lung fibrosis: 10x increased risk
• chronic obstructive pulmonary disease

5. C/O ASBETOSE EXPOSURE
• LARGE LUNG MASS(M)
• Bilateral pleural thickening with calcification

6. The Eighth Edition Lung Cancer Stage
Classification
• Issued by IASLC in 2017
• T classification –based on CT
• N & M – using CT & PET-CT
• Mainly applies for non small cell cancers

7. T-CLASSIFICATION
T0
• There is no primary tumor on imaging
Tis
• Carcinoma in situ, irrespective of size.
• This can only be diagnosed after resection of the tumor.

8. T1
• Tumor size ≤3cm
• Tumor ≤1cm => T1a
• Tumor >1cm but ≤2cm =>T1b
• Tumor >2cm but ≤3cm => T1c
• T1a(mi) is pathology proven 'minimally invasive', irrespective of size.
• T1a(ss) is a superficial spreading tumor in the central airways,
irrespective of location.

9. T1 tumor in the left lower lobe, completely surrounded
by pulmonary parenchyma.

10. T2
• Tumor size >3cm to ≤5cm
• Tumor of any size that
oinvades the visceral pleura
oinvolves main bronchus, irrespective of distance to the carina
oshows an atelectasis or obstructive pneumonitis that extends to the hilum
• T2a= >3 to 4cm
• T2b= >4 to 5cm

11. T2 tumor with atelectasis/pneumonitis of the left lower lobe
up to the hilum, due to involvement of the left main bronchus

12. T3
• Tumor size >5cm to 7cm or
• Pancoast tumour that involves thoracic nerve roots T1 and T2 only.
• Tumor of any size that
oinvades the chest wall
oinvades the pericardium
oinvades the phrenic nerve
oshows one or more satellite nodules in the same lung lobe

13. T3 tumor in the right upper lobe with invasion
of the chest wall.

14. T4
• Tumor size >7cm or
• Pancoast tumor that involves C8 or higher nerve roots, brachial
plexus, subclavian vessels or spine
• Tumor of any size that
oinvades mediastinal fat or mediastinal structures
oinvades the diaphragm
oinvolves the carina
oshows one or more satellite nodules in another lobe on the ipsilateral
side

15. T4 tumor in the right upper lobe with invasion
of the mediastinum.

16. N STAGING
• Lymph node staging is done according to the American Thoracic
Society mapping scheme.

18. For a tumor in the right lung the N-stages are:
N1
• Ipsilateral peribronchial and/or hilar lymph nodes--10R-14R
N2
• Ipsilateral mediastinal and/or subcarinal lymph nodes
• 2R, 3aR, 3p, 4R, 7, 8R, 9R
N3
• Contralateral mediastinal and/or hilar, as well as any
supraclavicular lymph nodes
• 1, 2L, 3aL, 4L, 5, 6, 8L, 9L, 10L-14L

20. M STAGING

21. Lung Cancer Stage Grouping (Eighth Edition)

22. WHO CLASSIFICATION OF LUNG CANCER
NEW 4th EDITION CLASSIFICATION 2015
• EPITHELIAL TUMOURS
• MESENCHYMAL TUMOURS
• LYMPHOHYSTIOCYTIC TUMOURS
• TUMOURS OF ECTOPIC ORIGIN
• METASTATIC TUMOURS

23. EPITHELIAL TUMOURS

24. ADENOCARCINOMA
• most common cell type of lung cancer
• accounting for 40% to 50% of lung cancer
• relatively weak association with smoking

25. ADENOCARCINOMA ctd…
• Arise from bronchiolar or alveolar epithelium
• often characterized by glandular differentiation.
• Invasion of lung parenchyma is often
• Early metastasis is more common than with SCC, particularly to the
central nervous system and adrenal glands
• Multiple genetic abnormalities-EGFR, KRAS, BRAF, ERBB2/HER2, ALK,
ROS1
• Subtypes-mucinous nonmucinous

26. • presenting as a solitary pulmonary nodule
• 75%-in the lung periphery
• most common in the upper lobes

27. • chest radiographs -ill-defined nodule
• On thin-slice CT-
 nodule of soft tissue attenuation (solid)
 nodule of ground-glass opacity (GGO) with some solid
components (subsolid or part solid)
nodule entirely of GGO (nonsolid)

28. ill-defined nodule in the left
lung apex
because of
irregular and spiculated edge
ass ground-glass component

29. c/o adenoCa as SOLID MASS
lobulated and spiculated nodule.
Ass fibrosis
Plueral tails
Air bronchograms are visible within the
nodule
Central necrosis is common
Cavitation is uncommon

30. PART SOLID NON SOLID

31. Presenting as GGO
• results from lepidic growth -
tumor spreading as a thin layer
of cells, using alveolar walls as a
framework or scaffold

32. may appear cystic or multicystic mass

33. classification

36. c/o invasive mucinous adenocarcinoma
• Earlier known as BAC
• multicentric, multilobar, and
bilateral lung involvement,
• likely as the result of
aerogenous metastases
• CT angiogram sign
• Bronchorrhoea
• Bad prognosis

37. SQUAMOUS CELL CARCINOMA
• Preinvasive Lesions
• Squamous Dysplasia and Squamous Cell Carcinoma In Situ
• not usually recognizable on CT.
• Squamous Cell Carcinoma
Keratinising
Non-keratising
basaloid

38. SQUAMOUS CELL CARCINOMA
• Accounts for 20% of cases.
• It is strongly associated with cigarette smoking

39. • 65% arises in main, lobar, or segmental bronchi
• tends to cause symptoms early in its course because of its proximal
and endobronchial location.
• no Early metastasis
• relatively good 5-year survival rate.

40. presentations
• polypoid endobronchial mass
• f/o bronchial obstruction-Atelectasis,consolidation, mucoid impaction (mucous
bronchograms), and bronchiectasis
• Hilar mass
ocentral location of the tumor
oDue to local invasion
oinvolvement of hilar lymph nodes
• Central necrosis and cavitation

41. right upper lobe atelectasis and a right
hilar mass with downward bulging
of the minor fissure

42. right hilar mass right upper lobe
bronchial
obstruction resulting in convexity of
the medial minor fissure
and right upper lobe collapse

43. necrotic
hilar and mediastinal lymph
nodes
mucous bronchograms

44. • right hilar mass (M) with
upward bowing of the
minor fissure
• Golden’s S sign.
• Mediastinal lymph node
enlargement

45. • Scc with cavitary lung mass

46. NEUROENDOCRINE TUMORS
• Cells with neuroendocrine morphology
• neuroendocrine markers
• Arise from neuroendocrine Kulchitsky cells associated with
respiratory epithelium,
• Contain secretory granules, and can produce active peptides.
• paraneoplastic syndromes.

47. NEUROENDOCRINE TUMORS

48. Small Cell Lung Carcinoma
• third most common- 15% to 20% of cases
• originates from neuroendocrine cells, and electron microscopy shows
neurosecretory granules
• strongly associated with smoking
• strong male predominance
• endocrine and neurologic paraneoplastic syndrome
• Poor prognosis-Over 90% of cases p/w mets at diagnosis.

49. • Central mass
• p/a large hilar or parahilar mass
• Occur main or lobar bronchi
• With extensive peribronchial
invasion
• marked mediastinal lymph node
enlargement
• Common cause of superior vena
cava (SVC) syndrome

50. • Interstitial thickening in
the middle lobe
indicates local
lymphangitic spread of
tumor.

51. • Extensive mediastinal lymph
node enlargement –typical
• Causing anterior displacement
and narrowing of svc

52. Staging of Small Cell Lung Carcinoma
• limited-stage (LS) SCLC –
involvement limited to one hemithorax
with no distant extrathoracic metastatic disease.
 Regional and ipsilateral supraclavicular lymph nodes were
considered LS-SCLC if they could be included in a single safe radiation
port
• extensive-stage (ES) SCLC- corresponds to stage IV

53. Large Cell Neuroendocrine Carcinoma
• formerly classified as a subtype of LCC.
• high-grade NEC-a high mitotic rate and a poor prognosis.
• strongly associated with smoking.
• typically presents as a
o round or oval nodule or mass
o peripheral lung.
o 1 to 9 cm or larger in diameter.
o lobulated (80%) and sharply marginated (75%)
o Inhomogeneous enhancement--- correlates with necrosis

54. Carcinoid Tumors
• originate from neuroendocrine cells in the bronchial wall
• classified as
typical
atypical

55. Typical carcinoid tumor
• low-grade malignancy.
• most often occurs in the central bronchi--an endobronchial mass
• locally invasive
• may also present as a lung nodule or mass.
• Metastases are relatively uncommon
• common in women.
• There is no association with smoking.
• Calcification and ossification can be seen
• To diagnose mets- Radionuclide imaging with somatostatin analogs
• Surgical resection is the treatment of choice

56. As endobronchial mass-80%

57. Atypical carcinoid tumor
• is a more aggressive-- intermediate-grade variant
• higher mitotic rate
• more often associated with metastases
• Lymph node metastases are present in approximately 50%
• present as a lung nodule or mass, round ovoid,lobulated,
• poorer prognosis

58. Diffuse Idiopathic Pulmonary Neuroendocrine
Cell Hyperplasia
• Preinvasive lesion
• typically superficial to the basement membrane
• “tumorlets” is used when there is extension of neuroendocrine cell
hyperplasia beyond the basement membrane
• Common in women
• associated with MEN1 and Cushing’s syndrome
• it may be localized or diffuse
• associated with constrictive bronchiolitis

60. LARGE CELL CARCINOMA
• undifferentiated tumor that does not show squamous, adenomatous, or
neuroendocrine characteristics
• accounts for 5% of lung cancers
• present as a large peripheral mass
• more than 60% are larger than 4 cm at presentation
• strongly associated with smoking
• metastasize early
• poor prognosis

61. c/o LARGE CELL CARCINOMA

62. ADENOSQUAMOUS CARCINOMA
• mixed histologic characteristics of both adenocarcinoma and SCC,
with each cell type constituting at least 10% of the tumor

63. MESENCHYMAL TUMORS

64. Pulmonary Hamartoma
• most common mesenchymal tumor of the respiratory tract
• accounts for more than 75% of benign lung tumors
• composed of varying amounts of at least two mesenchymal elements (such
as cartilage, fat, connective tissue, and smooth muscle), combined with
respiratory epithelium.
• It is neoplastic in origin
• older than 50
• twice common in men.
•

65. • PH are composed predominantly of chondroid or chondromyxoid
tissue intermixed with variable proportions of other mesenchymal
components, including fat, myxoid fibrousconnective tissue, smooth
muscle, and bone.
• Clefts of normal respiratory epithelium are present, being entrapped
by the expanding mesenchymal tumor

66. Radiological appearence
• 85% -solitary pulmonary nodule.
• 5% to 15%-endobronchial mass
Peripheral hamartomas
 are usually 1 to 4 cm in diameter,
well defined, Sharply circumscribed, often lobulated.
Calcification of cartilage-30% stippled or conglomerate
 fat –low attenuation areas within the tumor-few d/d
Rarely, cystic, air-filled PH

67. c/o PH with calcification

68. c/o PH with fat content

69. Leiomyoma and Leiomyosarcoma
• Leiomyoma
• arise from smooth muscle found in the walls of the bronchi or blood vessels.
• The average age at diagnosis is 50
• More common in women.
• Present as a lung nodule or an endobronchial lesion
• welldefined,lobulated, peripheral mass lesions and range up to 20 cm in
diameter.
• Endobronchial lesions usually occur in the main or lobar bronchi-these
present with bronchial obstruction

70. Leiomyosarcoma
• More commoner
• Common in men
• pulmonary mass -larger than leiomyomas.
• Cavitation may occur
• p/w f/o endobronchial obstruction

71. benign metastasizing leiomyoma
• Multiple pulmonary “leiomyomas” associated with benign smooth
muscle tumors of the uterus

73. THANKYOU