LUNG TUMORS presentation

1. • Most common cause of cancer mortality
worldwide

2. Indian-born (1970 ) American
physician, scientist
A hematologist and oncologist

3. • On average, smokers increase their risk of lung
cancer between 5 and 10-fold and in developed
countries,
• smoking is responsible for upwards of 80% of all
lung cancers.
• in a report from India, roughly two-thirds of all
patients with lung cancer were smokers, using
either cigarettes and/or bidis, hand-rolled
tobacco.

4. TUMORS OF THE LUNG
TYPES :
• Carcinomas – 90-95 %
• Carcinoids – 5%
• Mesenchymal tumour – 2-5 %

5. HISTOLOGIC CLASSIFICATION OF MALIGNANT
EPITHELIAL LUNG TUMORS
• Squamous Cell Carcinoma
• Adenocarcinoma
• Adenosquamous Carcinoma
• Large Cell Carcinoma
• Small cell carcinoma

6. • Carcinomas with pleomorphic, sarcomatoid,
or sarcomatous elements
• Carcinoid tumor
– Typical
– Atypical
. Carcinoma of salivary gland type
. Unclassified Carcinoma

8. Etiology and pathogenesis
• Several environmental factors are known to
cause genetic damage that transform benign
bronchial epithelium to neoplastic tissue

9. 1 -Tobacco Smoking
• Overwhelming evidence
• 87% lung carcinoma occurs in smokers
• 10 fold greater risk – Average smoker
• 60 fold greater risk – Heavy smokers
• Passive smoking – 3000 deaths per year

10. Histologic sequence of events:
• Normal epithelium
• Squamous Metaplasia
• Squamous Dysplasia
• Carcinoma in situ
• Invasive Carcinoma

12. Cytogenetics :
Mutations in p53 gene
( G: C > T: A)
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Carcinogens in cigarette smoke:
Polycyclic aromatic hydrocarbons – Benzopyrine
Phenol derivatives
Radioactive elements
– Polonium – 210
– Carbon – 14
– Potassium - 40
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13. Other Contaminants :
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Arsenic
Nickel
Molds
Additives

14. 2 -Industrial Hazards
• High dose Ionizing Radiation; High incidence in
Hiroshima / Nagasaki atomic bomb survivors
• Uranium – 4 times increased risk in nonsmoker
uranium miners
• Asbestos – 5 times increased risk in nonsmokers, 50-
90 times in smokers
• Latent period – 10-30 years

15. 3 -Air Pollution
• Indoor air pollution – Radon
• Increased incidence in miners .

16. Molecular Genetics
-For all practical purposes, lung cancer is divided into
two clinical subgroups :
a - Small Cell Carcinoma
b - Nonsmall Cell Carcinoma
-Supported by some specific molecular lesions in
each subgroup .
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17. Small Cell Carcinoma Genes :
• C-KIT
• MYC N
• MYC L
• p53
• 3p ( Early genetic change )
• RB
• BCL 2

18. Non Small Cell Carcinoma Genes :
• EGFR
• KRAS ( Late genetic change)
• p53
• p16 INK4a

19. MORPHOLOGY
• Origin :
– ¾ in the hilus – Bronchi
– ¼ in the periphery – Alveolar
septal cells, terminal
bronchioles

20. PRECURSOR LESION PHASE
• ( Squamous metaplasia ,Dysplasia,
Carcinoma in situ )
– Preceed invasive carcinoma
– May last for many years
– Asymptomatic
– No X-Ray changes; Small lesion
– Positive diagnostic test ;
Cytology ( Sputum, Bronchial lavage fluid/
brushings )

21. POST INVASION PHASE
• Larger tumour mass
• Symptomatic, obstruct major bronchus
– Infection ( Pneumonia )
– Atelectasis
. Grow inside the bronchus; fungating mass
. Penetrate the wall of the bronchus into the
peribronchial tissue

22. POST INVASION PHASE
INVASIVE LESION

23. • Cauliflower like intraparenchymal mass
• Grey white, firm to hard
• Yellowish white mottling and softening
• Extension to pleural surface and cavity
• Involve pericardium
• Regional lymph node involvement (Tracheal,
Bronchial, Mediastinal )

25. Metastasis
• Via both lymphatics and hematogenous
spread
• May be the first manifestation
• Any organ; most commonly
– Adrenals ( 60 %)
– Liver ( 30-50%)
– Brain ( 20% )
– Bone ( 20% )

27. SQUAMOUS CELL CARCINOMA
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Most common lung cancer in Males
Strong correlation with smoking
Arise from segmental bronchi
HISTOLOGY :
– Sheets / clusters of atypical squamous cells
– Keratinization / squamous pearls varies with grade
of tumour
– Intercellular bridges

34. Histologic Grades :
Well differentiated
Moderately differentiated
Poorly differentiated
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Cytogenetics :
- p53 mutation; Most common
- RB1, p16 ( INK4a), EGFR
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Alleles at 3p, 9p, 17p
EGFR overexpression

35. ADENOCARCINOMA
• Malignant epithelial tumour with glandular
differentiation or mucin production
• Patterns of growth :
– Acinar
– Papillary
– Bronchioloalveolar
– Solid with mucin formation

36. ADENOCARCINOMA; CHARACTERISTICS
Most common type in :
Woman
Non-smokers ( 75% v/s > 98% )
Lesion more peripherally located
Smaller size
Slow growth
Early and widespread mets
Cytogenetics ;
- K RAS ( Specific for adenocarcinoma )
- p53 , RB1, p16
- EGFR ( mutation, amplification )
- C-MET
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39. SMALL CELL CARCINOMA
• Highly malignant tumour
• Strong correlation to cigarette smoking (Only
1% in non-smokers)
• May arise centrally or peripherally
• No percursor / preinvasive lesion
• Widely metastatic
• Surgically incurable
• Ectopic hormone production

40. Small Cell Carcinoma
• Cytogenetics :
- p53 mutation
- RB1 mutation

43. Small Cell Carcinoma
Histology :
Clusters of relatively
small round/oval/spindle
shaped neoplastic
epithelial cells with scant
cytoplasm, illdefined cell
borders
Salt and pepper
chromatin
Absent /inconspicuous
nucleoli
Prominent nuclear
molding
High mitotic count
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44. LARGE CELL CARCINOMA
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Large neoplastic cells
Increased N/C ratio
Prominent Nucleoli
Represent poorly differentiated Squamous Cell
Carcinoma and Adenocarcinoma
Histologic variants :
– Large cell neuroendocrine carcinoma; organoid nests,
trabeculae, rosette-like and pallisading patterns
– Neuroendocrine features both on Immunohistochemistry
and Electron Microscopy
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45. Small Cell Carcinoma
Immunohistochemistry :
Synaptophysin
Chromogranin
CD 57
Parathyroid hormone- like product
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Electron Microscopy :
Dense core neurosecretory granules

46. Combined Carcinoma
• Histology similar to two or more of usual lung
carcinomas

47. Bronchioloalveolar Carcinoma
• Arises in terminal bronchioloalveolar region
• 1-9 %
• Gross :
– Single / multiple nodules in lung periphery
– Solid, grey white areas like pneumonia

49. Bronchioloalveolar Carcinoma
Histology :
Growth along the preexisting structures
Preservation of alveolar architecture
No stromal, vascular or pleural invasion
Sub types :
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- Mucinous: Tall columnar cells with cytoplasmic /
intraalveolar mucin
- Non-mucinous: Columnar or cuboidal cells

52. Complications of CA Lung
• Emphysema
• Atelectasis
• Severe suppurative /ulcerative bronchitis
• Bronchiectasis
• Lung Abscess
• Superior vena cava syndrome
• Pericarditis
• Pleuritis

53. CLINICAL PRESENTATION
• Cough
• Weight loss
• Chest pain
• Dyspnoea

54. INVESTIGATIONS
• Chest X-Ray
• Sputum for Cytology
• Bronchial washings / brushings for Cytology
• CT guided lung biopsy
• CT Scan / MRI

55. TREATMENT
Early stage disease ( 15% )
– Lobectomy
– Pneumonectomy
Last stage Disease
– Chemotherapy
– Radiotherapy
– EGFR inhibitors

56. SURVIVAL RATE
•Early stage : 48%
•Last stage : 10-15 %

57. Carcinoid tumour
• 1-5 %
• < 40 years of age
• 20-40 % nonsmokers
• Behavior; low grade malignant epithelial
neoplasm
• Subclassified into :
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Typical
Atypical
• Central / peripheral origin

58. Carcinoid Tumor
Morphology :
• Gross :
– Finger- like or spherical polypoidal masses
– Project into the lumen of mainstem bronchi
– Covered by intact mucosa
– Size ;usually < 3-4 cm

59. Carcinoid Tumor
Histology:
Patterns – Organoid, trabecular, pallisading, ribbon
or rosette-like
Delicate fibrovascular stroma
Regular, uniform, round cells with moderate
cytoplasm
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• Mitosis; < 2 /10 x HPF – Typical Carcinoid.
2-10 /10 x HPF – Atypical Carcinoid.

60. Carcinoid tumor of the lung.
A central carcinoid tumor (arrow) is
circumscribed and protrudes into the
lumen of the main bronchus. The
compression of the bronchus by the
tumor caused the postobstructive
pneumonia seen in the distal lung
parenchyma (right).
A microscopic view shows ribbons of
tumor cells embedded in a vascular
stroma.

61. MISCLENOUS TUMOURS
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Inflammatory Myofibroblastic Tumor
Fibroma
Fibrosarcoma
Lymphangioleiomyomatosis
Leiomyoma
Haemangioma
Haemangiopericytoma
Chordoma
Langerhan Cell Histiocytosis
Hamartoma

62. METASTASIS TO LUNG
• More common than any of the other lung
malignancy
• From any carcinoma/sarcoma

64. • TUMORS OF PLEURA

65. PLEURAL TUMORS

67. Pleural Tumors
Malignant Mesothelioma :
Asbestos exposure ; 7-10 %
Latent period ; 25-45 years
-Histology :
Asbestos bodies in the lung
Asbestos plaque
-Cytogenetics :
Del 1p, 3pCq ,9p or 22q
p16 mutation
p53 mutation
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68. Malignant Mesothelioma
Morphology :
Gross :
Thick layer of soft,gelatinous greyish
pink tumour “ensheathing” the lung
Histology :
. Epithelioid- 60 %; Cuboidal /Columnar cells,
tubules or papillary
.Sarcomatoid- 20%; spindle cell growth
resembling Fibrosarcoma
.Mixed- 20%
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73. Malignant Mesothelioma
- Clinical Presentation :
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Chest pain
Dyspnoea
Recurrent pleural effusions
Hilar Lymphadenopathy
Distant mets ; liver etc.
- Prognosis :
50% die within 12 months

74. Malignant Mesothelioma
Treatment :
• Extrapleural pneumonectomy
• Chemotherapy
• Radiotherapy