chest neoplasm

Chest neoplasm's


Chest neoplasms are best categorized by their primary location:
Lung tumors
Pleural tumors
Mediastinal tumors
Tumors of the airway Chest wall tumors

Classification of Pulmonary Neoplasm

Malignant tumors
Bronchogenic carcinoma Lymphoma
Metastases
Sarcomas, rare

LOW grade malignancies (previously bronchial adenoma) - Carcinoid, 90%

Adenoid cystic carcinoma (previously cylindroma, resembles salivary gland tumor), 6%
Mucoepidermoid carcinoma, 3%
Pleomorphic carcinoma, 1%


Benign tumors, rare
Hamartoma
Papilloma
Leiomyoma
Hemangioma
Chondroma
Multiple pulmonary fibroleiomyomas

Bronchogenic carcinoma

Bronchogenic carcinoma refers broadly to any carcinoma of the bronchus. However,the use of the term is usually restricted to the following entities:

Adenocarcinoma (most common), 40%

Bronchoalveolar carcinoma
Papillary adenocarcinoma
Acinar adenocarcinoma
Solid adenocarcinoma with mucus formation.

Squamous cell carcinoma, 30%

Small cell carcinoma, 15%
Oat cell
Large cell carcinoma 1%
Giant cell ca.


Risk Factors
-Smoking: 98% of male patients and 87% of female patients with lung cancer smoke; 10% of heavy smokers will develop lung cancer. The strongest relationship between smoking and cancer has been established for SCC followed by. adenocarcinoma; the least common association is for bronchoalveolar carcinoma
-Radiation, uranium miners ---Asbestos exposure
-Genetic predisposition (HLA-Bw44 associated?)

RADIOGRAPHIC SPECTRUM

Primary signs of malignancy
Mass (> 6 cm) or nodule (< 6 cm) with
spiculated, irregular borders
Unilateral enlargement of hilum: mediastinal
widening, hilar prominence
Cavitation
Most common in upper lobes or superior
segments of lower lobes
Wall thickness is indicative of malignancy
< 4 mm: 95% of cavitated lesions are
benign
> 15 mm: 85% of cavitated lesions are
malignant
Cavitation is most commonly seen in
squamous cell carcinoma
Certain tumors may present as chronic air space disease: bronchoalveolar
carcinoma, lymphoma
Some air bronchograms are commonly seen by HRCT in adenocarcinoma.


Secondary signs of malignancy-
Atelectasis (Golden's inverted "S" sign in RUL, LUL collapse)
Obstructive pneumonia
Pleural effusion
Interstitial patterns: lymphangitic tumor spread
Hilar and mediastinal adenopathy Metastases to ipsilateral, contralateral lung

LOCATION OF TUMORSTumorFrequencyLocation Comments< Adenocarcinoma30-35%PeripheralScar carcinoma- Squamous cell carcinoma30-35%Central, peripheral*CavitationSmall cell carcinoma15%Central, peripheral*-Endocrine activityLarge cell carcinoma1%Central, peripheralLarge mass'Rarely present as a resectable T1 lesion.

Paraneoplastic syndromes of lung cancer

Incidence: 2% of bronchogenic carcinoma.
Metabolic
Cushing's syndrome (ACTH)
Inappropriate antidiuresis (ADH)
Carcinoid syndrome (serotonin, other vasoactive substances) Hypercalcemia (PTH, bone mets)
Hypoglycemia (insulin-like factor)
Musculoskeletal
Neuromyopathies
Clubbing of fingers (HPO)


Other
Acanthosis nigricans
Thrombophlebitis
Anemia

Specific lung tumors

Adenocarcinoma

Now the most frequent primary lung cancer .. Typically presents

as a multilobulated , peripheral mass. May arise in scar tissue: scar carcinoma .

Squamous cell carcinoma

SCC is most directly linked with smoking. SCC carries the most favorable prognosis. The most characteristic radiographic appearances are:
Cavitating lung mass, 30% Peripheral nodule, 30%
Central obstructing lesion causing lobar collapse
Chest wall invasion

Pancoast Tumor (superior sulcus tumor)

Tumor located in the lung apex that has extended into the adjacent chest wall. Histologically, Pancoast tumors are often squamous cell_carcinoma. Clinically Horneir syndrome, pain , radiating into arm (invasion of pleura, bone, brachial plexus, or subclavian vessels).
Radiographic features
Apical mass
Chest wall invasion
Involvement of subclavian vessels
Brachial plexus involvement

Bone involvement: rib, vertebral body

Small Cell Carcinoma

Most aggressive lung tumor with poor prognosis. At diagnosis,

80% of patients already have extrathoracic spread:
Typical initial presentation; massive bilateral lymphadenopathy
With or without lobar collapse -
_ Brain metastases

Large cell carcinoma

presents as large (>70% are > 4 cm at initial diagnosis) peripheral mass lesions. Overall uncommon tumor.

Carcinoid (Neuroendocrine tumor types 1 and 2)

Represent 90% of low-grade malignancy tumors of the lung. The 10-year survival with surgical treatment is 85%. Types: -
Typical carcinoid: local tumor (Type 1)
Atypical carcinoidJ.10%-20%): metastasizes to regional lymph nodes (Type II); liver metastases are very rare and therefore the carcinoid syndrome rarely develops.


Radiographic features
Centrally located carcinoid. 80%
segmental or lobar collapse (most common finding) Periodic exacerbation of atelectasis Endobronchial mass

Peripherally located carcinoid, 20% Pulmonary nodule May enhance with contrast

Hamartomas

Hamartomas are benign tumors and are_composed of cartilage (predominant component), connective tissue, muscle, fat, and bone. 90% are peripheral, 10% are endobronchial.

Radiographic features

Well-circumscribed solitary nodules

Chondroid "popcorn" calcification is diagnostic, but uncommon (< 20%)

Fat attenuation within a lesion by HRCT is pathognomonic

Lung Metastates From Other Primaries

Pathway of metastatic spread from a primary extrathoracic site
to lungs (in order of frequency):
Spread via pulmonary arteries
Lymphatic spread (celiac nodes -> posterior mediastinalHYPERLINK "http://_no.de"_nodes and paraesophageal nodes) and in lung parenchyma "
Direct extension
Endobronchial spread


Neoplasms with rich vascular supply draining into systemic venous system
Renal cell carcinoma y
Sarcomas
Trophoblastic tumors
Testicle
Thyroid

Neoplasms with lymphatic dissemination Breast (usually unilateral) Stomach (usually bilateral) Pancreas Larynx Cervix

Other neoplasms with high propensity to localize in lung ' Colon

Melanoma ,
sarcoma

Radiographic features

Multiple lesions. 95% > solitary lesion, 5%
Lung bases > apices (related to blood flow)
Peripheral, 90% > central__lQ%
Metastases typically have sharp margins
Fuzzy margins can result from peritumoral hemorrhage (choriocarcinoma, chemotherapy)
Cavitations are common in squamous cell carcinomas from headand neck primaries .


Calcified Metastases

Calcification in lung metastases are observed in:

Bone tumor metastases
Osteosarcoma
Chondrosarcoma

Mucinous tumors

Ovarian
Thyroid
Pancreas _
Colon Stomach
Metastases after chemotherapy










Vascular invasion

Brachial plexus

Vertebral invasion

Tissuetissue mass m si s s

p calcification