Lung Tumors ppt - Prof Dr Faeza Aftan

LUNG TUMORS

Ch. 12 p (459 – 512) March. 9. 2016

LUNG TUMORS

Benign, malignant, epithelial, mesenchymal 90% Carcinoma 5% Carcinoids 2-5% Mesenchymal and others BIGGEST USA killer. a peak incidence in the 50s or 60s Only 15% 5 year survival.

Types of lung cancer

Adenocarcinoma Squamous cell carcinoma Large cell carcinoma Small cell carcinoma
NSCLC
SCLC
On the basis of likelihood of metastases and response to therapies

Types of lung cancer

Etiology and Pathogenesis
Tobacco, (10 - 60 times more in smokers)Secondhand smokeRadiation, asbestos, …..etc.familial clustering (polymorphisms)Genetic mutations Tumor suppressor genes include p53, Rb1, p16.Ch 3p. Oncogenes involved in lung cancer are; c-MYC, KRAS, EGFR, HER-2/neu, c-MET, and c-KIT.

Potentially curable asymptomatic cough hemoptysis
Presenting symptoms
Usually incurable dyspnea chest pain anorexia & weight loss hoarseness bone pain Pleural effusion

Positron Emission Tomography–computed tomography The bright red/yellow masses show hypermetabolic areas of with metastases
Spine
adrenal

At diagnosis, >50% have metastases Survival; Overall (all stages) 5ys = 16% Localized disease 5ys = 45%
Survival statistics…bad.

A precursor epithelial lesion

Sq. Dysplasia
Sq. CIS
Atypical adenomatous hyperplasia (AAH) , Adenocarcinoma in situ
The term precursor does not imply that progression to cancer will occur in all cases

Squamous cell carcinoma

Dx: Radiology, Cytology & Biopsy

Cytologic smears of sputum, bronchial lavage or brushings

Squamous cell carcinoma

Adenocarcinoma
Adenocarcinomas grow more slowly than Sq C ca, but tend to metastasize widely and earlier
Most common type in USA, especially in women < 45 years Usually peripheral, associated with scarring less frequently associated with a history of smoking (still, > 75% are in smokers) Sq C Ca or SC Ca(>98% in smokers).

Adenocarcinoma

aka “bronchioalveolar carcinoma”A rare type of adenocarcinoma5 year survival better (40%)Grows along existing architectureA precursor epithelial lesion. Adenocarcinoma in situ

Adenocarcinoma

Adenocarcinoma; involving most of the right lung

Consolidation (* ) similar to those seen with pneumonia. There is a loculated pleural effusion ( ) above the neoplasm, as seen on the left

Large cell carcinoma

Undifferentiated carcinomas Probably represent undifferentiated Sq C Ca or adenoca.

Totally different Ca.Small cells, minimal cytoplasm, “molding”strong relationship to cigarette smoking; only 1% occur in nonsmokersParaneoplastic syndromesHigh growth fraction treatment ineffectiveMedian survival (with treatment) = 1 year Small cell carcinoma

Small cell carcinoma

NSCLC & SCLC

Extension to the pleura Spread to LN, tracheal, bronchial, & mediastinal . Distant spread Adenoca & SCL Ca often spread early through the body. While Sq C Ca, metastasizes outside the thorax late
Local & Systemic Effects of Lung Tumor

Clinical Feature

Pathologic Basis
Pneumonia, abscess, lobar collapse
Tumor obstruction of airway
Pleural effusion
Tumor spread into pleura
Hoarseness Vocal cord paralysis
Recurrent laryngeal N. invasion
Dysphagia
Esophageal invasion
Diaphragm paralysis
Phrenic N. invasion
Pancoast syndrome
Involvement of brachial plexus
SVC syndrome
SVC compression by tumor
Horner syndrome
Sympathetic ganglia invasion
Pericarditis, tamponade
Pericardial involvement
Local Effects of Lung Tumor Spread

Superior vena cava syndrome in a person with bronchogenic Ca. swelling of his face first thing in the morning (left) and its resolution after being upright all day (right).

Pancoast syndrome

Horner syndrome; interruption of the sympathetic nerve supply to the eye, the classic triad of Miosis (constricted pupil), Anhidrosis (loss of hemifacial sweating), partial Ptosis,

MAP

Pancoast syndrome

• (ADH), hyponatremia due to inappropriate ADH secretion

• (ACTH), producing Cushing syndrome

• Parathormone, hypercalcemia

• Calcitonin, causing hypocalcemia

• Gonadotropins, causing gynecomastia

• Serotonin and bradykinin, associated with the carcinoid syndrome

Paraneoplastic Syndromes 1% to 10%

Lung Ca.Spread

Local: Pancoast tumor Neck Mediastinum SVC, Ns Distant spread Lymphatics Bl. (via pulm vein to liver, bone, brain, adrenal Non- Metastatic effects

T1
Tumor <3 cm without pleural or main stem bronchus involvement (T1a, <2 cm; T1b, 2–3 cm) T2
Tumor 3–7 cm or involvement of main stem bronchus 2 cm from carina, visceral pleural involvement, or lobar atelectasis (T2a, 3–5 cm; T2b, 5–7 cm) T3
Tumor >7 cm or one with involvement of chest wall (including superior sulcus tumors), diaphragm, mediastinal pleura, pericardium, main stem bronchus 2 cm from carina, or entire lung atelectasis, or separate tumor nodule(s) in the same lobe
T4
Tumor with invasion of mediastinum, heart, great vessels, trachea, esophagus, vertebral body, or carina or separate tumor nodules in a different ipsilateral lobe
N0
No demonstrable metastasis to regional lymph nodes
N1
Ipsilateral hilar or peribronchial nodal involvement
N2
Metastasis to ipsilateral mediastinal or subcarinal lymph nodes
N3
Metastasis to contralateral mediastinal or hilar lymph nodes, ipsilateral or contralateral scalene, or supraclavicular lymph nodes
M0
No distant metastasis
M1
Distant metastasis (M1a, separate tumor nodule in contralateral lobe or pleural nodules or malignant pleural effusion; M1b, distant metastasis)
International Staging System for Lung Cancer

Lung Tumors

SCC
Limited Stage (LS); (Lung & LN) Extended stage (ES) early metastasis
NSCLC
Adenocs; slowly growing but early metast SqCCa; Rapid growing but late metastasis Large cell Ca; Slowly growing & late Metas.

Treatment

Surg. Chemotherapy Radiotherapy Target therapy to the prodcts of mutant genes

Bronchial carcinoid

OTHER TUMORS

Coin lesions

Pulmonary hamartoma. islands of cartilage & respiratory epith.

METASTATIC TUMORS

Metastases to the lungs are more common even than primary lung neoplasms
Cannonball lesions

PLEURA

PLEURITIS PNEUMOTHORAX EFFUSIONS HYDRO-THORAX HEMO-THORAX CHYLO-THORAX MESOTHELIOMAS

Malignant tumor of mesothelial cells Most patients have had asbestos exposure Not related to smoking Highly malignant; short survival. Visceral or parietal pleura, pericardium, or peritoneum
Mesothelioma

Malignant mesothelioma

 EM H&E, IMMUNOCHEMISTRY

lung carcinoma. A, Gland-forming adenocarcinomaB, Well-diff. sq. c. ca. showing keratinization. C, SCLC with islands of small deeply basophilic cells D, Large cell ca., featuring pleomorphic, anaplastic tumor cells with no sq. or glandular differentiation.

PLEURITIS
Usual bacteria, viruses, etc.TB“Collagen” diseases, e.g., RA, SLEUremiaMetastaticInfarctsLung abscesses, empyema

PNEUMOTHORAX

SPONTANEOUS, TRAUMATIC, THERAPEUTICOPEN or CLOSED“TENSION” pneumothorax, “valvular” effect“Bleb” rupturePerforating injuriesPost needle biopsy

EFFUSIONS

TRANSUDATE EXUDATE BLOOD LYMPH

Mediastinal Tumors

Male Lung & bronchus 4105(12.7%) Bladder 3250 (10%) Leukemia 2618 (8%) NHL 2283(7%) Brain &CNS 2217 (6.9%) Larynx 1998(6%) Colorectal 1545(4.8%) Skin excluding 1342 (4%) Melanoma Stomach 1246(3.9%) Prostate 1081(3.3%)
Female Breast 9813 (31%) Leukemia 1858(6 %) Uterus including 1692 (5.3%) Cervix and corpus) Brain &CNS 1654(5.2%) NHL 1499(4.7%) Ovary 1203(3.8%) Colorectal 1191 (3.8%) Skin excluding 1083(3.4%) Melanoma Lung & bronchus 1052((3.3)
The 10 leading cancers by gender, site Iraqi Tumor Regestry 2009 J of Oncology

Primary site Total No Male No (%) Female No (%) Breast 10277 464(4.5%) 9813(95.5%) Lung & bronchus 5157 4105(79.6%) 1052(20.4%) Leukemia 4476 2618(58.5%) 1858(41.5%) Bladder 4253 3250(76.4%) 1003(23.6%) Brain &CNS 3871 2217(57.3%) 1654(42.7%) NHL 3782 2283(60.4%) 1499(39.6%) Colorectal 2736 1545(56.5%) 1191(43.5%) Larynx 2590 1998(77%) 592(23%) Skin excluding Melanoma 2425 1342(55.4%) 1083(44.6%) Stomach 2108 1246(59%) 862(41%) Uterus including Cervix and corpus) 1692 0 1692 Hodgkin disease 1502 925(61.6%) 577(38.4%) Thyroid 1334 446(33.4%) 888(66.6%) Kidney, pelvis& ureter 1232 754(61%) 478(39%) Ovary 1203 0 1203 Prostate 1081 1081 0 Pancreas 1014 575(56.7%) 439(43.3%) Bone & cartilage 999 58.7(58.8%) 412(41.2%) Liver &bile ducts 637 358(56%) 279(44%) Esophagus 539 342(63.5%) 197(36.5%)
Type of cancer by primary tumor site Iraqi Tumor Regestry 2009 J of Oncology