Neoplasms of Lung and Pleura Dr. Raid Jastania. Lung Neoplasms Neoplasm: –new growth –Monoclonal...
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Neoplasms of Lung and Pleura
Dr. Raid Jastania
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Lung Neoplasms• Neoplasm:
– new growth– Monoclonal proliferation– Genetic defect in genes controlling growth– Oncogens, tumor suppressor genes, genes
regulating apoptosis, DNA repair genes– Benign and Malignant– Features of malignancy
• Anaplasia, invasion, rapid growth, metastasis
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Lung Neoplasm• Primary, Secondary
• Benign, malignant
• Primary neoplasms:– Arise from any cell type (epithelial,
mesenchyml….)– 95% arise from bronchial epithelium
(Bronchogenic carcinoma)– Others: neuroendocrine cells, mesenchymal
cells
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Case
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Case
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What is the differential diagnoses of Mass lesion in the Lung
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Clinical Presentation
• Mass lesion: incidental, asymptomatic, or causing mass effect
• Dysfunction of the involved organ
• Invasion of the adjacent structures
• Metastasis
• Paraneoplstic syndromes
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Hamartoma of lung
• Not neoplastic, but mass lesion
• Discrete small peripheral nodule seen incidentally on x-ray on chest
• Benign, no risk of malignancy
• Consists of mature tissue in abnormal, disordered organization: cartilage, fat, fibrous tissue, vessels….
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Bronchogenic Carcinoma• 1st cause of death due to Cancer• Increasing incidence in females• M:F ratio is 2:1, age 55-65 years• Strong relation to smoking• It is malignant neoplasm arising from the
bronchial epithelium• Generally bad prognosis with high rate of
mortality, 50% presents with metastasis, Overall survival is 14%
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Clinical Presentation• Commonly presents as lung mass with hilar
lymphadenopathy, and symptoms related to lung disease
• If localized: can be asymptomatic, or presents with persistent cough
• Mass effect: resulting in respiratory dysfunction: cough, dyspnea, chest pain, hemoptysis
• Invasion of Pleura resulting in pleural effusion or pleuritis. Invasion of mediastal structures and vessels
• Mestastasis to brain, liver, adrenals….
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Clinical Presentation• Paraneoplastic Syndromes
– Hypercalcemia due to PTH-related peptide– Cushing syndrome due to ACTH secretion– Syndrome of inappropriate ADH secretion
SIADH– Neuromuscular syndrome: peripheral
neuropathy, polymyositis– Clubbing of fingers– Thrombophlebitis, non-bacterial endocarditis,
disseminated intravascular coagulation DIC
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Classification• Non-small cell lung cancer
– Squamous cell carcinoma– Adenocarcinoma– Large cell undifferentiated carcinoma
• Small cell lung cancer– Small cell carcinoma
• Neuroendocrine tumors– Carcinoid– Atypical carcinoid– Small cell carcinoma
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Value of the classificationSmall cell carcinoma
• Most present with advance disease
• High grade with fast progression
• Associated with smoking (almost all)
• Treatment is palliative
• Respond to chemotherapy and radiation
Non-small cell ca
• Can present with localized disease
• Variable behavior, depend on grade
• Sq ca is related to smoking, Adeno ca is less associated to smoking
• Treatment can be fro cure
• Surgery
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Etiology and Pathogenesis
• Common gene defects in lung cancer– SCLC: P53, RB mutation– NSLC: P16/CDKN2A– Adenocarcinoma: K-RAS
• Lung cancer develop through accumulation of genetic defects– Loss of 3p is very early event, occurs as a result
of smoking
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Etiology and Pathogenesis
• Smoking:– 90% of lung caner occurs in smokers– The risk shows linear increase with the
smoking intensity (pack-years)– 60x risk in a person with 40 pack-years
smoking– 2x risk in passive smokers
• Others: asbestos, vinyl chloride…• Genetic susceptibility
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Etiology and Pathogenesis
• Progression of lesions due to smoking:– Normal respiratory mucosa– Basal cell hyperplasia– Squamous metaplasia– Squamous dysplasia– Carcinoma in-situ– Invasive squamous cell carcinoma
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Morphology• Bronchial epithelium• Small mass arising from the bronchial epithelium• Invasion of submucosa and underlying lung tissue• Pushing and invasive borders• Central necrosis, hemorrhage, cavitation• Metastasis to lymph nodes: lobar, bronchial, hilar,
mediastinal, cervical, supraclavicular• Hematogenous spread: brain, liver, adrenal,
bone…• Body cavity metastasis: pleura
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Squamous cell carcinoma• M>F• Central mass, with areas of necrosis, and
cavitation• Hilar lymphadenopathy• Distal obstruction, atelectasis• Malignant cells in sputum and
bronchoalveolar lavage• Grade: well, moderate, poor differentiation• Paraneoplstic syndromes
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Adenocarcinoma
• Less associated with smoking
• Usually small, peripheral lung mass with gray gelatinous surface
• Grade: well, moderate, poor differentiation
• Metastasize early
• Special pattern: bronchioloalveolar carcinoma BAC
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Large cell undifferentiated carcinoma
• High grade tumor
• Poorly differentiated
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Small cell carcinoma
• Central mass with hilar and mediastinal lymphadopathy
• Small cells, nuclear molding, fine chromatin, mitosis, necrosis, neuroendocrine features
• High grade
• Respond to chemotherapy and radiation
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Special presentation of lung cancer
• Virchow node: supraclavicular node enlargement due to metastasis
• Superior vena cava syndrome: obstruction of the SVC by cancer
• Horner syndrome: ipsilateral enophthalmos, ptosis, meiosis, anhidrosis. It is caused by tumor involving the sympathetic nerves
• Pancoast tumor: lung cancer involving the upper lobe.
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Carcinoid
• Tumor arising from the endocrine cells (Kulchitsky cells)
• Mean age 40 years• Good prognosis• Mass lesion:
– Intraluminal mass in large bronchus– Peribronchial mass (collar-button lesion)
• Metastasis: rare 5-15%
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Carcinoid
• Micro: uniform cells with rounded nuclei, salt-and-pepper chromatin
• Atypical carcinoid: if the tumor cells show mitosis and necrosis
• 5 year survival: 50-95 %
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Malignant Mesothelioma
• Arise from parietal or visceral pleura or peritoneum
• 50% has relation to Asbestos, latent period 35-40 years
• Pleural fibrosis – plaque – localized mass – mass encasing the lungs
• Bad prognosis
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Diagnosis
• Clinical presentation
• Sputum
• Pleural fluid
• Fine needle aspiration
• Biopsy
• Resection
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