Lung Unit

Alveolus

TUMORS OF THE LUNG Histological classification

Primary tumors Bronchogenic tumors Non-bronchogenic tumor Secondary tumors (metastasis)

The incidence of the bronchogenic tumors

1. Non-small cell lung Ca (NSCLC): 70-75% a. SCC: 25 30 % b. AdenoCa, including bronchioloalveolar carcinoma: 30 35 % c. Large cell Ca: 10 15 % 2. Small Cell Lung Ca (SCLC) : 20 25 % 3. Combined : 5 1 0 % - SCC + adenoCa - SCC + SCLC

Bronchogenic Carcinoma

a. Squamous cell ca.: men >> women, smoking history central bronchus squamous metaplasia-displasia-Ca b. Adenocarcinoma : bronchial/ bronchioloalveolar type Women >> men, non smokers pheripherally location grow more slowly than SCC c. Small cell ca : Highly malignant tumor smokers, Hilar/ central EM: neurosecretory granules high response to chemotherapy : Undifferentiated ca

d. Large cell ca

Cytologic diagnoses of lung cancer

a. Sputum specimen b. FNA of Lnn : small cell ca

Clinical Relevances of Lung Cancer

Bronchogenic carcinoma
Silent, insidious lesion (become unresectable before they produce symptoms) Prognosis is bad when these symptoms appear: hoarseness, chest pain, superior vena cava syndrome, pericardial or pleural effusion persistent segmental atelectasis/pneumonitis Very often the tumor presents with symptoms due to metastasis to the brain (mental or neurologic changes), liver (hepatomegali), or bone (pain) NSCLCs have a better prognosis (lobectomy is possible when the tumor is detected before local spread or metastasis) than SCLCs

Clinical Relevances of Lung Cancer

Paraneoplastic Syndromes
1. Hypercalcemia due to secretion of parathyroid hormonerelated peptide --- SCC 2. Cushing syndrome (increased production of ACTH) 3. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) 4. Neuromuscular syndrome, including a myasthenic syndrome, peripheral neuropathy, and polymyositis. 5. Clubbing of the fingers and hypertrophic pulmonary steoarthropathy 6. Hemtologic manifestation: migratory thrombophlebitis, nonbacterial endocarditis, and dic --- adenocarcinoma 2,3,4,5, ----- small cell carcinoma

Bronchioloalveolar carcinoma

Terminal bronchoalveolar region Peripheral portion of the lung Males = females, all ages( 3rd decade- advanced years)

BRONCHIAL CARCINOID General remarks

Arise from Kulchitsky cells (neuroendocrine cells lining the bronchial mucosa) Occasionally occur in part of MEN Appear in early age (peak 40 years) 1-5% of all pulmonary neoplasms Mostly resectable and curable (not their neurondocrine counterpart : small cell carcinoma)

BRONCHIAL CARCINOID
PATHOLOGY
Small tumor : 3-4 cm - polypoid - penetrate the bronchial wall: - collar- button lesion Microscopical features: - nests of uniform round cells EM: dense-core granules IHC: serotonin, NSE, calcitonin etc

BRONCHIAL CARCINOID

SECONDARY TUMORS ( METASTASIS)

Pleural tumors
Neoplasma:Mesothelioma

Lymphnode stations

Lymphnode stations
Lymphnode stations are shown projected onto a chest-roentgenogram

S C Carcinoma in situ
SCC in situ Bronchial washing

No gross mucosal abnormalities

Bronchial brushing

Early invasive SCC

SCC in situ with foci of early invasion (nodular thickening)

Early invasive scc

SCC

Endobronchial SCC

Well differentiated SCC

Keratin mass

SCC moderately differentiated

Pearl formation

Individual cell keratinization

SCC moderately differentiated

Pearl formation Central squamous differentiation

SCC poorly differentiated

Dense eosinophilic cytoplasm

Adenocarcinoma

This lobectomy specimen shows a lobulated, somewhat glistening mass

Adenocarcinoma
Well differentiated

Adenocarcinoma
Moderately differentiated

Adenocarcinoma
Poorly differentiated

Adenocarcinoma
Cytology

3 dimension cell group, vacuolization

Bronchioloalveolar Carcinoma (BAC)

Nonmucinous type

Upper lobe is almost entirely consolidated by mucinous BAC, architecture is maintained, and there is an absence of necrosis and hemorrhage

Bronchioloalveolar Carcinoma (BAC)

Nonmucinous type

Bronchioloalveolar Carcinoma (BAC)

Nonmucinous type

Bronchioloalveolar Carcinoma (BAC)

Nonmucinous type

Bronchioloalveolar Carcinoma (BAC)

Mucinous type

Bronchioloalveolar Carcinoma (BAC)

Mucinous type

Pattern of Spread
1. Direct extention to adjecent structure 2. Aerogenous spread 3. Lymphatic spread 4. Hematogenous dissemination 5. Pleural seeding

Pattern of Spread

1. Direct extention

Pattern of Spread

2. Aerogenous dissemination

Pattern of Spread

3. Lymphangitic spread

Pattern of Spread

5. Pleural seeding

The Border of the Metastasis Tumor Mass

Alveolar soft part sarcoma, well circumscribed with pushing border. Metastases often have this appearance.

Irregular border: a nodule of metastatic leiomyosarcoma extends into the interstitium of the surrounding lung

Pattern of Metastasis
1. Milliary & Lymphangitic metastasis 2. Multinodular metastasis 3. Cannonball metastasis 4. Lymphangitic metastasis 5. Endobronchial metastasis 6. Intra-arterial metastasis 7. Pleural metastasis 8. Interstitial metastasis 9. Cavitary metastasis

Pattern of Metastasis

Miliary & Lymphangitic Metastasis

-Numerous minute nodules and larger area of ill-defined consolidation -Tthickening of the of small blood vessel, interlobular septa, and airways

Pattern of Metastasis

Multinodular metastasis

Yellow appearance to the metastatic nodules: abundant fat content of primary tumor: renalcell carcinoma

Black appearance in some nodules: primary Tumor is malignant melanoma

Pattern of Metastasis

Cannonball metastasis

Primary tumor: osteogenic sarcoma. A variety of tumors: sarcoma, renal cell Ca, malignant melanoma, colorectal Ca, may produce this appearance

Pattern of Metastasis

Lymphangitic metastasis

Primary tumor: leiomyosarcoma. Note the arborizing pattern produced by tumor within Perivascular lymphatics

Metastatic breast Ca. the perivascular lymphatics are markedly dilated and filled with clump of tumor cells

Pattern of Metastasis

Endobronchial metastasis

A nodular lesion protrudes into bronchial lumen

Pattern of Metastasis

Endobronchial metastasis

A submucosal nodule of metastatic rhabdomyosarcoma produces nodular protrusion of the bronchial mucosa into the lumen

Microscopic involvement of the airway is far More common than gross or clinically apparent involvement

Pattern of Metastasis

Intra-arterial metastasis

The tumor embolus is coiled in worm-like fashion within the lumen of the artery

Carcinomatous embolus in the lumen of small artery

Pattern of Metastasis

Pleural metastasis

Diffuse pleural metastasis simulating mesothelioma, the primary tumor is renal cell ca. Solid ring of the tumor occupies the pleural surface.

Pleural metrastasis of adenocarcinoma mimicking mesothelioma

Pattern of Metastasis

Interstitial metastasis

Interstitial metastasis of thymic carcinoid tumor nodular appearance.

Metastatic sarcomas more commonly adopt an Interstitial pattern than epithelial tumors.

Pattern of Metastasis

Cavitary metastasis

The primary tumor: teratoma of the testis undergo cavitary changes when it metastasizes to the lung.

The hemorrhagic tumor has undergone multifocal cavitation.