1. LUNG TUMORS

2. LUNG TUMORS
Primary :
• 95 % are Bronchogenic Carcinoma
– Extremely common
– M:F = 2:1 , Age 55-65
• 5% are Bronchial carcinoids
Mesenchymal malignancies
Lymphomas
Benign lesions: hamartoma
Secondary : very common

3. Bronchogenic Carcinoma:
• Commonest cause of cancer related deaths in
males, and in the US in females as well
• The rate of increase is declining in males but is
accelerating in females
• Majority are related to smoking
• Bad prognosis ( 5 year survival for all stages of
lung cancer combined < 15%)
• If localized to lung 5 yr survival is 45%

4. Types of Lung carcinoma :
• SMALL CELL LUNG CANCER (SCLC)
– Small Cell Carcinoma
• NON SMALL CELL LUNG CANCER : NSCLC
– Squamous Cell Carcinoma
– Adenocarcinoma
– Large Cell Carcinoma
• Note : Combined patterns are possible

5. - Squamous cell carcinoma was the most
common type but has recently been
replaced by adenocarcinoma
- Adenocarcinoma most common type in
females, nonsmokers and patients < 45
years

7. • Division is for therapeutic purposes
• Virtually all SCLC have metastasized by time of
diagnosis →→ treated by chemotherapy +/radiotherapy
• NSCLC better treated by surgery
• Genetic differences:
SCLC : RB gene mutation
NSCLC: p16/CDKN2A gene inactivation
KRAS & EGFR oncogene mutation

8. Etiology
1- Cigarette smoking – ↑↑↑ risk
– Contains numerous carcinogens
– Up to 90% squamous & small cell CA
occur in smokers
– Correlation between smoking in pack
years & lung CA : 60X increased risk in heavy
habitual smokers
– Passive smoking : 2X
– Effect of carcinogen is genetically
conditioned

9. 2 - Genetic Factors :
• Stepwise accumulation of genetic mutations
triggered by carcinogens
• Earliest is inactivation of suppressor gene on
chromosome 3P
• Later mutations in P53 & K- RAS …etc :
– Activating mutations in EGFR & K-RAS
in adenocarcinoma
– RB mutation in Small Cell Carcinoma
– P 16/ CDKN2A inactivation in NSCLC

10. 3- Environmental Hazards :
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•
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•
Asbestos workers
Uranium workers
Exposure to radiation
Nickel , arsenic , chromate….etc
4- Scarring in lung tissue
( Scar Cancer ) usually adenocarcinoma

11. Diagnostic techniques for lung cancer :
1- Chest X ray, CT, …..etc
2- Sputum Cytology & bronchial wash
3- Bronchial biopsy : Biopsy taken by
bronchoscope
4- Transbronchial biopsy : forceps down
bronchoscope into lung parenchyma to
take a biopsy.
5- Transcutaneous needle biopsy
6 -Open lung biopsy

12. A- Squamous cell CA
B- Small Cell CA

13. Gross appearance of most types :
Central
• Thickening of mucosa
• Later may show irregular whitish warty
lesion→ ulceration
• Infiltration of wall of bronchus into lung
• Hemorrhage, necrosis & cavitation may be
seen
Peripheral:
• Consolidated rounded lesion

14. Central Cancer

15. Peripheral Cancer

16. 1- SQUAMOUS CELL CA :
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•
•
•
Male> female, > 90% in smokers
Usually central location, Warty ± cavitation
May present with HYPERCALCEMIA
Precursor Lesion:
– Squamous metaplasia → Dysplasia →
Carcinoma in Situ → Squamous cell CA
• Histology :Various degrees of squamous
differentiation ± Keratin formation
• Prognosis better than Small Cell CA

17. Squamous metaplasia & Carcinoma in situ

18. 2- ADENOCARCINOMA :
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•
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•
•
Commonest in females
Least associated with smoking
Usually peripheral but may be central
Growth is slower than squamous but widely metastasize
Types include :
A- Usual bronchial derived ( 80%) ±mucin.
May be:
–
Acinar
–
Papillary
–
Solid

19. • B- Bronchioloalveolar CA :
•
•
•
•
Multifocal diffuse or localized nodule .
Peripheral location
May present as pneumonic consolidation
Growth along alveolar walls without
destruction of walls (non-invasive)
• Prognosis of better than usual
adenocarcinoma.

20. Bronchioalveolar Carcinoma

21. Precursor Lesions in
Adenocarcinoma:
• ? Presence of Bronchioalveolar Alveolar
Stem Cells (BASC) expansion after lung
injury
• Atypical Adenomatous Hyperplasia (AAH)
→ Bronchioalveolar CA →
Adenocarcinoma
• AAH has same 3P deletion & K-RAS
mutation similar to CA

22. 3- LARGE CELL ANAPLASTIC CARCINOMA :
• Poorly differentiated tumors
• Difficult to type, may need special
immunostains.
• Incidence is about ( 10-15 % )
• Probably poorly differentiated Squamous Cell
CA or Adenocarcinoma
• Prognosis is poor

23. 4- SMALL CELL CARCINOMA (SCLC)
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Male > Female , >90% in smokers
Arise from neuroendocrine cells
Central mass
Most aggressive,necrosis, metastasize early
Most frequent type with ectopic hormones
Cytology: Crush artefact, nuclear molding
Histology : Small blue cells (Oat Cell CA) mitosis+
+,necrosis++

24. A- Squamous cell CA
B- Small Cell CA

25. Types of Bronchial Carcinoma

26. Spread of lung cancer :
1- Local extension
pleura , pericardium & mediastinum ,
nerves & vessels
2- Lymph node metastases
regional L.N. ,bronchial, tracheal and
mediastinal
3-Distant metastases :
Adrenal (> 50% ) , Liver , Brain , bone …

27. Staging of Lung CA
• BASED ON TNM STAGING SYSTEM :
• Stage I = T1 N0 M0 (tumor <3cm.)
• Stage II = T2 N1 M0 ( tumor > 3cm.)
• Stage III = T3 N1 M0 ( tumor involving chest
wall, mediastinum, contralateral
nodes….etc.)
• Stage IV = Any T, any N, M1

28. Local & regional invasion :
i- Lymphatic : carina, mediastinum & neck
- Mediastinal invasion →
– Recurrent laryngeal n. on left →vocal cord
paralysis
– Phrenic nerve → diaphragmatic paralysis
– Esophagus → bronchoesophageal fistula
– Cardiac & pericardial invasion
– Chest wall invasion → Pain & pleural effusion

29. Late invasion of upper lobe tumors :
• Right upper lobe tumors or LN’s compress SVC →
Superior Vena Cava Syndrome
• Apical tumors ‘Pancoast’tumor :
– Brachial plexus → Pain in distribution of ulnar nerve
– Destruction of 1st.&2nd.rib ± vertebrae
– Sympathetic chain invasion→Horner’s Syndrome
(ipsilateral enophthalmus,ptosis,miosis &anhydrosis )

30. Extrathoracic Metastases :
adrenals → no symptoms
bone → pain , fracture,↑Ca & alkaline
phosphatase
brain → headache, convulsions …. etc
liver → incidental or hepatomegaly,
ascitis…etc.

31. Paraneoplastic Syndrome :
Present in 10% of tumors, most in SCLC
• Ectopic hormone production :
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ADH , ACTH, Gonadotrophic H….in SCLC
PTH relared peptide→↑ Calcium in Squamous cell
CA
• Migratory thrombophlebitis, DIC in AdenoCA
• Digital clubbing,hypertrophic osteoarthropathy
• Neuromuscular disorders …etc in SCLC

32. Carcinoid tumor (neuroendocrine cancer
grade I)
• Younger age than CA , 5% of lung tumors
• Arise from neuroendocrine cells
• Most arise in bronchial wall, fill lumen or
extend into lung
• Histology:
Uniform cells , absent mitoses , arranged in
nests, cords .
• Atypical Carcinoid :
Show mitoses , necrosis, atypia

33. Symptoms :
• Obstruction & atelectasis
• Infection
• Most cases are hormonally inactive but
few produce the Carcinoid syndrome
• Surgery curative in most cases
• About 30 % may metastasize to lymph
nodes ± distant metastases

34. Carcinoid tumor

35. Metastatic tumors in lung
• All types of carcinomas or sarcomas can
metastasize to the lung
• Reach lung by lymphatic or hematogenous route
& may show :
– Multiple discrete nodules , (Cannon Ball )
– Single nodule
– Diffuse lymphatic dissemination called
Lymphangitis Carcinomatosa
• Pleural effusion is common in metastatic tumors

37. Tumor- like lesions of the lung :
Lung Hamartoma :
• Consists of cartilage,& clefts lined by
respiratory epithelium surrounded by
connective tissue
• Usually peripheral , & incidental
( Coin Lesion )
• May simulate tumor radiologically

38. PLEURAL EFFUSION
• Pleural effusion is a common manifestation of both
primary and secondary pleural diseases. Normally,
no more than 15 mL of serous, relatively acellular,
clear fluid lubricates the pleural surface.
• Pleural Effusion : Accumulation of fluid
– Transudate – CHF, Liver failure ,Renal failure
– Exudate - Pneumonias
– Hemorrhagic- Cancer ,TB, Infarcts
•

39. • Increased accumulation of pleural fluid
occurs in the following settings:
• Increased hydrostatic pressure, as in congestive
heart failure
• Increased vascular permeability, as in
pneumonia
• Decreased osmotic pressure, as in nephrotic
syndrome
• Increased intrapleural negative pressure, as in
atelectasis
• Decreased lymphatic drainage, as in mediastinal
carcinomatosis

40. PLEURA
• Hemothorax : Blood in pleural cavity
– Trauma
– Rupture of dissecting aneurysm
• Pyothorax/Empyema : Pus in pleural
cavity

41. • Chylothorax :
– Accumulation of milky, lipid rich fluid due to lymphatic
obstruction, usually be tumor
• Pneumothorax :
– Traumatic – Penetrating injury
– Spontaneous : TB,emphysema , Asthma
• Tension Pneumothorax :
– Medical emergency with air entering under pressure
→ Atelectasis

42. • Clinical Picture :
Chest pain
– Ipsilateral shoulder pain – diaphragm
– Non-productive cough
• Compression Atelectasis

43. PLEURA
Malignant Mesothelioma :
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Rare tumors of mesothelial cells
Exposure to asbestos in >50%
Long latent period
Not related to smoking
• Pathogenesis :
– Inactivation of several tumor suppressor genes
– Simian virus 40 viral DNA in 60-80% cases
inactivates p53 & RB

44. Morphology :
• Starts as pleural fibrosis & plaque
• Later firm yellowish white tumor around
the pleura
• Microscopically : mixed pattern
– Epithelial
– Sarcomatoid
– Biphasic
• Prognosis : POOR

46. Tumors in Upper Respiratory Tract :
• Nasopharyngeal Carcinoma :
– EBV related
– Squamous cell & Undifferentiated carcinoma
– Numerous lymphocytes(Lymphoepithelioma)
• Laryngeal Tumors :
– Benign : Polyps & Papillomas
– Malignant : Carcinoma

47. Laryngeal Carcinoma :
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Squamous cell CA
Middle age , M>F
Etiology : Smoking & Alcohol
Mainly on vocal cords → hoarseness of
voice
• Carcinoma in situ → Invasive squamous
cell carcinoma → Lymph nodes & neck
• May be cured if early