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Lung Tumors


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Bronchogenic Carcinoma


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Introduction

Brochogenic carcinoma is also called Lung cancer.

It is a frequent and important neoplasm in both

developed country and developing country. In recent years, it has been reported that lung

cancer is the leading fatal neoplasm of men and

women. It is strongly associated with the use of tobacco

products, particularly with cigarettes.


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Incidence and prevalence

Lung cancer is the leading cause of cancer-related death of men in 28 developed countries of

the world

Squamous cell carcinoma is thought to be themost frequent form of the tumor (30-50 percent of

all cases),followed by adenocarcinoma, large cell

carcinoma, and small cell carcinoma.

Nowadays an increase has occurred in the

incidence of adenocarcinoma, which is the most

common histologic subtype.


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Endobronchial leiomyoma

Tracheal lipoma

Endobronchial schwannoma


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Etiology and pathogenesis

Cigarette smoking

Occupational associations: asbestos,

uranium (in miners), arsenical fumes,

nickel,radon gas ects.

Other factors include air pollutions ,

ionizing radiation .

Nowadays It is reported that tuberculosis is

associated with the incidence of lung

cancer.


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Pathogenesis

Many factors influence the formation oflung cancer. The development of lungcancer is a multistepp process. Thetransformation process of normalbronchial epithelial cells to malignantcells is unknown.

Perhaps It is related to: damage of

cellular DNA; alteration in cellularoncogen expression; tumor-derivedfactors that stimulate cellular division.


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Etiology and pathogenesis

Chronic inflammation of the lung, such

as from interstitial fibrosis and areas of

scarring is associated with the occurrenceof adenocarcinoma.

Genetic factors are also involved in the

formation of lung cancer.


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Major categories of genes that potentially

determine susceptibility to lung cancer, includeproto-oncogenes, tumor suppressor genes, ects.

Oncogene abnormalitiesOncogene SCLC NSCLC

Ki-ras 0 30-50% of adenocarcinomasH-ras 0 Rare mutation, over expression

N-ras 0 Rare mutation, over expression

Myc Majority Gene amplification and

overexpression


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ClassificationsAccording to anatomy:

(1)Central lung cancer,mostly is squamous cellcarcinoma and small cell carcinoma.

(2) Peripheral lung cancer, mostly is adenocarcinoma.

According to histologic classification:

Small cell lung cancer(SCLC)

Non-small cell lung cancer(NSCLC).

Squamous cell carcinoma

Large cell carcinoma

Adenocarcinoma

Adenosquamous carcinoma.


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Small Cell Carcinoma


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Adenocarcinoma


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Adenocarcinoma


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B. Non-Small Cell Carcinoma Squamous cell carcinoma: It is the most common

subtype.It arises from altered bronchial epitheliumand growth in situ.It is related to cigarettesmoking.Cavitation can occure distal to theobstructing mass.

Adenocarcinoma: It arises from the submucosalglands,located in peripheral airways andalveoli.Peripheral adenocarcinomas are usually well-circumscribed, grey-white masses that rarely cavitate.

Adenocarcinoma is usually a slow-growing cancer,but can be difficult to detect because the diseasetypically involves the periphery of the lung, resultingin fewer early symptoms than cancers that develop

centrally, near the airways


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Classification

Large-cell carcinoma, can be quite large and

not infrequently cavitate. The tumor cells have

large nuclei,prominent nucleoli and abundant

cytoplsma.

There are two types Giant-cell carcinoma

Clear-cell carcinoma.

Adenosquamouscc: There are definite featuresof adenocarcinoma and squamous ce carcinoma.


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Clinical Manifestations

Due to primary lesions:

cough, dyspnea, hemoptysis, sputum, wheezing,

weight loss, fever, pneumonia

Due to local extension:chest pain,hoarseness,superior vena cava

syndrome, horners syndrome, dysphagia,

pericardial effusion,pleural effusion,diaphragm paralysis

Only 5-15 percent of patients are asymptomaticwhen discovered to have bronchogenic carcinoma.


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Clinical manifestations

Regionnal spread to hilar and mediastinal

nodes may cause dysphagia due to esophageal

compression, horsenessdue to recurrent laryngealnerve compression, horners syndrome due to

sympathetic nerve involvement, and elevation of

the hemidiaphragm from phrenic nervecompression.


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Pancoasts Tumor


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Extrapulmonary manifestations. Including

metastasis to other organs, such as brain,

central nervous system, skeleton system,

liver,adrenal glands and lymph nodes ects.

Paraneoplastic syndromes are remote effects

of the tumor. They lead to metabolic and

neuromuscular disturbances unrelated to theprimary tumor, metastases, or treatment. They

may be the first sign of the tumor.They do not

indicate that a tumor has spread.


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Paraneoplastic syndromesinclude:

hypertrophic pulmonary osteoarthropathy hypercalcemia

inappropriate antidiuretic hormonesecretion syndrome

polymyositis

subacute cerebellar degeneration peripheral neuropathies cushingssyndrome ects.


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Physical examinations

Endobronchial obstruction may result in

a localized wheeze

Lobar collapse may result in an area of

decreased breath sounds and dullness to

percussion.


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Diagnosis of lung cancer requires:

A:detecting the tumor

B:establish the cell type

C:define the stage of the tumor among

these, determing cell type is the most

important because it influences the

treatment.

Diagnosis of Bronchogeniccarcinoma


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Available methods to detect the tumor: Chest X-ray

Computer Tomography(CT)

Magnetic Resonance imaging (MRI)

Positron Emission Tomography (PET)

Hystologic examination (mainly sputum

examination, bronchoscopy biopsy,bronchial

brushing , bronchial washings, transbronchialneedle aspiration and transthoracic needle).


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Chest X-ray

Is the most important examination method. Itcan detect the presence of lung cancer. Themost frequent finding is a tumoral mass in thelung field.

Secondary manifestations seen on the chestradiograph include lober collapse,pneumonitisbecause of endobronchial obstruction,elevationof the hemidiaphragm, pleural effusion, hilar

and mediastinal adenopathy and erosion of ribsor vertebrae due to metastases.

Alveolar cell cancer can manifest as a localizedinfiltrate mimicking pneumonia.


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Chest X-ray

If a patient presents with chronic cough,

sputum with blood stipes, and dyspnea, lowfever we must perform a chest X-ray. The

most frequent finding is a mass in the lung

field.


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On chest X-ray, secondary manifestations

include lobar collapse, pleural effusion,

pneumonitis, elevation of the hemidiaphragm,hilar and mediastinal adenopathy, and

erosion of ribs or vertebrae due to metastases.


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Obstructive atelectasis


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Central bronchogenic carcinoma


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Central lung cancer manifestations

on chest radiography

Secondary manifestations we mentioned

above may be exist if metastases happen,including lobar collaps, obstuctive

pneumonitis, pleural effusion.

Mainly shows a mass locate in the one side

of hilar,some times it makes the mediastinum

widen.


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Peripheral lung cancer on chest

radiography

The most frequent finding is a mass in the

lung field. Sometimes the mass is not smooth,and with a cavity. Secondary manifestations

can be also seen on the chest X-ray, such as

pleural effusion.


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Alveolar cancer on chestradiography

The chest X-ray usually shows dissiminatedsmall nodules in the lung field.


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Lung cancer on CT

CT is the most useful in evaluating patientswith pulmonary and mediastinal masses.It is also useful for detecting multiple

metastases.CT can show the exact location and size ofthe tumoral a mass in the ( important fromthe surgical point of wiew) It also shows the

nodules in the mediastinum.Sometimes,when a mass locates behind theheart, chest X-ray can`t detect it .CT candetect some hidden sites of lung cancer.


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Peripheral carcinoma


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BronchoscopyIt is important both for determining if a

tumor is present and for obtaining tissue for

histologic diagnosis.

Usually, the combination of bronchial

brushing and forceps biopsy is positive 90 to

93 percent of the tumors located in proximalairway.


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Bronchoscopic appearances of small

cell carcinoma

Thickened membranous portion of

posterior membrane with

prominent mucosal folds


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Transbronchial lung biopsy It may be utilized when the tumor is located

in peripheral airways.

Transthoracic needle biopsy with CT guidance

can be used to detect lesions located near the

chest wall


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Thoracotomy

If the methods mentioned above are not

useful for detecting the cell type of lung

cancer, thoracotomy may be used.We should analyse some other factors

before we adopt the method, for example the

age of the patient,the pulmonary function,and complicating illness.


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In some circumstances,a histologic diagnosis

can be made by biopsy of metastatic sites,such

as lymphy nodes, liver, bone or bone marrow.

Histologic examination


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Adenocarcinoma

Squamosus cell carcinoma


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Other laboratory examinations

tumor markers

CEA

CA199

CA211

NSEGene examination (p53gene, ras gene)


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Medical history


Physical examination

Laboratory and Imaging examinations

(chest X-ray, CT scanning, histologic

examination of sputum, biopsy tissueobtained by bronchoscopy, bronchial

brushing.)

Positive Diagnosis based on:


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TNM classification of lung cancer

Primary Tumor(T)

TX:primary tumor can not be assessed. tumor present asdetermined by presence of malignant cells in

bronchopulmonary secretions, but not radiographicallyvisible; no evidence of primary tumor

T0:No evidence of primary tumor

Tis:carcinoma in situ

T1:Tumor 3 cm or less surrounded by lung or visceral pleura,but without evidence of invasion proximal to lobar bronchusat bronchoscopy

T2:Tumor more than 3 cm or tumor invading visceral pleuraor associated with obstructive pneumonitis or atelectasis;involving less than entire lung; at bronchoscopy, proximalextent of visible tumor must be within a lobar bronchus or atleast 2 cm distal to carina


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T3:Tumor of any size with direct extension into chestwall, diaphragm, or mediastinal pleuraor pericardium

without involving heart, great vessels, trachea,

esophagus, or vertebral body; also includes superior

sulcus tumors and

T4:Tumor of any size invading mediastinum or

involving heart ,great vessels, trachea,esophagus,

vertebral body,or carina or presence of malignantpleural effusion


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Nodal Involvement(N)

Nx: can not assess regional lymph node N0:No demonstrable metastasis to regional lymph

nodes

N1:metastasis to peribronchial or the ipsilateral, orboth,hilar lymph nodes,including direct extension

N2:metastasis to ipsilateral mediastinal lymphnodes and subcarinal lymph nodes

N3:metastasis to contralteral mediastinal lymphnodes,contralateral hilar lymph nodes,ipsilateral orcontralateral scalene or supraclavicular lymphnodes


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Distant metastasis(M) Mx: distant metastasis can not be assessed

M0:No distant metastasis

M1:Distant metastasis present


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Small cell lung cancer has often metastasized

at the time of diagnosis.TNM staging is not suited to small cell lung

cancer.


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TreatmentIncluding:

A:Surgery

B:ChemotherapyC:Radiation therapy

D:Some other therapy

immunologic therapy


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We must measure pulmonary function before

surgical therapy.

Forced vital capacity greater than 2 liters and a

forced expiratory volume in the first second

(FEV1)of greater than 50 percent of the forced

vital capacity predict that a patient can tolerate

the consequences of pneumonectomy.

Surgery


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Surgery


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Surgery

S


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Surgery


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Chemotherapy

Non-small cell lung cancer

MVP:MMC 6-8mg/m2 (1), VDS 3mg/m2

NP:VP-16 (d1,d8). DDP 100mg/m2 (d1)GP

Small-cell lung cancer it is highly responsive to

chemotherapy.EP regimen VP-16 100mg/m2 d1~d3.

DDP 100mg/m2 d1. GP


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Chemotherapy drawbacksAggressive chemotherapy produces

complications and symptoms in all patients.

All experience anemia,leukopenia andopportunistic infections.

Other complications include nausea,vomiting

possible cadiotoxicity, hemorrhagic cystitis and

peripheral neuropathy.


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Radiation therapy

It is of proven benefit in controlling bone

pain,spinal cord compression, superior vena

cava syndrome and bronchial obstruction.

1 Epithelial Tumours


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1 Epithelial Tumours1.1.Benign

1.1.1. Papillomas

1.1.1.1. Squamous cell papillomaExophytic

Inverted

1.1.1.2. Glandular papilloma

1.1.1.3. Mixed squamous cell and glandular apilloma

1.1.2. Adenomas

1.1.2.1. Alveolar adenoma

1.1.2.2. Papillary adenoma

1.1.2.3. Adenomas of salivary-gland type

Mucous gland adenomaPleomorphic adenoma

Others

1.1.2.4. Mucinous cystadenoma

1.1.2.5. Other

1. Epithelial Tumours


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1.2. Preinvasive lesions

1.2.1. Squamous dysplasia/Carcinoma in situ

1.2.2. Atypical adenomatous hyperplasia1.2.3. Diffuse idiopathic pulmonary neuroendocrine cell

hyperplasia

1.3. Malignant

1.3.1. Small Cell Carcinoma1.3.2. Non-Small Cell Carcinoma

1.3.2.1. Squamous Cell Carcinoma

1.3.2.2. Adenocarcinoma

Acinar

Papillary

Bronchioloalveolar carcinoma

Solid adenocarcinoma with mucin

1. Epithelial Tumours

1 3 4 ll i


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1.3.4. Large cell carcinoma

Variants

1.3.4.1. Large cell neuroendocrine carcinoma

1.3.4.1.1. Combined large cell neuroendocrinecarcinoma

1.3.4.2. Basaloid carcinoma

1.3.4.3. Lymphoepithelioma-like carcinoma

1.3.4.4. Clear cell carcinoma1.3.4.5. Large cell carcinoma with rhabdoid

phenotype

1.3.5. Adenosquamous carcinoma

1.3.6. Carcinomas with pleomorphic,

sarcomatoid or

sarcomatous elements

1 3 2 3 L C ll C i


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1.3.2.3. Large Cell Carcinoma

1.3.2.4. Adenosquamous carcinoma

1.3.2.5. Carcinoid tumor

Typical carcinoidAtipical carcinoid

2.Soft Tissue Tumours

2.1 Localized fibrous tumour2.2 Epithelioid hemangioendothelioma

2.3 Pleuropulmonary blastoma

2.4 Chondroma

2.5 Calcifying fibrous pseudotumour of the pleura

2.6 Congenital peribronchial myofibroblastic tumour

2.7 Diffuse pulmonary lymphangiomatosis

2.8 Desmoplastic small round cell tumour

2.9 Other

3 Mesothelial Tumours


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3 Mesothelial Tumours3.1 Benign

3.1.1 Adenomatoid tumour

3.2 Malignant

3.2.1 Epithelioid mesothelioma

3.2.2 Sarcomatoid mesothelioma

3.2.3 Biphasic mesothelioma

4 Miscellaneous Tumours4.1 Hamartoma

4.2 Sclerosing hemangioma

4.3 Clear cell tumour

4.4 Germ cell neoplasmsTeratoma, mature or immature

Malignant germ cell tumour

4.5 Thymona

4.6 Melanoma


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Combined Small Cell CC and Adenocarcinoma


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Combined Small Cell CC and Squamous Cell CC


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Large Cell Carcinoma


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Lung Cancer: Overview


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Lung Cancer: Overview

Lungcancer is the leading cause of cancer death in both men and

women, and accounted for approximately 27% of all cancer deaths

Alarmingly, 87% of lung cancer deaths could be prevented by

eliminating tobacco abuse.(American Cancer Society Illinois Cancer Facts & Figures, 2006)


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Lung Cancer: Women

Account for 12% of all new cases

More deaths from lung cancer than breast,ovarian,

and

uterine cancers combined.

Women are more susceptible to tobacco effects. 1.5times more likely to develop lung cancer than men with

similar smoking patterns.

Jemal A, Thomas A, Murray T, Thun M. (2002).American Cancer SocietyFacts & Figures (2004


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Metastatic nodes


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Sputum Sample of Bronchogenic Carcinoma


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Sputum Sample of Bronchogenic Carcinoma

Hamartoma


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Hamartoma

Tracheal papillomatosis


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Tracheal papillomatosis

Endobronchial amyloidoma


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Endobronchial amyloidoma