neoplasms of lung and pleura william k. funkhouser, m.d. ph.d. –x 3-1069...
TRANSCRIPT
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Neoplasms of Lung and Pleura
• Primary Neoplasms of Lung
• Primary Neoplasms of Pleura
• Metastatic Neoplasms to Lung and/or Pleura
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Neoplasms of Lung and Pleura: Classification by Lineage
• Epithelial – most common
• Melanocytic
• Stromal
• Mesothelial
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Benign Lung Neoplasms
• Hamartoma
• Squamous papillomatosis
• Pleomorphic adenoma (ENT)
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Hamartoma
• Clin: Adolescence adulthood
• None in newborns - not congenital
• Rad: Solitary nodule +/- popcorn calcification
• Peripheral > central
• Path: Gross: solitary, lobulated, cartilagenous Micro: normal tissues in
excess/disarray
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Hamartoma
Solitary PulmonaryNodule
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BivalvedHamartoma
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Hamartoma
Cartilage in excess and disarray
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Malignant epithelial neoplasms(Carcinomas)
• Squamous cell carcinoma
• Adenocarcinoma
• Large cell undifferentiated carcinoma
• Small cell undifferentiated carcinoma
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Lung Carcinomas:Epidemiology
• Estimated Incidence (2003): 172,000 (US)• Estimated Mortality (2003): 157,000 (US)• >85% of lung carcinoma deaths (and 30% of all
cancer deaths) occur in cigarette smokers• Risk = f(# cigarettes smoked), 15-30X in heavy
smokers, 50-60X in asbestos workers who smoke• Risk decreases with cessation of cigarette
smoking: baseline after 15 years
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USA Tobacco Use
• 25% of US adults smoke cigarettes
• M=F
• US adults consume 2,400 cigs/person/year
• 36% of US high school students smoke
• est. 1.8 million new smokers/year (65% < 18 yo)
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Tobacco: Morbidity and Mortality
• Premature ASVD: major risk factor• Emphysema: Linear with exposure: 7%/10 years • Chronic bronchitis • Carcinomas of pharynx, larynx, lung, esophagus,
bladder, kidney• Fetal tobacco syndrome
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Tobacco: Chemistry
• 80% air, 20% gases and particulates
• Gases: CO, CO2, formaldehyde, acrolein, methanol, phenol, anthracenes, pyrenes
• Nicotine: 1% of smoke 85% absorbed in lung equivalent to 1 mg IV
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Tobacco: Chemistry
• Particulates: – resin cores in 0.5 M diameter water droplets– est. 109 particles/ml – 50% deposited in and cleared by cilia– remainder: phagocytosis, lymphatic transport
• Overall: 4,000 chemical compounds, of which 43 are considered carcinogenic
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Squamous cell carcinoma
• Clin: Smokers (98%) 20-30% of common carcinomas May secrete PTH-like compound
• Rad: central > > peripheral
• Path: Bronchi > Larynx > Trachea +/- Desmosomes (intercellular bridges) +/- Keratin production, e.g. keratin
pearls
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Normal
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Squamous cell carcinoma
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Squamous cell carcinoma in situRespiratory mucosa
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Invasive Squamous Carcinoma
Keratin
Desmosomes
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Metastatic squamous cell carcinoma to lymph node
Normal lymph node lymphocytes
Mets in subcapsular sinuses
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Adenocarcinoma
• Clin: 30-40% of common carcinomas Most common carcinoma in non-smokers,
but 80% of adenoCAs occur in smokers
• Rad: peripheral > central
• Path: +/- glands +/- mucin Bronchiolo-alveolar carcinoma subset
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Adenocarcinoma
Primary
Pleural effusion
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Adenocarcinoma
Gland formation
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Adenocarcinoma
Mucin production (red on PASd stain)
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Bronchioloalveolar carcinoma (BAC)
• Clin: Rising incidence (presently 20-25%) Not associated with cigarette smoking
• Rad: Peripheral, can be multifocal and bilateral
• Path: Lepidic (butterfly-like) growth pattern Mucinous or non-mucinous Unifocal or multifocal Distinction of multifocal primary from
mets
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Bronchiolo-alveolar carcinoma
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Bronchiolo-alveolar carcinoma
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Bronchiolo-alveolar carcinoma
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Large cell undifferentiated carcinoma
• Clin: 10% of common carcinomas
• Rad: non-specific
• Path: H&E: Undifferentiated EM: ? adenocarcinomas
cDNA microarrays: distinct disease
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Large cell undifferentiated carcinoma
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Large cell undifferentiated carcinoma
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Non-Small Cell Lung Carcinomas: Prognostic variables
• Definitely: Stage, performance status, weight loss
• Possibly gender, ploidy, k-ras mutation, p53 protein accumulation
• Not age, histology
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Small cell carcinoma
• Clin: Smokers 20 % of common carcinomas
Ectopic ACTH, ADH, Eaton-Lambert, carcinoid s.
Commonly high stage at presentation Responsive to chemo/RT, but low 5 yr survival
• Rad: Central in >90% Frequent metastases to LNs and distant sites
• Path: Malignant cytology No nucleoli High mitotic activity and necrosis
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Small cell undifferentiated carcinoma
At diagnosis Response to therapy
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Small cell undifferentiated carcinoma
Viable carcinoma
Necrotic carcinoma
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Small cell undifferentiated carcinoma
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Small cell undifferentiated carcinoma
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Metastatic small cell carcinomaNormal lymphocytes
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Small Cell Lung Carcinoma: Prognostic variables
• Definitely: Stage, performance status
• Probably: Gender, age, # of metastatic sites
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Neoplasms of Lung & Pleura: Classification by Lineage
• Epithelial
• Melanocytic
• Stromal
• Mesothelial
• Metastases
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Mesothelioma
• Clin: Associated with asbestos exposure• Rad: Diffuse pleural involvement
May have associated effusion• Path: Malignant Deeply invasive
growth pattern Epithelial, spindle cell, or biphasic Immuno: Keratin (+) EM: long microvilli
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Mesothelioma: PA Chest
VisibleC-PAngle
Loss of C-P Angle= Pleural effusion or mass
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Mesothelioma: CT
Thickened pleura Normal thickness pleura
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Normal thin pleura
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Deeply invasive mesothelioma (cytokeratin immunostain)
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Epithelioid cytology of this mesothelioma mimics adenocarcinoma
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Adenocarcinoma Mesothelioma N. Weidner
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Asbestos body (Ferruginous body)
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Neoplasms of Lung & Pleura: Metastases
• Most common malignant neoplasms involving the lung
• Multiple nodules favor metastases over primary neoplasms (except BAC)
• Carcinomas• Sarcomas• Melanoma
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Metastatic carcinomas
• Breast adenoCA
• GI adenoCA
• Renal adenoCA
• Head/neck squamous cell CA
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Metastatic Breast CA
Pleural Thickening due to Metastases +/- Pleural Effusion
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Metastatic breast carcinoma
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Metastatic colon carcinoma
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Metastaticrenal cell carcinoma
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MetastaticENT carcinoma
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Metastatic sarcomas
• Osteosarcomas
• Soft tissue sarcomas
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Metastaticosteosarcoma
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Metastatic melanoma
• Clin: Extrapulmonary 1 melanoma much more common than pulmonary 1 No known 1 in 5-10% of cases
• Path: Variable architecture & cytology May be pigmented
Use immunohistochemistry to confirm
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Metastatic melanoma
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Neoplasms of Lung and Pleura
• 1 Lung Neoplasms - Most are carcinomas
• 1 Pleural Neoplasms - Mesotheliomas
• Mets to Lung and/or pleura – All lineages possible
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Thanks for your time.
Questions?