The lung and the Upper The lung and the Upper Respiratory TractRespiratory Tract

Lung Tumors Lung Tumors

Lung tumors : General featuresLung tumors : General features

Most are malignant.Most are malignant.

Metastatitc neoplasms are most Metastatitc neoplasms are most common.common.

TypesTypes

Bronchogenic Carcinoma.Bronchogenic Carcinoma.

Bronchial carcinoids.Bronchial carcinoids.

Lymphoma.Lymphoma.

HamartomaHamartoma

Bronchogenic carcinomaBronchogenic carcinoma

1.1. Squamous cell carcinoma ( most Squamous cell carcinoma ( most common)common)

2.2. Adenocarcinoma Adenocarcinoma 1.1. Bronchial derivedBronchial derived

2.2. BroncheoloalveolarBroncheoloalveolar

3.3. Larger cell carcinomaLarger cell carcinoma

4.4. Small cell (oat cell) carcinoma.Small cell (oat cell) carcinoma.

Non small cell carcinoma

Bronchogenic CarcinomaBronchogenic Carcinoma

Leading case of cancer death (M/F)Leading case of cancer death (M/F)Increase in women and decreasing in men.Increase in women and decreasing in men.Age:Age: old adult. old adult.Etiology:Etiology: – smoking of cigarettes ( amount/ years).smoking of cigarettes ( amount/ years).– AsbestosisAsbestosis– Uranium and radiationUranium and radiation– Air pollutionAir pollution– Radon Radon

Molecular pathologyMolecular pathology

Non-Small Cell Lung CarcinomasNon-Small Cell Lung Carcinomas (NSCLC) (NSCLC) 70-75% of all lung Ca cases: 70-75% of all lung Ca cases: – p16/CDKN2Ap16/CDKN2A & & K-RAS K-RAS mutations, mutations, – p53p53 mutation ( inhibit apoptosis). mutation ( inhibit apoptosis).

Small Cell Lung Carcinoma (CSLCSmall Cell Lung Carcinoma (CSLC) 20-25%, ) 20-25%, TP53 TP53

& & RB RB gene mutations ( deregulate cell cycle).gene mutations ( deregulate cell cycle).

Squamous cell carcinomaSquamous cell carcinoma

Central tumorCentral tumorArising from Squamous cell ( often from Arising from Squamous cell ( often from main bronchus)main bronchus)Smoking is main etiology also caused by Smoking is main etiology also caused by radon.radon.p53 mutation and overexpression of p53 mutation and overexpression of epidermal growth-factor receptor very epidermal growth-factor receptor very common.common.Morphology: nextMorphology: next

Squamous cell carcinoma: The neoplasm is very firm and has a pale white to tan cut surface. Central

necrosis is frequently seen.

Central necrosis

Micro: nests of polygonal cells with pink cytoplasm and distinct cell borders

with intercellular bridges and keratin pearl.

AdenocarcinomaAdenocarcinoma

Peripheral tumor.Peripheral tumor.Sex: female. Age: much younger Sex: female. Age: much younger person.person.Types:Types:– Bronchial derivedBronchial derived: occur in the site of : occur in the site of

previous scar (previous scar (scar carcinomascar carcinoma). Not clearly ). Not clearly linked to smoking.linked to smoking.

– Bronchoalveolar CaBronchoalveolar Ca: Not related to : Not related to smoking. Multiple tumor, present as smoking. Multiple tumor, present as pneumonia.pneumonia.

Adenocarcinoma : peripheral tumorAdenocarcinoma : peripheral tumorK-RASK-RAS mutations are seen primarily in adenocarcinoma mutations are seen primarily in adenocarcinoma..

Adenocarcinoma: Adenocarcinoma: The glandular structures formed by this neoplasm + mucin production ( mucin stained purple with PAS)

Bronchioloalveolar carcinomaBronchioloalveolar carcinoma

Appears as pneumonic Appears as pneumonic consolidation.consolidation.

Well differentiated tumor: better prognosis.

Bronchioloalveolar carcinoma is composed of columnar cells that proliferate along the

framework of alveolar septae.

Small Cell Carcinoma: central tumorSmall Cell Carcinoma: central tumor

Central tumor. Aka- oat cell carcinomaCentral tumor. Aka- oat cell carcinoma

Origin: Neuroendocrine Origin: Neuroendocrine argentaffinargentaffin (Kulchitsky) (Kulchitsky) cells.cells.

Smoking is main etiologySmoking is main etiology

Gene: p53Gene: p53 and and RBRB tumor suppressor genes + tumor suppressor genes + over expression of the anti-apoptotic gene over expression of the anti-apoptotic gene BCL2.BCL2.

Poor prognosis.Poor prognosis.

Gross: ThGross: This tumor has a soft, lobulated, white

to tan appearance.

Micro: sheets of blue cells are regular, and round molded nuclei and a moderate amount of eosinophilic

cytoplasm.

Blue round cells

Large cell carcinomaLarge cell carcinoma

Micro: large anaplastic cells.Poor prognosis

Relax your eyesRelax your eyesNext topic : Clinical features of tumorsNext topic : Clinical features of tumors

ClinicalClinical

Common presentation: Cough, hemoptysis, Common presentation: Cough, hemoptysis, weight loss.weight loss.

Clubbing of the fingers.Clubbing of the fingers.

Others:Others:– Due to spread of tumorDue to spread of tumor– Due to paraneoplastic syndromesDue to paraneoplastic syndromes

Clinical: Due to spread of tumorClinical: Due to spread of tumor

Local lymph nodes metastasis;Local lymph nodes metastasis;– Supraclavicular node (Virchow node).Supraclavicular node (Virchow node).

Distant : Brain, Liver ,Bone.Distant : Brain, Liver ,Bone.– Adrenals cortex (Addison’s disease- Adrenals cortex (Addison’s disease-

deficiency of cortical hormones- skin & deficiency of cortical hormones- skin & mucosa hyper pigmentation) mucosa hyper pigmentation)

OthersOthers

Superior Vena caval syndrome (Superior Vena caval syndrome (common in small cell common in small cell carcinoma, followed by squamous cell Ca.carcinoma, followed by squamous cell Ca.))– Congestion of veins of neck, face: redCongestion of veins of neck, face: red– Engorges jugular vein- edema in arms.Engorges jugular vein- edema in arms.

Hoarseness: recurrent laryngeal nerve invasion Hoarseness: recurrent laryngeal nerve invasion ( ( with apical tumorwith apical tumor).).

Acanthosis nigricans: black, thick skin with skin Acanthosis nigricans: black, thick skin with skin tags= axillae, groin etc (tags= axillae, groin etc (common in adenocarcinomacommon in adenocarcinoma).).

Clinical: Due to spread of tumorClinical: Due to spread of tumor

Horner syndrome ( in Horner syndrome ( in Pancoast tumorPancoast tumor ): ): – Seen in Seen in apical tumorsapical tumors due to involvement of due to involvement of

cervical sympathetic plexus.cervical sympathetic plexus.– Features are:Features are:

Ipsilateral enophthalmos.Ipsilateral enophthalmos.

Ptosis, Meiosis.Ptosis, Meiosis.

Anhidrosis.Anhidrosis.

Clinical: Due to paraneoplastic syndromesClinical: Due to paraneoplastic syndromes

Squamous cell Squamous cell carcinomacarcinoma

Secret PTH like hormone > Secret PTH like hormone > HypercalcemiaHypercalcemia→ renal calculi→ renal calculi

Small cell Small cell carcinomacarcinoma

Secret ACTH>Cushing syndrome= Secret ACTH>Cushing syndrome= weight gain, hypertension. Skin weight gain, hypertension. Skin pigmentationpigmentation

Secret ADH > SIADH >Secret ADH > SIADH >

Hyponatremia= cerebral edemaHyponatremia= cerebral edema

Other Paraneoplastic syndromes in bronchogenic Other Paraneoplastic syndromes in bronchogenic carcinomacarcinoma

Hematologic manifestations (In adenocarcinoma).Hematologic manifestations (In adenocarcinoma).– Migratory thrombophlebitis.Migratory thrombophlebitis.

Lambert-Eaton myasthenic syndromeLambert-Eaton myasthenic syndrome ( In Small ( In Small cell carcinoma: muscle weakness is caused by cell carcinoma: muscle weakness is caused by auto-antibodies directed to the neuronal calcium auto-antibodies directed to the neuronal calcium channel) .channel) .

CalcitoninCalcitonin, causing hypocalcemia., causing hypocalcemia.

Bronchial CarcinoidBronchial Carcinoid

OriginOrigin: Kulchitsy cells: a neuroendocrine cells : Kulchitsy cells: a neuroendocrine cells that line the bronchial mucosa.that line the bronchial mucosa.

Age:Age: mean around 40. mean around 40.

Gross:Gross: yellow polypoid mass. yellow polypoid mass.

Micro:Micro: – LM:LM: Salt pepper. Salt pepper. – EM:EM: Dense core neurosecretory granules in Dense core neurosecretory granules in

their cytoplasm their cytoplasm

Microscopy Microscopy

Salt pepperSalt pepperDense core granulesDense core granules

Presentation of CarcinoidPresentation of Carcinoid

Benign carcinoid:Benign carcinoid:

– Cough.Cough.

– Hemoptysis, bronchiectasis.Hemoptysis, bronchiectasis.

– Recurrent bronchial & pulmonary Recurrent bronchial & pulmonary infections.infections.

Malignant carcinoidMalignant carcinoid: liver mets. and Secret : liver mets. and Secret serotonin > carcinoid syndrome: diarrhea serotonin > carcinoid syndrome: diarrhea and flushing on skin.and flushing on skin.

HamartomaHamartoma

CommonLess than 2 cm. Micro: haphazard lung tissue and cartilage.

Clinical: Present as a "coin lesion" on X-ray.

d/d of coin lesionGranuloma are multiple.

coin lesion

Metastatic Cancer to the lungsMetastatic Cancer to the lungs

Multiple variably-sized masses are seen in all lung fields.

Next TopicNext Topic

MesotheliomaMesothelioma

Pleural effusionPleural effusion

Malignant MesotheliomaMalignant Mesothelioma

Site:Site: The visceral or the parietal pleura. The visceral or the parietal pleura.

CarcinogenCarcinogen: asbestosis- amphiboles by reactive : asbestosis- amphiboles by reactive free radicals. free radicals.

MorphologyMorphology: : – Asbestos bodied are found in the tumor.Asbestos bodied are found in the tumor.– Lung gets Lung gets ensheathed by tumorensheathed by tumor tissue may tissue may

produce cicatrisation and atelectasis. produce cicatrisation and atelectasis.

Diagnosis of malignant mesotheliomaDiagnosis of malignant mesothelioma

Positive staining with:Positive staining with:

Acid mucopolysaccharideAcid mucopolysaccharide

KeratinKeratin

Electron microscopy (EM): presence of long Electron microscopy (EM): presence of long microvilli and abundant tonofilaments.microvilli and abundant tonofilaments.

Pleural effusionPleural effusion

Empyema- Pus in pleural cavity following Empyema- Pus in pleural cavity following abscess.abscess.

Chylothorax : Chyle (lymph)= Chylothorax : Chyle (lymph)= – It is a Milky white fluid due to tumor emboli It is a Milky white fluid due to tumor emboli

in lymphatic or in Lymphoma.in lymphatic or in Lymphoma.

All patient present with respiratory distress, relieved when the effusion in drained by thoracentesis .

Pneumothorax Pneumothorax

Def: air in pleural cavityDef: air in pleural cavity

Types:Types:– Traumatic: Trauma Traumatic: Trauma – Spontaneous: rupture of paraseptal bullaSpontaneous: rupture of paraseptal bulla– Tension : due to shift of the mediastinum Tension : due to shift of the mediastinum

from the midline.from the midline.

Tracheal shifting to other side , and hyperresonant lung on side of injury.

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