Part solid lesions

Sesión Tórax
18 mayo 2011

Nódulo pulmonar

Nódulo sólido

Nódulo pulmonar

Nódulo sólido Nódulo en vidrio deslustrado
GGO

Non-solid nodule

Nódulo pulmonar

Nódulo sólido Nódulo parcialmente sólido Nódulo en vidrio deslustrado
Part-solid nodule GGO

Sub-solid nodule Non-solid nodule

Nódulos parcialmente sólidos
Transitorios

Inﬂamatorio

Hemorragia focal

Park CM, Goo JM, Lee HJ, Lee CH, Chun EJ, Im J. Nodular Ground-Glass Opacity at Thin-Section CT: Histologic Correlation and Evaluation of Change at Follow-up. Radiographics 2007


Aspergilosis
Transitorios

Neumonía eosinóﬁla
Inﬂamatorio NOC
Criptococosis

Hemorragia focal



Aspergilosis
Transitorios

Inﬂamatorio NOC
Criptococosis

Endometriosis torácica
Hemorragia focal Lesión traumática focal
Vasculitis
Sangrado lesión tumoral



Aspergilosis
Transitorios

Inﬂamatorio NOC
Criptococosis

Vasculitis

Aspergilosis Neumonía eosinóﬁla NOC Traumatismo Hemorragia tumoral



Aspergilosis
Transitorios

Inﬂamatorio NOC
Criptococosis

Vasculitis

¿Podemos predecir si una lesión será transitoria?



Aspergilosis
Transitorios

Inﬂamatorio NOC
Criptococosis

Vasculitis

70 % nódulos parcialmente sólidos son transitorios

Lee S, Park C, Goo J, Lee C, Lee H, Kim K, et al. Transient Part-Solid Nodules Detected at Screening Thin-Section CT for Lung Cancer: Comparison with Persistent Part-Solid Nodules. Radiology. 2010


Aspergilosis
Transitorios

Inﬂamatorio NOC
Criptococosis

Vasculitis


94 % lesiones que aparecen en seguimiento son transitorias



Aspergilosis
Transitorios

Inﬂamatorio NOC
Criptococosis

Vasculitis



Datos clínicos
Hombres jóvenes
Fumadores
Eosinoﬁlia



Aspergilosis
Transitorios

Inflamatorio NOC
Criptococosis

Vasculitis



Datos clínicos Datos radiológicos
Hombres jóvenes Lesiones transitorias mayores que las persistentes
Fumadores Lesiones múltiples
Eosinofilia Bordes mal definidos



Aspergilosis
Transitorios

Inﬂamatorio NOC
Criptococosis

Vasculitis
Persistentes

Fibrosis intersticial focal

Neoformativo


Respuesta tisular no específica
Engrosamiento fibroso de paredes alveolares con depósito de colágeno, antracosis y engrosamiento peribroncovascular

Park CM, Goo JM, Lee HJ, Lee CH, Chung DH, Chun EJ, Im J. Focal interstitial fibrosis manifesting as nodular ground-glass opacity: thin-section CT findings. Eur Radiol 2007


Infecciones
Radiación
Fármacos
Presión
Neoplasias
Cicatrices
...

Aumento de densidad en vidrio deslustrado
x40



Infecciones
Radiación
Fármacos
Presión
Neoplasias
Cicatrices
...


¿Alguna característica que permita diagnóstico de certeza?



Infecciones
Radiación
Fármacos
Presión
Neoplasias
Cicatrices
...


Morfología poligonal
...NO... Halo inverso
Retracción vascular/pleural


Transitorios

Inﬂamatorio

Hemorragia focal
Persistentes


Neoformativo


World Health Organization Classification of Tumours
s and Heart is the latest
g of human tumours. This
ndard for oncologists and

WHO Classification Tumours of the Lung, Pleura, Thymus and Heart
sign of studies monitoring

erations are described in a
s and their variants include
nical signs and symptoms,
Pathology & Genetics
han 670 color photographs,
(MR) images, charts, and
Tumours of the Lung, Pleura,
Thymus and Heart
Edited by William D. Travis, Elizabeth Brambilla,
H. Konrad Müller-Hermelink and Curtis C. Harris

IARC

Tumores epiteliales malignos Tumores epiteliales benignos

Carcinoma de células escamosas Papilomas
Papilar Papiloma de células escamosas
Células claras Exofítico
Célula pequeña Invertido
Basaloide Papiloma glandular
Papiloma mixto
Carcinoma de células pequeñas Adenomas
Carcinoma de células pequeñas combinado Adenoma alveolar
Adenoma papilar
Adenocarcinoma Adenomas tipo glándulas salivares
Adenocarcinoma acinar Adenoma de glándula mucosa
Adenocarcinoma papilar Adenoma pleomórfico
Carcinoma bronquioloalveolar Otros
No mucinoso Cistoadenoma mucinoso
Mucinoso
Mixto o indeterminado
Tumores mesenquimales
Adenocarcinoma, subtipo mixto
Adenocarcinoma sólido productor de mucina
Hemangioendotelioma epitelioide
Adenocarcinoma fetal
Angiosarcoma
Carcinoma coloide
Blastoma pleuropulmonar
Cistoadenocarcinoma mucinoso
Condroma
Adenocarcinoma en anillo de sello
Tumor miofibroblástico peribronquial congénito
Adenocarcinoma de células claras
Linfangiomatosis pulmonar difusa
Tumor miofibroblástico inflamatorio
Carcinoma de células grandes
Linfangioleiomiomatosis
Carcinoma neuroendocrino de células grandes
Sarcoma sinovial
Carcinoma basaloide
Monofásico
Carcinoma linfoepitelioma-like
Bifásico
Carcinoma de células claras
Sarcoma de arteria pulmonar
Carcinoma de células grandes con fenotipo rabdoide
Sarcoma de vena pulmonar
Carcinoma adenoescamoso
Tumores linfoproliferativos
Carcinoma sarcomatoide
Carcinoma pleomórfico Linfoma MALT de células B de zona marginal
Carcinoma de células en huso Linfoma difuso de células B grandes
Carcinoma de células gigantes Granulomatosis linfomatoide
Carcinosarcoma Histiocitosis de células de Langerhans
Blastoma pulmonar
Tumores miscelánea
Tumor carcinoide
Carcinoide típico Hamartoma
Carcinoide atípico Hemangioma esclerosante
Tumor de células claras
Tumores de las glándulas salivares Tumor de células germinales
Carcinoma mucoepidermoide Teratoma, maduro
Carcinoma adenoide quístico Inmaduro
Carcinoma epitelial-mioepitelial Otros tumores de células germinales
Timoma intrapulmonar
Lesiones preinvasivas Melanoma
Carcinoma escamoso in situ
Hiperplasia adenomatosa atípica
Hiperplasia de células neuroendocrinas pulmonares idiopática difusa Tumores metastásicos

Tumores epiteliales malignos Tumores epiteliales benignos

Carcinoma de células escamosas Papilomas
Papilar Papiloma de células escamosas
Células claras Exofítico
Célula pequeña Invertido
Basaloide Papiloma glandular
Papiloma mixto
Adenocarcinoma
Carcinoma de células pequeñas Adenomas
Adenocarcinoma acinar pequeñas combinado
Carcinoma de células Adenoma alveolar
Adenoma papilar
Adenocarcinoma papilar
Adenocarcinoma Adenomas tipo glándulas salivares
Carcinoma bronquioloalveolar
Adenocarcinoma acinar Adenoma de glándula mucosa
Adenocarcinoma papilar Adenoma pleomórfico
No mucinoso bronquioloalveolar
Carcinoma Otros
Mucinoso No mucinoso Cistoadenoma mucinoso
Mucinoso
Tumores mesenquimales
Hemangioendotelioma epitelioide
Angiosarcoma
Carcinoma coloide
Blastoma pleuropulmonar
Cistoadenocarcinoma mucinoso
Carcinoma coloide en anillo de sello
Adenocarcinoma
Condroma
Tumor miofibroblástico peribronquial congénito
Cistoadenocarcinoma de células claras
Adenocarcinoma mucinoso
Linfangiomatosis pulmonar difusa
Adenocarcinomagrandes
Carcinoma de células en anillo de sello
Tumor miofibroblástico inflamatorio
Linfangioleiomiomatosis
Adenocarcinoma de célulascélulas grandes
Carcinoma neuroendocrino de claras
Sarcoma sinovial
Carcinoma basaloide
Monofásico
Carcinoma linfoepitelioma-like
Bifásico
Carcinoma de células claras
Sarcoma de arteria pulmonar
Carcinoma de células grandes con fenotipo rabdoide
Sarcoma de vena pulmonar
Carcinoma adenoescamoso
Tumores linfoproliferativos
Carcinoma sarcomatoide
Carcinoma pleomórfico Linfoma MALT de células B de zona marginal
Carcinoma de células en huso Linfoma difuso de células B grandes
Carcinoma de células gigantes Granulomatosis linfomatoide
Carcinosarcoma Histiocitosis de células de Langerhans
Blastoma pulmonar
Tumores miscelánea
Tumor carcinoide
Carcinoide típico Hamartoma
Carcinoide atípico Hemangioma esclerosante
Tumor de células claras
Tumores de las glándulas salivares Tumor de células germinales
Carcinoma mucoepidermoide Teratoma, maduro
Carcinoma adenoide quístico Inmaduro
Lesiones preinvasivas
Carcinoma epitelial-mioepitelial Otros tumores de células germinales
Lesiones preinvasivas
Timoma intrapulmonar
Melanoma
Hiperplasia de células células neuroendocrinas pulmonares idiopática difusa
Hiperplasia de
neuroendocrinas pulmonares idiopática difusa Tumores metastásicos

Travis WD, Brambilla E, Noguchi M, Nicholson A, Geisinger K, Yatabe Y, et al. IASLC/ATS/ERS International Multidisciplinary Classiﬁcation of Lung Adenocarcinoma. Journal of Thoracic Oncology. 2011

Lesiones premalignas

Adenocarcinoma subtipo mixto
Lesiones malignas



Adenocarcinoma subtipo mixto Lesiones malignas


Hiperplasia adenomatosa atípica Hiperplasia adenomatosa atípica



Carcinoma bronquioloalveolar Adenocarcinoma in situ (AIS)



Carcinoma bronquioloalveolar Adenocarcinoma in situ (AIS)

Adenocarcinoma mínimamente invasivo (MIA)
Adenocarcinoma invasivo de predominio lepídico



Hiperplasia de células neuroendocrinas
Tumor carcinoide
pulmonares idiopática difusa

Carcinoma escamoso in situ Carcinoma escamoso

Hiperplasia adenomatosa atípica Adenocarcinoma

Brambilla E, Travis WD, Colby TV, Corrin B, Shimosato Y. The new World Health Organization classiﬁcation of lung tumours. Eur. Respir. J 2001


Tumor carcinoide



...proliferation of minimally atypical cuboidal type II pneumonocytes with gaps between cells;
AAH generally measures <5 mm in diameter...



Tumor carcinoide




Presente hasta en un 60% de los adenocarcinomas



Tumor carcinoide



x400 x400

Presente hasta en un 60% de los adenocarcinomas

Normal HAA HAA



Adenocarcinoma in situ (AIS)

Sólo crecimiento lepídico SIN invasión

Si invasión estromal, vascular o pleural

Adenocarcinoma mínimamente invasivo
Adenocarcinoma invasivo


Adenocarcinoma in situ (AIS)

Sólo crecimiento lepídico SIN invasión

Si invasión estromal, vascular o pleural

Adenocarcinoma mínimamente invasivo
Adenocarcinoma invasivo

2044

Small Adenocarcinoma of the Lung
Histologic Characteristics and Prognosis
Masayuki Noguchi, M.D.,* Akio Morikawa, M.D.,* Masanori Kawasaki, M.D.,*
Yoshihiro Matsuno, M.D.,* Tesshi Yamada, M.D.," Sefsuo Hirohashi, M.D.,*
Haruhiko Kondo, M.D.,t and Yukio Shimosato, M.D.3

Noguchi M, Morikawa A, Kawasaki M, Matsuno Y, Yamada T, Hirohashi S, Kondo H, Shimosato Y. Small adenocarcinoma of the lung. Histologic characteristics and prognosis. Cancer 1995
Key words: pulmonary adenocarcinoma, bronchioloal-

2044

Small Adenocarcinoma of the Lung
Histologic Characteristics and Prognosis
Masayuki Noguchi, M.D.,* Akio Morikawa, M.D.,* Masanori Kawasaki, M.D.,*
Yoshihiro Matsuno, M.D.,* Tesshi Yamada, M.D.," Sefsuo Hirohashi, M.D.,*
Haruhiko Kondo, M.D.,t and Yukio Shimosato, M.D.3

Background. Although there are many reported Key words: pulmonary adenocarcinoma, bronchioloal-
prognostic indicators for pulmonary adenocarcinoma, veolar carcinoma, prognosis, active fibroblastic prolifer-
the clinicopathologic characteristics and prognostic fac- ation, adenoma.
tors of early stage adenocarcinoma have not been evalu-
ated fully, except for several studies of nonmucinous and
sclerosing bronchioloalveolar carcinoma. Among several histologic types of lung carcinoma, a
Method. Two hundred thirty-six surgically resected gradual increase in the incidence of adenocarcinoma
small peripheral adenocarcinomas measuring 2 cm or
has been recognized.',' However, the pathologic and bi-
less in greatest dimension were reviewed using a simple
ologic behavior of lung adenocarcinoma is not fully
histologic classification of six types based on tumor
growth patterns. characterized, and the outcome of surgical treatment re-
Results. Type A (localized bronchioloalveolar carci- mains unsati~factory.~ Although the TNM system is
noma [LBAC]) (n = 14) revealed replacement growth of currently the simplest and best method for making a
alveolar-lining epithelial cells with a relatively thin prognosis, several authors have studied other prognos-
stroma. In type B (LBAC with foci of structural collapse tic indicators for pulmonary adenocarcinoma, such as
of alveoli) (n = 14),fibrotic foci due to alveolar collapse histopathologic characteristic^,^-' immunohistochemi-
were observed in tumors of LBAC. Type C (LBAC with cal reactivity with certain antibodies,' nuclear DNA
foci of active fibroblastic proliferation) (n = 141) was the content,"," and genetic alterations of several onco-
largest group in this study, and foci of active fibroblastic gene~'','~ and anti- oncogene^.'^ In particular, in small
proliferation were evident. Type D (poorly differentiated adenocarcinomas, Shimosato et al. have demonstrated
adenocarcinoma), type E (tubular adenocarcinoma) and that central or subpleural fibrosis occurs as a result of
type F (papillary adenocarcinoma with a compressive alveolar collapse secondary to degeneration and death
growth pattern) (n = 61) showed compressive and exof tumor cells lining the alveoli and that a high degree
panding growth. Types A and B showed no lymph node of collagenization is correlated with a poorer o ~ t c o m e . ~
metastasis and the most favorable prognosis (100%5-year
Furthermore, Kurokawa et al. confirmed that the grade
survival) of the six types.
of fibrotic scarring (central fibrosis) is one of the most
Conclusion. Histologic types A and B are thought to
be in situ peripheral adenocarcinoma, whereas type C ap-
important prognostic factors for small bronchioloal-
pears to be an advanced stage of types A and B. Con- veolar carcinomas and that this feature is often lacking
versely, types D, E,and F are small advanced adenocarci- in surgically curable small cancers.*
nomas with a less favorable prognosis. Cancer 1995;75: Conversely, histologic and cytologic heterogeneity
2044-52. is one of the unique characteristics of pulmonary ade-
nocarcinoma, and many cytologic subtypes of adeno-
carcinoma have been advocated, including the bron-
From the *Pathology Division, National Cancer Center Research chial surface epithelial cell type with no or only scanty
Institute; and the tSurgica1 Division and $Clinical Laboratory Divi- mucus, the bronchial surface epithelial cell type with
sion, National Cancer Center Hospital, Tokyo, Japan. mucin, the bronchial gland cell type, the nonciliated
Address for reprints: Masayuki Noguchi, M.D., Pathology Divi- bronchiolar cell type (Clara cell type), and the type I1
sion, National Cancer Center Research Institute, 1-1, Tsukiji 5-
alveolar epithelial cell type.15 Usually, in advanced tu-

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