pulmonary Neoplasia

1. LUNG TUMORS

2. LUNG TUMORS
Primary : Benign: Hamartoma
Malignant :
 95 % are Bronchogenic Carcinoma
 Extremely common
 Age 55-65, M:F = 2:1
 Incidence is ↓in males, ↑in females
 Commonest cause of cancer related death
 Majority are related to smoking
 Bad prognosis (5-year survival < 15%)
 5% are Bronchial carcinoids, Mesenchymal tumors, Lymphoid
tumors and others
Secondary: very common

3. Classification of malignant epithelial lung
tumors :
 Until recently, carcinomas of the lung were classified into two
broad groups: small cell lung cancer (SCLC) and non–small cell
lung cancer (NSCLC).
 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

4. This classification has been recently replaced by
a 2015 World Health Organization classification
Histologic Classification of Malignant Epithelial
Lung Tumors (2015 WHO Classification, Simplified
Version)
Adenocarcinoma
Acinar, papillary, micropapillary, solid, lepidic predominant,
mucinous subtypes
Squamous cell carcinoma
Large cell carcinoma
Neuroendocrine carcinoma
Small cell carcinoma
Large cell neuroendocrine carcinoma
Carcinoid tumor
Mixed carcinomas
Adenosquamous carcinoma
Combined small cell carcinoma
Other unusual morphologic variants
Sarcomatoid carcinoma
Spindle cell carcinoma
Giant cell carcinoma

5. Etiology
1- Cigarette smoking –  risk
 Contain numerous carcinogens (Polycyclic Hydrocarbons )
 Up to 90% squamous & small cell CA occur in smokers
 Correlation between smoking in pack per years & lung CA
 Passive smoking
 Effect of carcinogen is genetically conditioned

6. Etiology
2 - Genetic Factors:
 Step wise 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

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

8. 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

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

10. Gross appearance of most types :
Central
 Thickening mucosa
 Later may show irregular whitish warty lesion ulceration
 Infiltration of wall of bronchus into lung
 Hemorrhage & necrosis may be seen
Peripheral:
 Consolidated rounded lesion

11. Central Cancer

12. Peripheral Cancer

13. 1- SQUAMOUS CELL CA :
 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

14. Squamous metaplasia & Carcinoma in situ

15. Squamous cell carcinoma with nests of polygonal cells with pink
cytoplasm and distinct cell borders. The nuclei are hyperchromatic
and angular.

16. 2- ADENOCARCINOMA :
 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

17. Adenocarcinoma of the lung.
The glandular structures formed by this neoplasm are
consistent with a moderately differentiated
adenocarcinoma

18.  Multifocal diffuse or localized nodule .
 Peripheral location with diameter of 3 cm or less
 May present as pneumonic consolidation
 Growth along alveolar walls without destruction of walls
(non-invasive)
 Prognosis is better than usual adenocarcinoma.
B- Bronchioloalveolar CA/
Adenocarcinoma in situ

19. Adenocarcinoma in situ/Bronchioalveolar Carcinoma
composed of columnar cells that proliferate along the framework
of alveolar septae. The neoplastic cells are well-differentiated with
no destruction of alveolar architecture or stromal invasion.

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

21. 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

22. 4- SMALL CELL CARCINOMA (SCLC)
 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++

23. Small cell anaplastic (oat cell) carcinoma
Arising centrally in this lung and spreading extensively
(soft, lobulated, white to tan appearance)

24. 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 …

25. 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

26. T1 Tumor <3 cm without pleural or main stem bronchus involvement
T2 Tumor >3 cm or involvement of main stem bronchus 2 cm from carina, visceral pleural
involvement, or lobar atelectasis
T3 Tumor with involvement of chest wall (including superior sulcus tumors), diaphragm,
mediastinal pleura, pericardium, main stem bronchus 2 cm from carina, or entire lung
atelectasis
T4 Tumor with invasion of mediastinum, heart, great vessels, trachea, esophagus, vertebral
body, or carina or with a malignant pleural effusion
N0 No demonstrable metastasis to regional lymph nodes
N1 Ipsilateral hilar or peribronchial nodal involvement
N2 Metastasis to ipsilateral mediastinal or subcarinal lymph nodes
N3 Metastasis to contralateral mediastinal or hilar lymph nodes, ipsilateral or contralateral
scalene, or supraclavicular lymph nodes
M0 No (known) distant metastasis
M1 Distant metastasis present
TNM, Lung

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

28. Carcinoid Tumor: (Low grade neuroendocrine Ca.)
 Younger age than CA , 5% of lung tumors
 Arise from neuroendocrine Kulchitsky cells lining bronchi
 Most arise in bronchial wall, fill lumen or extend into lung
 Histology: Typical Carcinoid : Uniform small round cells, absent
mitoses, arranged in nests & cords
 Atypical Carcinoid : Show mitoses, necrosis, atypia
 Clinical course:
 Obstruction & atelectasis, Infection
 Most cases are hormonally inactive, but few produce the Carcinoid
syndrome (characterized by intermittent attacks of diarrhea, flushing,
and cyanosis)
 Surgery curative in most cases
 About 30 % may metastasize to lymph nodes ± distant metastases

29. Carcinoid tumor

31. Continuous assessment
 What type of lung cancer fits this description? The tumour
cells originate from neuroendocrine (Kulchitsky) cells. It is
associated with smoking and is centrally located along the
bronchial airways. There is an association with
paraneoplastic syndromes, for example Cushing’s.
a. Adenocarcinoma
b. Carcinoid tumour
c. Squamous cell carcinoma
d. Small cell carcinoma