Lung Tumors

Bronchogenic Carcinoma


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.
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 the
most 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.
Incidence and prevalence
Squamous cell carcinoma 30% to 50%
Adenocarcinoma 25% to 40%
Large cell carcinoma 20% to 25%
Small cell carcinoma 10% to 15%

Gross specimen of bronchogenic carcinoma with lymph nodes
Endobronchial leiomyoma
Tracheal lipoma
Endobronchial schwannoma
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.
Pathogenesis
Many factors influence the formation of
lung cancer. The development of lung
cancer is a multistepp process. The
transformation process of normal
bronchial epithelial cells to malignant
cells is unknown.
Perhaps It is related to: damage of
cellular DNA; alteration in cellular
oncogen expression; tumor-derived
factors that stimulate cellular division.
Etiology and pathogenesis
Chronic inflammation of the lung, such
as from interstitial fibrosis and areas of
scarring is associated with the occurrence
of adenocarcinoma.
Genetic factors are also involved in the
formation of lung cancer.
Major categories of genes that potentially
determine susceptibility to lung cancer, include
proto-oncogenes, tumor suppressor genes, ects.

Oncogene abnormalities
Oncogene SCLC NSCLC
Ki-ras 0 30-50% of adenocarcinomas
H-ras 0 Rare mutation, over expression
N-ras 0 Rare mutation, over expression
Myc Majority Gene amplification and
overexpression
Classifications
According to anatomy:
(1)Central lung cancer,mostly is squamous cell
carcinoma 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.
Classification
Subtypes :
Oat-cell carcinoma
Intermediate cell type
Combined oat- cell carcinoma
SCLC belongs in a group of tumors derived
from neuroendocrine cells that are
responsible for the production and secretion
of specific peptide product. They may
related to paraneoplastic syndrome.
A. Small Cell Carcinoma
Small Cell Carcinoma
Small Cell Carcinoma
Adenocarcinoma
Adenocarcinoma
B. Non-Small Cell Carcinoma
Squamous cell carcinoma: It is the most common
subtype.It arises from altered bronchial epithelium
and growth in situ.It is related to cigarette
smoking.Cavitation can occure distal to the
obstructing mass.
Adenocarcinoma: It arises from the submucosal
glands,located in peripheral airways and
alveoli.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 disease
typically involves the periphery of the lung, resulting
in fewer early symptoms than cancers that develop
centrally, near the airways
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.
Adenosquamous cc : There are definite features
of adenocarcinoma and squamous ce carcinoma.
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 asymptomatic
when discovered to have bronchogenic carcinoma.

Clinical manifestations
Regionnal spread to hilar and mediastinal
nodes may cause dysphagia due to esophageal
compression, horseness due to recurrent laryngeal
nerve compression, horners syndrome due to
sympathetic nerve involvement, and elevation of
the hemidiaphragm from phrenic nerve
compression.

Clinical manifestations
Superior sulcus, or pancoasts tumor
may involve the brachial plexus, resulting
in a c7-t2 neuropathy with pain,
numbness, and weakness of the arm.
Cardiac involvement is seen in About 20-
25 percent of patients

Pancoasts Tumor
Clinical manifestations
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 the
primary tumor, metastases, or treatment. They
may be the first sign of the tumor.They do not
indicate that a tumor has spread.

Clinical manifestations
Paraneoplastic syndromes include:
hypertrophic pulmonary osteoarthropathy
hypercalcemia
inappropriate antidiuretic hormone
secretion syndrome
polymyositis
subacute cerebellar degeneration
peripheral neuropathies
cushings syndrome ects.

Physical examinations
Usually in early stage, most of the patients with
lung cancer have no positive physical findings.
General findings include abnormal percussion,
breath sounds changes, moist rales (when
pneumonia happens)
Digital clubbing, superior vena cava syndrome,
horners syndrome(unilaterally constricted
pupil, enophthalmos,narrowed palpebral
fissure and loss of sweating on the same side of
the face.

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.
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 Bronchogenic
carcinoma
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, transbronchial
needle aspiration and transthoracic needle).
Chest X-ray
Is the most important examination method. It
can detect the presence of lung cancer. The
most frequent finding is a tumoral mass in the
lung field.
Secondary manifestations seen on the chest
radiograph include lober collapse,pneumonitis
because of endobronchial obstruction,elevation
of the hemidiaphragm, pleural effusion, hilar
and mediastinal adenopathy and erosion of ribs
or vertebrae due to metastases.
Alveolar cell cancer can manifest as a localized
infiltrate mimicking pneumonia.

Chest X-ray
If a patient presents with chronic cough,
sputum with blood stipes, and dyspnea, low
fever we must perform a chest X-ray. The
most frequent finding is a mass in the lung
field.
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.

Obstructive atelectasis

Central bronchogenic carcinoma
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.

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.
Alveolar cancer on chest
radiography
The chest X-ray usually shows dissiminated
small nodules in the lung field.
Bronchioloalveolar carcinoma
Lung cancer on CT
CT is the most useful in evaluating patients
with pulmonary and mediastinal masses.
It is also useful for detecting multiple
metastases.
CT can show the exact location and size of
the tumoral a mass in the ( important from
the surgical point of wiew) It also shows the
nodules in the mediastinum.
Sometimes,when a mass locates behind the
heart, chest X-ray can`t detect it .CT can
detect some hidden sites of lung cancer.
Peripheral carcinoma
Bronchoscopy
It 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 proximal
airway.
Bronchoscopic appearances of
Small Cell Carcinoma
Tumors may be infiltrating, nodular, and obstructive
Bronchoscopic appearances of small
cell carcinoma
Thickened membranous portion of
posterior membrane with
prominent mucosal folds
Bronchoscopic appearances of Small Cell
Carcinoma
Segmental Subcarinal Nodular
infiltration appearance involvement

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
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.
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
Small Cell Carcinoma
Adenocarcinoma
Squamosus cell carcinoma
Other laboratory examinations
tumor markers
CEA
CA199
CA211
NSE
Gene examination (p53gene, ras gene)
Medical history
Clinical manifestations
Physical examination
Laboratory and Imaging examinations
(chest X-ray, CT scanning, histologic
examination of sputum, biopsy tissue
obtained by bronchoscopy, bronchial
brushing.)
Positive Diagnosis based on:
Staging of lung cancer
Non-small cell lung cancer.
TNM classification of Non-small cell lung
cancer.
Small cell lung cancer has often metastasized
at the time of diagnosis.
TNM staging is not suited to small cell lung
cancer. Small cell lung cancer is divided into
limited and extensive stage disease.
TNM classification of lung cancer
Primary Tumor(T)
TX:primary tumor can not be assessed. tumor present as
determined by presence of malignant cells in
bronchopulmonary secretions, but not radiographically
visible; 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 bronchus
at bronchoscopy
T2:Tumor more than 3 cm or tumor invading visceral pleura
or associated with obstructive pneumonitis or atelectasis;
involving less than entire lung; at bronchoscopy, proximal
extent of visible tumor must be within a lobar bronchus or at
least 2 cm distal to carina
T3:Tumor of any size with direct extension into chest
wall, 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 malignant
pleural effusion

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, or
both,hilar lymph nodes,including direct extension
N2:metastasis to ipsilateral mediastinal lymph
nodes and subcarinal lymph nodes
N3:metastasis to contralteral mediastinal lymph
nodes,contralateral hilar lymph nodes,ipsilateral or
contralateral scalene or supraclavicular lymph
nodes
Distant metastasis(M)
Mx: distant metastasis can not be assessed
M0:No distant metastasis
M1:Distant metastasis present
Stage grouping
0 stage TisNoMo
stage
A
T
1
N
0
M
0


B
T
2
N
0
M
0
stage
A
T
1
N
1
M
0

B
T
2
N
1
M
0
, T
2
N
0
M
0
, T
3
N
0
M
0
stage
A
T
3
N
1
M
0
, T
1
N
2
M
0
, T
2
N
2
M
0
, T
3
N
2
M
0

B
T
4
N
0
M
0
, T
4
N
1
M
0
, T
4
N
2
M
0
, T
1
N
3
M
0
,
T
2
N
3
M
0
, T
3
N
3
M
0
, T
4
N
3
M
0

stage any T and any N, M
1
Small cell lung cancer has often metastasized
at the time of diagnosis.
TNM staging is not suited to small cell lung
cancer.
Treatment
Including:
A:Surgery
B:Chemotherapy
C:Radiation therapy
D:Some other therapy
immunologic therapy

Surgery
Non-small cell lung cancer: patients with
stage I and II are considered candidates for
surgical resection, with stage III cancer may
be candidates for surgery with postoperative
radiation of the mediastinum.
Surgery
More than 90 percent of small cell lung
cancer has often metastasized at the time of
diagnosis.
So these patients usually adopt radiation
therapy or chemotherapy before surgery.
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
Surgery
Surgery
Surgery
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
Chemotherapy drawbacks
Aggressive chemotherapy produces
complications and symptoms in all patients.
All experience anemia,leukopenia and
opportunistic infections.
Other complications include nausea,vomiting
possible cadiotoxicity, hemorrhagic cystitis and
peripheral neuropathy.
Radiation therapy
It is of proven benefit in controlling bone
pain,spinal cord compression, superior vena
cava syndrome and bronchial obstruction.
1 Epithelial Tumours
1.1. Benign
1.1.1. Papillomas
1.1.1.1. Squamous cell papilloma
Exophytic
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 adenoma
Pleomorphic adenoma
Others
1.1.2.4. Mucinous cystadenoma
1.1.2.5. Other


1.2. Preinvasive lesions
1.2.1. Squamous dysplasia/Carcinoma in situ
1.2.2. Atypical adenomatous hyperplasia
1.2.3. Diffuse idiopathic pulmonary neuroendocrine cell
hyperplasia
1.3. Malignant
1.3.1. Small Cell Carcinoma
1.3.2. 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. Large cell carcinoma
Variants
1.3.4.1. Large cell neuroendocrine carcinoma
1.3.4.1.1. Combined large cell neuroendocrine
carcinoma
1.3.4.2. Basaloid carcinoma
1.3.4.3. Lymphoepithelioma-like carcinoma
1.3.4.4. Clear cell carcinoma
1.3.4.5. 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. Large Cell Carcinoma
1.3.2.4. Adenosquamous carcinoma
1.3.2.5. Carcinoid tumor
Typical carcinoid
Atipical carcinoid

2 .Soft Tissue Tumours
2.1 Localized fibrous tumour
2.2 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
3.1 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 Tumours
4.1 Hamartoma
4.2 Sclerosing hemangioma
4.3 Clear cell tumour
4.4 Germ cell neoplasms
Teratoma, mature or immature
Malignant germ cell tumour
4.5 Thymona
4.6 Melanoma
5 Lymphoproliferative Disease
5.1 Lymphoid interstitial pneumonia
5.2 Nodular lymphoid hyperplasia
5.3 Low-grade marginal zone B-cell lymphoma of the
mucosa-associated lymphoid tissue
5.4 Lymphomatoid granulomatosis
SERIES HIGHLIGHTS IN LUNG CANCER
Edited by C. Brambilla and S. Spiro
The new World Health Organization classification of lung tumours
E. Brambilla*, W.D. Travis#, T.V. Colby}, B. Corrinz, Y. Shimosato
Carcinoid tumor
Combined Small Cell CC and Adenocarcinoma
Combined Small Cell CC and Squamous Cell CC
Large Cell Carcinoma
Small Cell Carcinoma
Small Cell Carcinoma
Lung Cancer: Overview



Lung cancer 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)

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. 1.5
times more likely to develop lung cancer than men with
similar smoking patterns.


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


Metastatic nodes



























Sputum Sample of Bronchogenic Carcinoma

Hamartoma

Tracheal papillomatosis

Endobronchial amyloidoma