Benign Lung Tumor

7/28/2019 Benign Lung Tumor

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BENIGN LUNG TUMOR

I. INTRODUCTION

Tumors are neoplasms in which an abnormal growth of new tissue. This situation is

caused by abnormal growth and differentiation genes that control the damage or apoptosis of

cells. In medical term, a tumor known as neoplasia. Neo means new, plasia means growth /

division, so neoplasia refers to the growth of new cells, which differs from surrounding cells

those are normally grow. There are two main functions of our cells, namely implementing its

functional activity and multiply by dividing. However, in tumor cells that occur, most of the

cell's energy is used exclusively for proliferation. This proliferation function regulated by the

nucleus of the cell (nucleus), resulting in tumor cells found that the cell nucleus is enlarged

because of increased work demands. Lung is an elastic organ and is located inside the cone-

shaped chest cavity (cavum thoracis). Lung tumors are one type of tumor is difficult to cure.

These tumors are caused by cells that divide and grow uncontrollably in the pulmonary organs.

Lung tumors can be classified to two of the primary lung tumors and secondary lung tumors.

Primary lung tumors can be divided into benign and malignant tumors. From the above

definitions of tumors, the tumors were divided form the two major categories of benign tumors

(benign) and malignant tumors (malignant) or popularly called as cancer. There are significant

differences in the nature of them. Rare benign lung tumor usually found incidentally on routineexamination because benign tumors are rarely giving a complaint and grow very slowly. Benign

lung tumors that are often encountered is Hamartoma. Other types of benign tumor that is the

fibroma, lipoma and others very rarely found. Solitary pulmonary nodules found on the level of

1-2 per 1000 chest radiography. Approximately 30% of the nodules proved to be malignant.

From the remaining nodules, benign lung tumors makes about 2-5% of primary lung tumors.

Benign lung tumors are a heterogeneous group of neoplastic lesions from lung structures. These

tumors include bronchial adenomas, hamartomas, and unusual group of neoplasms (eg,

chondromas, fibromas, lipomas, leiomyomas, hemangiomas, teratomas, pseudolymphomas,

endometriosis, and bronchial glomus tumors).1,2,3,4


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Many of malignant lung tumors, are also found as carcinoma bronchogen because most

of primary malignant tumor originating from the lower respiratory system are derived from

epithelial and mucosal bronchial branching. Secondary lung tumors are more common than

primary lung tumors. Travel or metastasis from elsewhere to the lung usually haematogenous,

limfogen or directly. Usually tumors that metastasize to the lungs was already very advanced or

in high stage. Malignant tumors of other organs that often metastasize to the lungs, among others

osteosarkoma, breast carcinoma, breast carcinoma, carcinoma of the skin and womb.1,2,3,4

II. INCIDENCE

Benign lung tumors are rarely encountered that is only about 2-5% of all primary lung

tumors. In America malignant lung tumors in the reported cause of death as many as 136 000

people a year (1987). Most of cases are occur with patient over 35 years old. The highest

incidence occurred at the age of 55-65 years and men are more than women with a ratio of 4:1.

Although benign lung tumors do not cause significant health problems, complications can result

from obstructive lesions that can affect the patient's pneumonia, atelectasis, and hemoptysis.

Exact incidence is unknown because these tumors are often asymptomatic and detected only

during autopsy.1,2,3,4

III. DIVISION

Benign epithelial tumours Benign tumours arising from the submucosal glands

Sclerosing pneumocytoma

Alveolar adenoma

Squamous papilomaBenign mesenchymal tumours Hamartoma

Lipoma

Leiomyoma

Granular cell tumors


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Benign tumors arising from submucosal glands

Most tumours of the submucosal glands are of low grade malignancy and form a small

subgroup of bronchopulmunary carcinoma. Benign tumours of the submucosal glands are even

rarer than their malignant counterparts. They include mucous cell adenoma, pleomorphic

adenoma and oncocytoma. All these tumours tend to affect young adults and even children and

are unrelated to smoking. They often grow as an intrabronchial polyp.

Pleomorphic adenoma shows a mixed pattern of differentiation with both connective

tissue and epithelial components the former probably representing metaplasia of their

myoeepithelial elements. Oncocytoma is an adenoma of unusual appearance due to cytoplasm

being packed with large number of mitochondria which are apparently inactive. This is taken to

represent a degenerative change. Similar large eosinophilic cells are sometimes found in the

ducts of otherwise normal submucosal glands. In spite of their name, these tumours are quite

benign.8

Sclerosing pneumocytoma

These benign tumours are found in the periphery of the lung. They are more common in

women than in men and affect populations in the far East more than elsewhere. There is marked

vascular and less evident epithelial component. Although originally believed to be angiomatous

in nature or even mesothelial it is probable that these tumours arise from epithelial alveolar

lining cells and the term sclerosing pneumocytoma is therefore preferred to the older one of

sclerosing haemangioma.8

Alveolar adenoma

These will-circumscribed tumours arise in the periphery of the lung of elderly patient.

They resemble lymphangiomas microscopically but the flattened cells that line their narrow

spaces are epithelial rather than endothelial and they are possibly related to the sclerosing

pneumocytoma described above. Their nature is generally only recognised once they are excised,

following which they do not recur.8


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Squamous papillomas

Squamous papillomas may be solitary or multiple, the latter forming the condition known

as juvenile papillomatosis. This condition most commonly affects the larynx but may extend into

the trachea or large bronchi and very rarely into the distal lung. The onset is generally before the

age of 11 years and most examples regress before puberty. However repeated laser therapy may

first be required, because the lesions are prone or recur. Multiple laryngeal, tracheal and

bronchial papillomas cause hoarseness, stridor, and respiratory obstruction, while the rare

pulmonary lesions appear on chest radiographs as solid or cystic rounded nodules. The human

papilloma virus is an aetiological factor and types 6 and 11 have been identified in the lesions.

Solitary papillomas are generally found in elderly smokers with human papilloma virus

again involved, although here the virus is of types 16 and 18 rather than 6 and 11. The epithelial

covering can show the whole range of changes described in the development of squamous cell

carcinoma in flat bronchial epithelium: squamous metaplasia, dysplasia, carcinoma in-situ and

invasive tumours. In general, older patients are more likely to have premalignant lesions.

Figure 1

Figure 1 : shows multiple cysts of varying sizes in the right upper and mid-zone with ill

defined opacities in the right lower zone silhouetting the raised right dome of diaphragm8


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Hamartoma

Hamartoma is the most common benign neoplasm of the lung, accounting for up to 8% of

all primary tumours. In dorland`s hamartoma means a benign tumours-likes nodule composed of

an over-growth of mature cells and tissue normally present in the affected part but with

disorganization and often with one elements predominating. Its pathogenesis is currently

believed to involve clonal proliferations of mesenchymal elements. Tumours are typically

composed of cartilage, fibromyxoid stroma, and adipose tissue along with incorporated

bronchiolar epithelium and less common diverse elements such as bone or hair. Incidence of

Hamartomas occurs more frequently in men, and the mean age at presentation is the six decade,

with only rare cases described before the third decade of life. Many cases of Hamartomas

unrecognized and are found only at autopsy.9

Hamartoma typically present as a solitary pulmonary nodule, usually discovered

incidentally on chest films or during the course of a surgical procedure for another indication.

Most patient are completely asymptomatic. An exception is the endobronchial hamartoma, which

represents fewer than 20% of cases. Patient with endobronchial hamartoma often complain of

cough, dyspnea, wheezing, and occasionally hemoptysis.9

Radiographically, hamartoma are usually solitarybut multiple nodules have been reported

in up to 3% of cases. The nodules are typically smooth, lobulated, peripheral lesions,

approximately 0.5 to 3 cm in diameter. These tumours grow very slowly. Classically, hamartoma

have an eccentric `popcorn` calcification pattern on plain chest radiographs. Calcification can be

seen more frequently and to better advantage by CT-Scan. These scan may also reveal central fat

within the lesion, a distinctive and characteristic finding in hamartoma. If a diagnostic workup is

pursued, then transthoracic needle aspiration should be performed, as it has proven diagnostic

yield of greater than 85%. Biopsy-proven hamartomas can be safely observed with out specific

therapy. Excision is warranted when patients have symptoms or when lesions demonstratesignificant growth. Lung-sparing surgical resection is the treatment of choice because

hamartomas rarely recur. No additional adjuvant therapy is required for the typical case.9


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Figure 2 : `popcorn` calcification pattern on plain chest radiographs

Figure 3 : computed tomography scan after intravenous contrast demonstrate the presense of

calsification and fat within the hamartoma


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Lipoma

Lipomas are the most frequent tumors of the body, 'pulmonary' lipomas are very rare.

Endobronchial lipomas have an incidence of 0.1 to 0.5% of all lung tumors. Lipomas, as benign

pulmonary tumors, can be found endobronchially, intrapulmonary, and mediastinal. Lipomas

may arise within a bronchus or the periphery of the lung. They are probably one-sided

developments of the mixed mesenchymoma referred to hamartomas. They have no premalignant

connotation. Computer tomography can suggest this diagnosis because the tumours have the

radiolucency of fat. Cough as the most frequent complaint. The other symptoms include:

increased sputum, hemoptysis, fever, and dyspnea. Eighty percent of patients have abnormalities

on chest radiograph (e.g., atelectasis, consolidation, or mass). Management of lipoma are

resection by bronchoscopy is the first choice of treatment.8

Figure 4 : showed a hilar mass on the right side, with the density of fat (-100 HU),

identified as a hilar lipoma. There was also a large cystic structure in the right upper lobe,

adjacent to the right hilus.

Leiomyoma

As with smooth muscle tumour elsewhere in the body the histological differentiation of

benign leiomyoma from low-grade leiomyosarcoma is difficult. However, in the lung most

smooth muscle are benign. They may be found in the trachea, bronchi, or in association with

peripheral bronchioles. In all cases the possibility of metastasis from another site, such as a low

grade leiomyosarcoma of the uterus should be considered. Pulmonary leiomyoma seem to to

occur with about equel frequency in the proximal bronchi and parenchyme.8


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Granular cell tumour

Granular cell tumors (GCT) are uncommon, usually benign neoplasms, most frequently

originating from tongue, skin, and breast. Granular cell tumour were originally believed to be

derived from smooth muscle but it is now accepted that they are benign lesions derived from

schwann cells. As seen with nerve shealth tumours, they express the S100 neural marker but are

composed of polygonal rather than spindle cells and have abundant eosinophilic cytoplasm . The

lesions are usually small but may occasionally measure several centimetres in diameter. They

occurs in the major airway present with obstructive symptoms. Histologically the outstanding

feature is numerous fine, acidophilic, cytoplasmic granules, which appear similar to lysosomes

under electron microscopy.8

Figure 5 : Chest radiograph showing a mass lesion (arrow) intimately associated with a

segmental bronchus of the left lower lobe. Although Chest computed tomogram showing

localized expansion of mass, which measured 2.8 2.0 cm in size.

IV. ETIOLOGY

The cause of benign lung tumors till now is not understood certainty. While pulmonary

malignant tumors according to the ACS (the American Cancer Society) for more than eight out

of 10 cases of lung cancer caused by smoking. And not only the cigarette as the cause but alsothe cigar and pipe smokers have a higher risk for lung cancer. The number of smokers each year,

the number of smokers every day and how long the person inhaled smoke are at risk for

developing lung cancer. The development of lung cancer through passive smoking also increases

the exposed through the air when someone else smokes.1,4,5,7


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A carcinogen is found in air is 3.4 benzpiren pollution. In certain circumstances

bronchogenic carcinoma is a disease caused by work. From various industrial materials, one of

the most dangerous is asbestos. The risk of cancer due to asbestos 10 times greater. There is also

an increased risk among those who work with uranium, chromate, arsenic, iron and iron oxide.

Lung cancer risk either due to contact with asbestos and uranium is greater if the person is

smoking.1,4,5,7

Other factors may also play a role in increasing the risk of lung cancer is diet and

environment especially family. Some research shows that smokers of low vitamin A diets

increase the risk of lung cancer. The loss of chromosomes (partial 11p, 13q, 17p, and 3p) tumor

gene mutations suppressor (p53, Hap-1, ErbAb etc.) and others that implicate familial factors in

the formation of lung cancer. The factors that have been in explaining this clearly states that

although smoking plays a central role in increasing the incidence of lung cancer but also many

guidelines that state that smoking is not the only factor. Chronic infection, caused by air

marshals in motor vehicles and industrial work that led to contact with carcinogenic substances,

dietary factors, family factors and perhaps other factors are not learned and is a predisposing the

occurrence of lung cancer.6

V. ANATOMY AND PHYSIOLOGY

The lungs are the essential organs of respiration; they are two in number, placed one on

either side within the thorax, and separated from each other by the heart and other contents of the

mediastinum. The substance of the lung is of a light, porous, spongy texture; it floats in water,

and crepitates when handled, owing to the presence of air in the alveoli; it is also highly elastic;

hence the retracted state of these organs when they are removed from the closed cavity of the

thorax. The surface is smooth, shining, and marked out into numerous polyhedral areas,

indicating the lobules of the organ: each of these areas is crossed by numerous lighter lines. 10


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Figure 6 : Front view of the lungs

Each lung is conical in shape, and presents for examination an apex, a base, three

borders, and two surfaces. The apex (apex pulmonis) is rounded, and extends into the root of

the neck, reaching from 2.5 to 4 cm. above the level of the sternal end of the first rib. A sulcus

produced by the subclavian artery as it curves in front of the pleura runs upward and lateral ward

immediately below the apex. The base (basis pulmonis) is broad, concave, and rests upon the

convex surface of the diaphragm, which separates the right lung from the right lobe of the liver,

and the left lung from the left lobe of the liver, the stomach, and the spleen. Since the diaphragm

extends higher on the right than on the left side, the concavity on the base of the right lung is

deeper than that on the left. Laterally and behind, the base is bounded by a thin, sharp margin

which projects for some distance into the phrenicocostal sinus of the pleura, between the lower

ribs and the costal attachment of the diaphragm. The base of the lung descends during inspiration

and ascends during expiration.10


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Figure 7 : Anatomy of lungs

Both lungs are filling most of the thorax cavity of each is wrapped by two membrane

called the pleura. Larger right lung and has three lobes while the left lung has two lobes. Each

lobe is further towards bronkhopulmuner segments each have segment bronchus. Tracheal

branching will end up with two main branches of lung bronchi of the right bronchus and left

bronchi. In the lungs there are branching bronchi again to form secondary and tertiary bronchi.

Furthermore, a small bronkhiolus and ends with bronkhiolus terminalis. The final part of

bronkhiolus terminalis called alveoli. Alveoli sacs in the form of thematic clusters of alveoli at

the end of the bronchial terminalis. Each lung consists of 300 million alveoli with a surface area

of 40-80m2. The alveoli are lined by a delicate layer of simple squamous epithelium, the cells of

which are united at their edges by cement substance. Between the squames are here and there

smaller, polygonal, nucleated cells. Outside the epithelial lining is a little delicate connective

tissue containing numerous elastic fibers and a close net-work of blood capillaries, and forming a

common wall to adjacent alveoli. Inoxygenate of blood in the heart are taken into the lungs

through the arteries to the bronchi will pulmunalis and bronkhiolus. Oxygenate blood of thesystem will pass through the capillary-venule venule pulmuner who will unite to form veana

pulmunalis. Lymph channels in the lungs is a closed channel which is located between alveolar

cells and on arterial pulmunalis endhothelium. Lymphatic fluid carry proteins, lipids, dead cells

and foreign particles away from the lungs intersisiel space which plays an important role in lung

defense system from disease.10


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Contraction and relaxation of muscles in the chest and diaphragm occur if done

inspiration and expiration. As inspiration, the diaphragm and intercostal muscles will contract. In

expiration, the diaphragm and intercostal muscles relax. Respiration center located at the brain

stem controls breathing. Oxygen is obtained from the process of inspiration, through the alveoli

into the blood vessels,then will then be taken to the left side of the heart through pulmonary

veins to be pumped to the entire body. Deoxygenated blood from the body will flow to the right

side of heart to be pumped back into the lungs through the pulmonary artery. Carbon dioxide

from the capillaries will enter into the alveoli and then flow into the alveolar space and will be

released through the expiration process.10

VI. PATHOPHYSIOLOGY

Pathogenesis of primary lung tumors either benign or malignant is less understandable.

Nomenclature of benign and malignant lung tumors based on histological. Neoplastic lesions is a

proliferative lesion of autonomous cells without the normal control mechanisms of their growth.

Neoplastic lesion characterized by the proliferation of autonomous cells with no response to

normal control mechanisms that regulate their growth. An additional characteristic of benign

tumors is an extension without an invasive local tissue or spread to other sites.3


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For secondary lung tumors, there are two prominent mechanisms of cancer spread to the

lungs those are direct extension and true metastatic. Usually a direct extension of primary tumors

involving other organs (such as thyroid, esophagus, and thymus) or derived from the tumor

metastases to other intrathoracal structure (eg mediastinal lymph glands), which generally causes

obstructive abnormalities in the trachea or bronchus. Direct extension can also occur through

blood flow, like the spread of cancer cells from the kidney or testis as thrombus that is carried

within vascular into the lungs via the inferior vena cava and the right heart. True metastatic

occurs through the pulmonary artery, bronchial arteries or lymphatic system or the lungs, pleural

cavity or through the airway passage.3

VII. CLINICAL SYMPTOMS

Most of primary lung tumors are already found in an advanced stage. In the advanced

stage there is no lung cancer patients who do not have any complaints and clinical symptoms.

Conversely in the early stages of this disease is sometimes a long time does not cause significant

complaints or clinical symptoms. Complaints and symptoms of lung cancer originating from

airway disorders, the emphasis into the surrounding organs and metastases. Disturbances in the

respiratory tract causing symptoms such as cough and haemoptysis. Tumors in the central region

generally give symptoms of cough because intrabronchial irritation. Shortness of breath may

caused by bronchial obstruction. Pressure and infiltration of surrounding organs can lead to

dysphagia, pain, dyspnoea so that it can happen intrabronkial tumor capillary rupture. Metastasis

via the bloodstream can attack and organ systems as far as the other lymph glands and liver most

frequently in children and kidney, brain, bone and kidney rarest.7,8,9

VIII. DIAGNOSIS

Diagnosis of lung tumors can be decided through the anamnesis of the major complaintsand other complaint that was followed at the same time of chief complaint. Also asked about

smoking habits, how stem spent each day, how long these habits and when to stop. Also related

to air pollution in the workplace or home environment.10


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On physical examination noted a general state of patients according to Karnofsky scale,

deformities and thoracic movement, voice change, enlargement of lymph glands, especially in

the area of supraclavicular. Investigations including routine laboratory examinations of blood,

sputum cytology, liver function, kidney function, and others. Thoracic radiology examination is

an absolute must to determine the exact location of the tumor. Bonchoscopy inspection is also

important to be done. Transthoracal biopsy or transthoracic needle aspiration biopsy is useful to

determine the histological or cytological diagnosis, by taking material directly from the tumor. In

addition to lung cancer TNM classificationthere is also UICC & AICC 1987 staging.7

T Primary tumor

TX

T0

Tis

T1

T2

T3

T4

Primary tumor can not be assessed

The tumor did not appear

Carcinoma in situ

Tumor 3 cm

Tumors> 3 cm invasion into the pleural visceralis followed by atelectasis or obstructive

pneumonitis

Tumors of various sizes which infiltrated the thoracic wall, diaphragm, mediastinal pleura,

parietal pericardium

Tumors of various sizes which infiltrated the mediastinum, heart, great vessels, trachea,

esophagus, spinal


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N Regional lymph nodes

NX

N0

N1

N2

N3

Regional lymph nodes can not be assessed

There was no metastasis to regional lymph nodes

Metastases in the lymph glands on the same side or same side of the hilum

Mediastinal metastases the same side and / or glandular subkarina

Contralateral mediastinal metastases, contralateral hilum lymph nodes

M Distant metastases

MX

M0

M1

Can not be in the assessed of distant metastases

No distant metastasis

There are distant metastases

IX. MANAGEMENT

Benign lung tumors were best treated by surgical resection of the tumor. The extent of

surgery may be simple endoscopic resection, thoracotomy with bronchotomy/local excision,

segmental resection, lobectomy, sleeve resection, or pneumonectomy. The extent is usually

determined at surgery and is as conservative as possible. Endoscopic resection using the rigid

bronchoscope is readily used to resect endobronchial benign lung tumors except for bronchial

adenomas. Recently, bronchoscopic resection offers an alternative to surgical resection. At 1 and

10 years, respectively, 100% and 94% of completely resected carcinoids were free of disease.

Commonly, surgical resection is recommended for bronchial adenomas because of the potentialfor malignancy. The surgical approach should include complete resection, sparing of as much

lung as possible, and lymph node dissection. Endoscopic resection with neodymium: yttrium-

aluminum-garnet (Nd:YAG) laser can be used for adenoma in high-risk or elderly patients.7,9,10


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Treatment of malignant lung tumors or lung cancer based on histopathological type,

degree (stage, stage) and appearance (performance status) patients. In general, this treatment is a

combination of surgery, radiation or chemotherapy and consumption of cytostatic Lung

carcinoma surgery called as curative treatment if the tumor was carried out and the perfect gland

dissection accompanied by pathological examination found no metastasis to the gland that was

lifted. Patients with extensive-stage disease was handled with only chemotherapy. Several

combination chemotherapy regimens were often used consisted of cyclophosphamide and

doxorubicin.7,9,10

X. PROGNOSIS

Prognosis of benign lung tumors such as bronchial adenoma which has been operated is

good. Reported 5 years survival rates after resection reached 95% and will decrease to 70% if

regional lymph nodes are affected. Overall prognosis for patients with carcinoma bronkogenik is

bad. If there are any symptoms or signs of disease were 75% was not able to recover again. For

patients who had made the diagnosis, one-year survival reached 20%, 5 years survival rates less

than 10% and only slightly increased in recent years.4

Benign Lung Tumor

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