Neoplasms of Lung and Pleura William K. Funkhouser, M.D. Ph.D. –x 3-1069...
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Transcript of Neoplasms of Lung and Pleura William K. Funkhouser, M.D. Ph.D. –x 3-1069...
Neoplasms of Lung and Pleura
William K. Funkhouser, M.D. Ph.D.– x 3-1069 – [email protected]
Neoplasms of Lung and Pleura
• Primary Neoplasms of Lung
• Primary Neoplasms of Pleura
• Metastatic Neoplasms to Lung and/or Pleura
Neoplasms of Lung and Pleura: Classification by Lineage
• Epithelial – most common
• Melanocytic
• Stromal
• Mesothelial
Benign Lung Neoplasms
• Hamartoma
• Squamous papillomatosis
• Pleomorphic adenoma (ENT)
Hamartoma
• Clin: Adolescence adulthood
• None in newborns - not congenital
• Rad: Solitary nodule +/- popcorn calcification
• Peripheral > central
• Path: Gross: solitary, lobulated, cartilagenous Micro: normal tissues in
excess/disarray
Hamartoma
Solitary PulmonaryNodule
BivalvedHamartoma
Hamartoma
Cartilage in excess and disarray
Malignant epithelial neoplasms(Carcinomas)
• Squamous cell carcinoma
• Adenocarcinoma
• Large cell undifferentiated carcinoma
• Small cell undifferentiated carcinoma
Lung Carcinomas:Epidemiology
• Estimated Incidence (2003): 172,000 (US)• Estimated Mortality (2003): 157,000 (US)• >85% of lung carcinoma deaths (and 30% of all
cancer deaths) occur in cigarette smokers• Risk = f(# cigarettes smoked), 15-30X in heavy
smokers, 50-60X in asbestos workers who smoke• Risk decreases with cessation of cigarette
smoking: baseline after 15 years
USA Tobacco Use
• 25% of US adults smoke cigarettes
• M=F
• US adults consume 2,400 cigs/person/year
• 36% of US high school students smoke
• est. 1.8 million new smokers/year (65% < 18 yo)
Tobacco: Morbidity and Mortality
• Premature ASVD: major risk factor• Emphysema: Linear with exposure: 7%/10 years • Chronic bronchitis • Carcinomas of pharynx, larynx, lung, esophagus,
bladder, kidney• Fetal tobacco syndrome
Tobacco: Chemistry
• 80% air, 20% gases and particulates
• Gases: CO, CO2, formaldehyde, acrolein, methanol, phenol, anthracenes, pyrenes
• Nicotine: 1% of smoke 85% absorbed in lung equivalent to 1 mg IV
Tobacco: Chemistry
• Particulates: – resin cores in 0.5 M diameter water droplets– est. 109 particles/ml – 50% deposited in and cleared by cilia– remainder: phagocytosis, lymphatic transport
• Overall: 4,000 chemical compounds, of which 43 are considered carcinogenic
Squamous cell carcinoma
• Clin: Smokers (98%) 20-30% of common carcinomas May secrete PTH-like compound
• Rad: central > > peripheral
• Path: Bronchi > Larynx > Trachea +/- Desmosomes (intercellular bridges) +/- Keratin production, e.g. keratin
pearls
Normal
Squamous cell carcinoma
Squamous cell carcinoma in situRespiratory mucosa
Invasive Squamous Carcinoma
Keratin
Desmosomes
Metastatic squamous cell carcinoma to lymph node
Normal lymph node lymphocytes
Mets in subcapsular sinuses
Adenocarcinoma
• Clin: 30-40% of common carcinomas Most common carcinoma in non-smokers,
but 80% of adenoCAs occur in smokers
• Rad: peripheral > central
• Path: +/- glands +/- mucin Bronchiolo-alveolar carcinoma subset
Adenocarcinoma
Primary
Pleural effusion
Adenocarcinoma
Gland formation
Adenocarcinoma
Mucin production (red on PASd stain)
Bronchioloalveolar carcinoma (BAC)
• Clin: Rising incidence (presently 20-25%) Not associated with cigarette smoking
• Rad: Peripheral, can be multifocal and bilateral
• Path: Lepidic (butterfly-like) growth pattern Mucinous or non-mucinous Unifocal or multifocal Distinction of multifocal primary from
mets
Bronchiolo-alveolar carcinoma
Bronchiolo-alveolar carcinoma
Bronchiolo-alveolar carcinoma
Large cell undifferentiated carcinoma
• Clin: 10% of common carcinomas
• Rad: non-specific
• Path: H&E: Undifferentiated EM: ? adenocarcinomas
cDNA microarrays: distinct disease
Large cell undifferentiated carcinoma
Large cell undifferentiated carcinoma
Non-Small Cell Lung Carcinomas: Prognostic variables
• Definitely: Stage, performance status, weight loss
• Possibly gender, ploidy, k-ras mutation, p53 protein accumulation
• Not age, histology
Small cell carcinoma
• Clin: Smokers 20 % of common carcinomas
Ectopic ACTH, ADH, Eaton-Lambert, carcinoid s.
Commonly high stage at presentation Responsive to chemo/RT, but low 5 yr survival
• Rad: Central in >90% Frequent metastases to LNs and distant sites
• Path: Malignant cytology No nucleoli High mitotic activity and necrosis
Small cell undifferentiated carcinoma
At diagnosis Response to therapy
Small cell undifferentiated carcinoma
Viable carcinoma
Necrotic carcinoma
Small cell undifferentiated carcinoma
Small cell undifferentiated carcinoma
Metastatic small cell carcinomaNormal lymphocytes
Small Cell Lung Carcinoma: Prognostic variables
• Definitely: Stage, performance status
• Probably: Gender, age, # of metastatic sites
Neoplasms of Lung & Pleura: Classification by Lineage
• Epithelial
• Melanocytic
• Stromal
• Mesothelial
• Metastases
Mesothelioma
• Clin: Associated with asbestos exposure• Rad: Diffuse pleural involvement
May have associated effusion• Path: Malignant Deeply invasive
growth pattern Epithelial, spindle cell, or biphasic Immuno: Keratin (+) EM: long microvilli
Mesothelioma: PA Chest
VisibleC-PAngle
Loss of C-P Angle= Pleural effusion or mass
Mesothelioma: CT
Thickened pleura Normal thickness pleura
Normal thin pleura
Deeply invasive mesothelioma (cytokeratin immunostain)
Epithelioid cytology of this mesothelioma mimics adenocarcinoma
Adenocarcinoma Mesothelioma N. Weidner
Asbestos body (Ferruginous body)
Neoplasms of Lung & Pleura: Metastases
• Most common malignant neoplasms involving the lung
• Multiple nodules favor metastases over primary neoplasms (except BAC)
• Carcinomas• Sarcomas• Melanoma
Metastatic carcinomas
• Breast adenoCA
• GI adenoCA
• Renal adenoCA
• Head/neck squamous cell CA
Metastatic Breast CA
Pleural Thickening due to Metastases +/- Pleural Effusion
Metastatic breast carcinoma
Metastatic colon carcinoma
Metastaticrenal cell carcinoma
MetastaticENT carcinoma
Metastatic sarcomas
• Osteosarcomas
• Soft tissue sarcomas
Metastaticosteosarcoma
Metastatic melanoma
• Clin: Extrapulmonary 1 melanoma much more common than pulmonary 1 No known 1 in 5-10% of cases
• Path: Variable architecture & cytology May be pigmented
Use immunohistochemistry to confirm
Metastatic melanoma
Neoplasms of Lung and Pleura
• 1 Lung Neoplasms - Most are carcinomas
• 1 Pleural Neoplasms - Mesotheliomas
• Mets to Lung and/or pleura – All lineages possible
Thanks for your time.
Questions?