Lung tumours Flashcards
what is Bronchogenic carcinoma
malignant and epithelial
aka lung cancer 95% of all primary lung tumours 2nd most common cancer Incidence still rising in women Most common fatal malignancy Peak incidence in 50-70 age group
what is carcinoid
borderline malignant and epithelial
what is bronchial adenoma
benign epithelial
what are leiomyosarcoma and liposarcoma
malignant and connective tissues
what are leiomyoma and lipoma
benign and connective tissue
what is a Pulmonary hamartoma
A developmental disorder of cell growth in which there is
excessive growth of cells and tissues normally present at
that site.
Well- defined peripheral lesion
risk of smoking in lung cancer
Compared with non-smokers – average smokers have 10 x increased risk and heavy smokers (>40/day) have 60 x increased risk.
Directly related to amount of daily smoking, tendency to inhale and duration of habit
Women apparently more susceptible to the carcinogens.
Cessation of smoking for 10years reduces risk but never to control levels.
Also assocd with ca of the mouth, pharynx, larynx, oesophagus, pancreas, cervix, kidney, bladder
Cigar and pipe smoking also related but not as bad.
Statistically related to ‘pack years’:
(packs/day x years of smoking)
80% of cancers occur in smokers
6 stages of normal tissue to invasive cancer
1 - normal epithelium 2 - hyperplasia 3 - squamous metaplasia 4 = dysplasia 5 - carcinoma in situ 6 - invasive carcinoma
Estimated 10 to 20 genetic mutations have occurred by the time tumour is clinically apparent
Multiple hits
8 complications of lung cancer
1 - Hoarseness – Left laryngeal nerve palsy
2 - Haemoptysis – Vascular destruction
3 - Pneumonia, bronchiectasis, abscess – Obstruction
4 - Dysphagia – Oesophageal invasion
5 - Diaphragm paralysis – Phrenic nerve invasion
6 - SVC syndrome – SVC obstruction (Superior vena cava syndrome (SVCS) is obstruction of blood flow through the superior vena cava (SVC). It is a medical emergency and most often manifests in patients with a malignant disease process within the thorax.)
7 - Pleural effusion – Tumour invasion
8 - Pericarditis – Tumour invasion
9- horner’s syndrome due to sympathetic ganglia invasion. (constricted pupil, sunken eye, ptosis, ipsilateral loss of sweating.
whats a Pancoast’s tumour and what are the possible complications
Apical tumour invades sympathetic ganglia»_space;
Horner’s syndrome = constricted pupil, sunken eye, ptosis and ipsilateral loss of sweating
Shoulder and arm pain from brachial plexus involvement
Hoarseness from laryngeal
nerve palsy
what are Paraneoplastic syndromes
A syndrome associated with tumour but not due to either local or metastatic spread
Often associated with ectopic hormone production
May precede a macroscopically identifiable lesion
Common in lung cancer
Related to histological type
5 lung cancer endocrinopathies
Endocrinopathies
Hyponatraemia - Syndrome of inappropriate anti-diuretic hormone secretion (SIADH)
Cushing’s syndrome – ACTH or ACTH-like production
Hypercalcaemia – Parathyroid hormone, parathyroid hormone related peptide or prostaglandin E secretion
Hypocalcaemia – Calcitonin secretion
Gynaecomastia – Gonadotrophin secretion
what happens in SIADH
Syndrome of inappropriate anti-diuretic hormone secretion (SIADH) - – hyponatraemia, cerebral oedema and neurologic manifestations
what happens in cushing’s
Hypertension, weight gain, truncal obesity, moon facies, buffalo hump, proximal limb weakness, secondary diabetes, fragile skin with easy bruising, osteoporosis
5 non endocrine syndromes that can be caused by lung cancer systemic effects
Non-endocrine syndromes
1 - Myasthenia (Lambert-Eaton syndrome) – autoantibodies against pre-synaptic calcium channel
2 - Hypertrophic osteoarthropathy (clubbing, periosteal new bone formation in small long bones and arthritis of adjacent joints) – Unknown mechanism
3 - Trousseau’s syndrome (migratory thrombophlebitis) – tumour mucins that activate clotting
4 - Dermatomyositis – auto-antibody production
5 = Acanthosis nigricans – secretion of epidermal growth factor
what is Squamous cell carcinoma
30% tumours (from 40% previously)
M>F
Strongest link to smoking – 98% are in smokers
Hypercalcaemia is the commonest paraneoplastic syndrome
Central in position
Locally advanced before metastatic spread
Arise from stem cell population (reserve cells)
Following squamous metaplasia of respiratory epithelium
After undergoing increasing dysplasia and carcinoma-in-situ formation
Large poorly-circumscribed mass with direct origin
from main bronchus
what is squamous metaplasia
Squamous metaplasia – a change from 1 epithelial cell type to another in response to environmental insult
what is dysplasia
Dysplasia – cytological and architectural atypia without breach of the basement membrane
what is adenocarcinoma
30% of tumours (from 25% previously) F>M, but increase is in males Least association with smoking But 75% still in smokers Paraneoplastic syndromes rare
Can be peripheral as well as central
Peripheral tumours occasionally associated with scarring (scar cancers)
Arise from stem cell population
Via dysplasia without metaplasia
A poorly-circumscribed mass whether central or
peripheral. Bronchial origin only identifiable if central.
what is Bronchioloalveolar carcinoma
A rare specific subtype of adenocarcinoma
<1% lung cancers
Usually peripheral
Arise from distal bronchi/bronchioles
Extend into alveolar spaces
All well-differentiated histologically so not graded further
Better prognosis than other adenocarcinomata
Mimics consolidation clinically and radiologically
An ill-defined parenchymal
mass that mimics the
consolidation of pneumonia
Tumour cells extend along alveolar walls
what is Large cell carcinoma
aka anaplastic carcinoma 10% of tumours Not a specific entity Represents unrecognisable squamous and adenocarcinomas Lack of differentiation prevents further typing All by definition high grade Poor prognosis Paraneoplastic phenomena rare
Poorly-circumscribed large
mass arising centrally and
with cavitation due to
tumour necrosis
Large cells with marked cytological atypia including
nuclear pleomorphism and high mitotic activity. No
obvious differentiation.
what is Small Cell Carcinoma
Arise from neuroendocrine cells 25% of tumours Strongly associated with smoking 99% in smokers, M>F Cushing’s and SIADH common
Central in position
Metastasise early
All high grade so not graded further
Poorly-circumscribed
relatively small mass arising
centrally from bronchial wall
overview of lung cancer treatment and prognosis
Mostly dependent on histological type:
Small cell carcinoma vs Non-small cell Squamous cell carcinoma Adeno Large cell
Stage also affects prognosis and management
Grade (where present) alters prognosis but not management
treatment and prognosis of small cell lung cancer
Metastases usual at time of presentation
70% have extensive metastatic disease 2-4 months survival untreated Chemotherapy as highly sensitive initially Radiotherapy if SVC obstruction Surgery contra-indicated in most cases 10-20 months survival with treatment
treatment and prognosis of Non-Small Cell Lung Cancer (NSCLC)
5 year survival dependent on stage Wide range (3-60%) but overall only 20%
About 25% have resectable local disease
Surgery if resectable and no metastasis
Radiotherapy if non-resectable
Chemotherapy if metastatic, but response poor
staging of lung cancer
A measure of how far tumour has spread
T (tumour) N (nodes) M (distant metastases) commonly used
Information derived from:
Clinical – Bronchoscopy, Surgery
Radiology – CT, MRI, Bone scan, PET scan Pathology – Cytology, Histology, PM
Common distant sites include adrenal, brain, liver and bone
Staging NSCLC
TNM used to produce stage grouping
Useful prognostic tool:
Stage I – 60% 5 year survival Stage II – 40% 5 year survival Stage IIIa – 20% 5 year survival Stage IIIb – 5% 5 year survival Stage IV – 3% 5 year survival
Staging SCLC
TNM not used as most tumours metastatic
Instead use limited vs extensive disease:
Limited – 1-2 year median survival. Disease confined to ipsilateral thorax, Including supraclavicular fossa and pleural effusion
Extensive – 6-12 month median survival
All other patients
what are carcinoid tumours
Low grade malignant tumour
CF from their intraluminal growth, capacity to metastasise, ability of some lesions to emanate vasoactive amines.
Multiple Endocrine Neoplasia type 1 (MEN1) is a rare hereditary endocrine cancer syndrome - tumors of the parathyroid glands (95% of cases), endocrine gastroenteropancreatic (GEP) tract (30-80% of cases), and anterior pituitary (15-90% of cases).
Other endocrine and non-endocrine neoplasms including adrenocortical and thyroid tumors, visceral and cutaneous lipomas, meningiomas, facial angiofibromas and collagenomas, and thymic, gastric, and bronchial carcinoids also occur.
MEN 2 – thyroid, pth and adrenal usually
5% of all lung tumours
Arise from neuroendocrine cells
M=F, <40 years
No known relationship with smoking. Carcinoid tumours – younger patients, not usually smoking related
Can occur as part of Multiple Endocrine Neoplasia (MEN) syndromes
Can cause local and paraneoplastic symptoms
Carcinoid syndrome most common
90% benign and 10% malignant
Usually small and well-circumscribed yellow mass.
Peripheral or central position.
what is carcinoid syndrome
Due to Serotonin (5HT) production Enters systemic circulation Flushing Nausea and vomiting Abdominal pain Coughing and wheezing Carcinoid heart disease: Endocardial, Tricuspid & pulmonary valve scarring Rarely Aortic & Mitral stenosis
Cardiac problems in 50% of people with carcinoid syndrome
Serotonin and bradykinin have direct effect on right side of heart
These are inactivated as travel through the pulmonary circulation due to high monoamine oxidase levels
details on lung metastases
Most common lung tumour
Common in both carcinoma and sarcoma
Breast, GI tract and kidney most common sites
Therefore adenocarcinoma most common histological type
Can’t usually be distinguished histologically from a primary tumour
Use immunohistochemistry to give a “clue” as to the primary
Haematogenous spread – discrete nodules
Lymphatic spread – diffuse dissemination with macroscopic nodularity (lymphangitis carcinomatosa) or microscopic only
what is Lymphangitis carcinomatosa
tumour dispersed
within lymphatic vessels
what is malignant mesothelioma
Primary pleural tumour
Arise from mesothelial cells
Often extensive and bilateral
Aggressive - direct invasion to lung and mediastinum
Metastatic spread less common
Aetiology and Pathogenesis of malignant mesothelioma
Rare overall, about 1000 cases yearly in UK
Asbestos exposure
Mining, fabrication and working with insulation
10% lifetime risk if heavy exposure
Up to 40 year latency period
Smoking does not increase risk of mesothelioma
But magnifies risk of lung cancer in smokers
Clinical Presentation of malignant mesothelioma
Chest pain
Dyspnoea
Pleural effusion
Weight loss
Diagnosis can be difficult but IMPORTANT!
Diffuse and widespread thickening of pleura with extension into underlying lung
Variable histology - spindle cell ‘sarcoma-like’
areas & acinar ‘adenocarcinoma-like’ areas.
Diagnosis between mesothelioma and adenocarcinoma requires immunohistochemistry
Treatment and Prognosis of malignant mesothelioma
Surgery rarely possible
Poor response to radio and chemotherapy
50% dead within 1 year, most within 2 years
If known occupational exposure then an ‘unnatural’ cause of death
Requires referral to Coroner, post mortem (if diagnosis not confirmed in life) and inquest
diagnostic method of lung and pleural tumours
History and examination
Chest X-ray Low specificity / positive predictive value Many mimics of tumour Tumour type not identifiable 20% of tumours not visible
CT / MRI
High specificity but expensive
Tumour type still not identifiable
Bronchoscopy
Pathological Diagnosis of lung and pleural tumours
Sputum Cytology
Can be induced
Samples large volume of lung
Pleural Fluid
Drained for symptomatic relief
Diagnosis is an extra “bonus”
Bronchoscopic specimens Best for central lesions Bronchial washings and brushings Bronchial or transbronchial biopsy Transbronchial fine needle aspiration
Transthoracic Fine Needle Aspiration or biopsy
Peripheral lesions
CT guided
so usually:
Central:
Bronchoscopic diagnosis - Washings / Brushings / Biopsy
Peripheral:
CT guided transthoracic FNA / biopsy
Pleural:
Pleural fluid
CT guided transthoracic FNA / biopsy
what are benign lung tumours often like?
Well-circumscribed usually single masses of one cell type
that are well-differentiated and show little cytological atypia
clinical features of lung cancer
Usually presents at late stage:
Local tumour growth: Cough – mucosal irritation Dyspnoea – atelectasis, obstruction Weight loss – tumour cachexia Chest pain – invasion of chest wall
Metastatic tumour spread
Paraneoplastic phenomena
how are lung cancers graded
by degree of differentiation.
