The lung and the Upper Respiratory Tract

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The lung and the Upper Respiratory Tract

• Lung Tumors

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Lung tumors General features

• Most are malignant.
• Metastatitc neoplasms are most common.

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Types

• Bronchogenic Carcinoma.
• Bronchial carcinoids.
• Lymphoma.
• Hamartoma

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Bronchogenic carcinoma

1. Squamous cell carcinoma ( most common)
2. Adenocarcinoma
3. Bronchial derived
4. Broncheoloalveolar
5. Larger cell carcinoma
6. Small cell (oat cell) carcinoma.

Non small cell carcinoma
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Bronchogenic Carcinoma

• Leading case of cancer death (M/F)
• Increase in women and decreasing in men.
• Age old adult.
• Etiology
• smoking of cigarettes ( amount/ years).
• Asbestosis
• Uranium and radiation
• Air pollution
• Radon

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Molecular pathology

• Non-Small Cell Lung Carcinomas (NSCLC) 70-75 of
  all lung Ca cases
• p16/CDKN2A K-RAS mutations,
• p53 mutation ( inhibit apoptosis).
• Small Cell Lung Carcinoma (CSLC) 20-25, TP53
• RB gene mutations ( deregulate cell cycle).

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Squamous cell carcinoma

• Central tumor
• Arising from Squamous cell ( often from main
  bronchus)
• Smoking is main etiology also caused by radon.
• p53 mutation and overexpression of epidermal
  growth-factor receptor very common.
• Morphology next

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Squamous cell carcinoma The neoplasm is very
firm and has a pale white to tan cut surface.
Central necrosis is frequently seen.
Central necrosis
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Micro nests of polygonal cells with pink
cytoplasm and distinct cell borders with
intercellular bridges and keratin pearl.
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Adenocarcinoma

• Peripheral tumor.
• Sex female. Age much younger person.
• Types
• Bronchial derived occur in the site of previous
  scar (scar carcinoma). Not clearly linked to
  smoking.
• Bronchoalveolar Ca Not related to smoking.
  Multiple tumor, present as pneumonia.

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Adenocarcinoma peripheral tumor
K-RAS mutations are seen primarily in
adenocarcinoma.
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Adenocarcinoma The glandular structures formed
by this neoplasm mucin production ( mucin
stained purple with PAS)
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Bronchioloalveolar carcinoma
Appears as pneumonic consolidation. Well
differentiated tumor better prognosis.
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Bronchioloalveolar carcinoma is composed of
columnar cells that proliferate along the
framework of alveolar septae.
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Small Cell Carcinoma central tumor

• Central tumor. Aka- oat cell carcinoma
• Origin Neuroendocrine argentaffin (Kulchitsky)
  cells.
• Smoking is main etiology
• Gene p53 and RB tumor suppressor genes over
  expression of the anti-apoptotic gene BCL2.
• Poor prognosis.

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Gross This tumor has a soft, lobulated, white to
tan appearance.
Micro sheets of blue cells are regular, and
round molded nuclei and a moderate amount of
eosinophilic cytoplasm.
Blue round cells
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Large cell carcinoma
Micro large anaplastic cells. Poor prognosis
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Relax your eyes Next topic Clinical features of
tumors
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Clinical

• Common presentation Cough, hemoptysis, weight
  loss.
• Clubbing of the fingers.
• Others
• Due to spread of tumor
• Due to paraneoplastic syndromes

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Clinical Due to spread of tumor

• Local lymph nodes metastasis
• Supraclavicular node (Virchow node).
• Distant Brain, Liver ,Bone.
• Adrenals cortex (Addisons disease- deficiency of
  cortical hormones- skin mucosa hyper
  pigmentation)

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Others

• Superior Vena caval syndrome (common in small
  cell carcinoma, followed by squamous cell Ca.)
• Congestion of veins of neck, face red
• Engorges jugular vein- edema in arms.
• Hoarseness recurrent laryngeal nerve invasion (
  with apical tumor).
• Acanthosis nigricans black, thick skin with skin
  tags axillae, groin etc (common in
  adenocarcinoma).

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Clinical Due to spread of tumor

• Horner syndrome ( in Pancoast tumor )
• Seen in apical tumors due to involvement of
  cervical sympathetic plexus.
• Features are
• Ipsilateral enophthalmos.
• Ptosis, Meiosis.
• Anhidrosis.

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Clinical Due to paraneoplastic syndromes
Squamous cell carcinoma Secret PTH like hormone gt Hypercalcemia? renal calculi
Small cell carcinoma Secret ACTHgtCushing syndrome weight gain, hypertension. Skin pigmentation
Small cell carcinoma Secret ADH gt SIADH gt Hyponatremia cerebral edema
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Other Paraneoplastic syndromes in bronchogenic
carcinoma

• Hematologic manifestations (In adenocarcinoma).
• Migratory thrombophlebitis.
• Lambert-Eaton myasthenic syndrome ( In Small cell
  carcinoma muscle weakness is caused by
  auto-antibodies directed to the neuronal calcium
  channel) .
• Calcitonin, causing hypocalcemia.

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Bronchial Carcinoid

• Origin Kulchitsy cells a neuroendocrine cells
  that line the bronchial mucosa.
• Age mean around 40.
• Gross yellow polypoid mass.
• Micro
• LM Salt pepper.
• EM Dense core neurosecretory granules in their
  cytoplasm

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Microscopy
Dense core granules
Salt pepper
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Presentation of Carcinoid

• Benign carcinoid
• Cough.
• Hemoptysis, bronchiectasis.
• Recurrent bronchial pulmonary infections.
• Malignant carcinoid liver mets. and Secret
  serotonin gt carcinoid syndrome diarrhea and
  flushing on skin.

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Hamartoma
coin lesion
Common Less than 2 cm. Micro haphazard lung
tissue and cartilage.
Clinical Present as a "coin lesion" on
X-ray. d/d of coin lesion Granuloma are multiple.
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Metastatic Cancer to the lungs
Multiple variably-sized masses are seen in all
lung fields.
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Next Topic

• Mesothelioma
• Pleural effusion

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Malignant Mesothelioma

• Site The visceral or the parietal pleura.
• Carcinogen asbestosis- amphiboles by reactive
  free radicals.
• Morphology
• Asbestos bodied are found in the tumor.
• Lung gets ensheathed by tumor tissue may produce
  cicatrisation and atelectasis.

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Diagnosis of malignant mesothelioma
Positive staining with Acid mucopolysaccharide Keratin
Electron microscopy (EM) presence of long microvilli and abundant tonofilaments.
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Pleural effusion

• Empyema- Pus in pleural cavity following
  abscess.
• Chylothorax Chyle (lymph)
• It is a Milky white fluid due to tumor emboli in
  lymphatic or in Lymphoma.

All patient present with respiratory distress,
relieved when the effusion in drained by
thoracentesis .
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Pneumothorax

• Def air in pleural cavity
• Types
• Traumatic Trauma
• Spontaneous rupture of paraseptal bulla
• Tension due to shift of the mediastinum from
  the midline.

Tracheal shifting to other side , and
hyperresonant lung on side of injury.
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