CARCINOMA LUNG AND LYMHANGITIS

CARCINOMATOSA
PRESENTOR :SUBA ARUL DEVI
MODERATOR:DR VINAY B S
 EPIDEMIOLOGY

 Lung cancer is the most common fatal malignancy worldwide both in male and

female.

 The most common cause of cancer in men, and the 6th most frequent cancer in

women worldwide.

 It accounts for approximately 20% of all cancer deaths.

 RISK FACTORS

The major risk factor is CIGARETTE SMOKING which is implicated in 90% of cases
and increase the risk of lung cancer 20-30 times.

Other risk factors:

 Asbestos: 5x increased risk
 Occupational exposure: uranium, radon, arsenic, chromium
 Diffuse lung fibrosis: 10x increased risk
 Chronic obstructive pulmonary disease
 CLINICAL PRESENTATION

 Patients with lung cancer may be asymptomatic in up to 50% of cases.

 Cough and dyspnea are rather non-specific symptoms

 Central tumors may result in hemoptysis

 Peripheral lesions with pleuritic chest pain.

 Pneumonia, pleural effusion, wheeze, lymphadenopathy .

 Other symptoms may be secondary to metastases (brain, liver, bone) or to paraneoplastic syndromes.
 OTHER

 Finger clubbing
 Hypertrophic pulmonary osteoarthropathy (HPOA): squamous cell carcinoma
subtype
 Nephrotic syndrome
 Polymyositis
 Dermatomyositis
 Eosinophilia

 Acanthosis nigricans
 Thrombophlebitis: adenocarcinoma subtype
 ADENOCARCINOMA
• Most common cell type of lung cancer
• Glandular differentiation, pneumocyte marker expression, or mucin production.
• Weak association with smoking.
• Arise from bronchiolar or alveolar epithelium.
CHARACTERISTIC FEATURES
• Originate in the lung periphery, presenting as a solitary pulmonary nodule.
• Most common in the upper lobes >>> large central airway.
• Associated with lung fibrosis (i.e., a scar carcinoma or in association with other causes of
pulmonary fibrosis) or may result in a desmoplastic fibrotic reaction in surrounding lung.
CHEST RADIOGRAPH: Appear as an ill-defined nodule on chest radiographs.

On thin-slice CT : Appears as a nodule of soft tissue attenuation (solid)

Nodule of ground-glass opacity (GGO) + some solid components (subsolid

or part solid)

Nodule entirely of GGO (nonsolid)

OTHER FEATURES : Pleural tail sign.

 SUBTYPES

• Atypical adenomatous hyperplasia (AAH),

• Minimally invasive adenocarcinoma (MIA),

• Lepidic (prominent) adenocarcinoma (LA or LPA),

• Invasive mucinous adenocarcinoma (IMA)

 ATYPICAL ADENOMATOUS HYPERPLASIA (AAH)

• It is a benign or premalignant lesion characterized by lepidic growth.

• It represents a pneumocyte proliferation that resembles, but does not
meet, the criteria for adenocarcinoma in situ.
• It is typically 5 mm or less in diameter.
• On CT, AAH appears as small (usually ≤5 mm) rounded nodule of GGO.
 ADENOCARCINOMA IN SITU
• It is defined as a localized, small (≤3 cm) adenocarcinoma.

• Consisting of neoplastic pneumocytes growing along alveolar walls (lepidic growth)

• Lack stromal, vascular, or pleural invasion.

• It is typically a non mucinous tumor - type 2 pneumocytes and/or Clara cells.

• On CT - GGO nodule >>>small soft tissue component

• Contain air bronchograms.

• The bubbly lucencies represent cystic air-filled areas within the tumor and are termed pseudo
cavitation.
 MINIMALLY INVASIVE ADENOCARCINOMA (MIA)

• Defined as a small adenocarcinoma (≤3 cm), with a predominantly lepidic pattern and
≤5 mm invasion (in its greatest dimension).
• Non-mucinous.
• If the tumor does not invades lymphatics, blood vessels, or pleura / tumor necrosis
/tumor has spread through airspaces (aerogenous spread).
• On CT - GGO nodule or GGO nodule + small (i.e., ≤5 mm) solid focus near the center of
the nodule.
• Air bronchograms or pseudo cavitation.
 INVASIVE ADENOCARCINOMAS
LEPIDIC PREDOMINANT ADENOCARCINOMA:

• Lepidic proliferation of pneumocytes

• Invasive adenocarcinoma present in at least one site >5 mm.

• Invasion - nonlepidic growth (acinar, papillary, micropapillary, and/or solid) and/or

myofibroblastic stroma associated with invasive tumor cells.

• Tumor invades lymphatics, blood vessels, or pleura or if it contains regions of necrosis.

• On CT, LPA often appears as a GGO nodule with a solid component greater than 5 mm.
 INVASIVE MUCINOUS ADENOCARCINOMA

• A tumor consisting of malignant cells having goblet or columnar cell morphology with
abundant intracytoplasmic mucin.
• KRAS mutation
• Multicentric, multilobar, and bilateral lung involvement, likely as the result of
aerogenous metastases (metastatic spread via airways).
• Lung consolidation or multiple ill-defined nodules, which are solid or of GGO
• The CT angiogram sign, in which opacified vessels are visible within consolidated lung,
is often seen if CT is obtained with contrast infusion.
• Profuse bronchorrhea.
 SQUAMOUS CELL CARCINOMA
• 20% of cases.
• Strong association with cigarette smoking .
• Intercellular bridging, squamous pearl formation, and individual cell keratinization.
• Squamous cell markers (p40, p63, negative for TTF1).
• Arises in main, lobar, or segmental bronchi.
• CT - A polypoid endobronchial mass or bronchial obstruction.
Hilar mass is also common due to the central location of the tumor.
Atelectasis, consolidation, mucoid impaction (mucous bronchograms), and bronchiectasis.
• 30% - lung periphery as a lung nodule or mass.
• Central necrosis and cavitation are more common than with other cell types.
 NEUROENDOCRINE TUMORS

SMALL CELL LUNG CARCINOMA

• 15% to 20% of cases.
• It is made up of small cells, similar in size to lymphocytes, which have scanty cytoplasm.
• Originates from neuroendocrine cells ; electron microscopy - neurosecretory granules.
• Men = women.
• Main or lobar bronchi and is associated with extensive peribronchial invasion
• Large hilar or Para hilar mass - compresses bronchi - Atelectasis
• Marked mediastinal lymph node enlargement.

• It is a common cause of superior vena cava (SVC) syndrome

• Inappropriate antidiuretic hormone secretion, Cushing’s syndrome, acromegaly,

autoimmune neuropathy (Eaton-Lambert syndrome), encephalomyelitis, and limbic
encephalitis.

• Neurologic symptoms may precede.

• Prognosis - very poor

• FDG PET - demonstrating the extent of disease.

 CARCINOID TUMORS

• Originate from neuroendocrine cells in the bronchial wall.

• Typical or atypical.

• Typical carcinoid tumor : Low-grade malignancy

Occurs in the central bronchi - endobronchial mass - locally invasive.

• Atypical carcinoid tumor: Is a more aggressive, intermediate-grade variant.

Higher mitotic rate.

Poorer prognosis.
 TYPICAL CARCINOID TUMOR
• Slowly growing and locally invasive.
• 40 to 60 years of age
• Women > Men
• No association with smoking.
• Centrally, in the main, lobar, or segmental bronchi
• Cough, fever, and wheezing.
• Highly vascular - hemoptysis .
• Prognosis is good.
• CT FEATURES : 4 cm in diameter.

Appear as intraluminal masses - convex margin pointing toward the hilum.

Can expand the bronchus as they grow, typically resulting in a flaring of the

bronchial lumen

Highly vascular, dense enhancement

A peripheral nodule or mass - well defined, round or oval, and slightly lobulated.

Calcifications may be large and “chunky.”

 ATYPICAL CARCINOID TUMOR

• More aggressive behavior - increased frequency of mitoses + presence of necrosis.

• Lymph node metastases - 50% of patients.
• Slightly older
• Men > women.
• Associated with smoking.
• Present as a lung nodule or mass, round or ovoid, lobulated.
• More aggressive surgical approach is usually employed (lobectomy, sometimes with
radiation or chemotherapy).
 CLINICAL SYNDROMES

• Carcinoid syndrome - 2% to 5% of patients

It is most common in the presence of liver metastases.

Flushing, fever, nausea, diarrhea, hypotension, and wheezing

Cardiac valvular lesions and heart murmurs - left side of the heart.

• Cushing’s syndrome - Production of ACTH or ACTH-releasing hormone

Produced by bronchial carcinoid.

• Zollinger-Ellison syndrome, hyperinsulinemia, and acromegaly.

 LARGE CELL CARCINOMA

• 5% of lung cancers.

• It is strongly associated with smoking.

• Large peripheral mass.

• Larger than 4 cm at presentation.

• Metastasize early

• Poor prognosis.
 PULMONARY HAMARTOMA

• Most common mesenchymal tumor of the respiratory tract.

• Composed of varying amounts of at least two mesenchymal elements (such as cartilage, fat,
connective tissue, and smooth muscle), combined with respiratory epithelium.

• Chondroid or chondromyxoid tissue intermixed with variable proportions of other mesenchymal

components, including fat, myxoid fibrous connective tissue, smooth muscle, and bone.

• > 50 years ; men>>women.

• 1 to 4 cm - well defined, sharply circumscribed, and often lobulated.

• Grow slowly - 0.5 to 5 mm/year.

• On CT - Calcification is visible more often than on plain radiographs.

Stippled or conglomerate

Accumulations of fat - lucent or low attenuation areas within the tumor.

 SUPERIOR SULCUS (PANCOAST) TUMOR

• Arising at or near the lung apex.

• Invade structures in the thoracic inlet, including the brachial plexus, cervicothoracic
sympathetic ganglia, subclavian artery and vein and vertebral column.
PANCOAST SYNDROME - brachial plexus and sympathetic ganglia.
1.Pain in the shoulder
2. Radicular pain along the distribution of the eighth cervical and first and second
thoracic nerves.
3. Horner’s syndrome - ptosis, miosis, and hemi facial anhidrosis
• Radiographic findings - apical mass (60%),

• unilateral or asymmetrical apical pleural thickening (“apical cap,” 40%)

• bone destruction (25%)

• Asymmetry in the thickness of an apical cap exceeding 5 mm is considered suggestive.

TREATMENT : Pre- or postoperative radiation + chemotherapy + En bloc resection of the tumor and
adjacent chest wall
CONTRAINDICATIONS (1) tumor involvement of the great vessels - subclavian artery or vein
(2) extensive brachial plexus invasion
(3) extensive vertebral body or spinal canal invasion
(4) clinical evidence of recurrent laryngeal nerve or phrenic nerve
involvement
(5) involvement of the mediastinum, including the trachea or esophagus
(6) distant metastases.
• MRI in the sagittal or coronal planes more accurate than CT - apical chest wall invasion and its
extent.
• MRI - preoperatively - define the relationship of the tumor to great vessels and the brachial plexus
 WHAT IS NEW IN THE TNM 8TH EDITION

• New M-categories were introduced regarding extra thoracic metastatic disease.

• Size of a solid lesion is defined as maximum diameter in any of the three orthogonal
planes in lung window.

• In subsolid lesions T-classification is defined by the diameter of the solid component and
not the diameter of the complete groundglass lesion.
 T – STAGING
• T0 - There is no primary tumor on imaging
• Tis - Carcinoma in situ, irrespective of size.
This can only be diagnosed after resection of the tumor.
• T1 - Tumor size ≤3cm
Tumor ≤1cm => T1a
Tumor >1cm but ≤2cm =>T1b
Tumor >2cm but ≤3cm => T1c
• T1a(mi) is pathology proven 'minimally invasive', irrespective of size.
• T1a(ss) is a superficial spreading tumor in the central airways, irrespective of location.
• T2 - Tumor size >3cm to ≤5cm or
T2a= >3 to 4cm
T2b= >4 to 5cm
Tumor of any size that - invades the visceral pleura/main bronchus, but not the carina
- atelectasis or obstructive pneumonitis that extends to the hilum

T3 - Tumor size >5cm to 7cm or

Pancoast that involves thoracic nerve roots T1 and T2 only.
Tumor of any size that - invades the chest wall/pericardium/phrenic nerve.
- shows one or more satellite nodules in the same lung lobe
• T4 - Tumor size >7cm or
Pancoast tumor that involves C8 or higher nerve roots, brachial plexus, subclavian
vessels or spine
Tumor of any size - invades mediastinal fat or mediastinal structures
invades the diaphragm
involves the carina
one or more satellite nodules in another lobe on the ipsilateral side
 N - STAGING

• N1 – Nodes - ipsilateral nodes within the lung up to hilar nodes.

• N2 – Nodes - represent ipsilateral mediastinal or subcarinal lymphadenopathy.

• N3 – Nodes - contralateral mediastinal or contralateral hilar lymphadenopathy or scalene or

supraclavicular nodes.
 M – STAGING

• M0: No distant metastases

• M1: Distant metastases

M1a: Regional metastatic disease defined as malignant pleural or pericardial effusion/nodules, as well

as contralateral or bilateral pulmonary nodules.

M1b: solitary extrathoracic metastasis

M1c: Multiple extrathoracic metastases, either in a single organ or in multiple organs