Lung Tumors PDF

## LUNG TUMORS ### WHO Classification of Lung tumors (2015) **Epithelial tumors** * **Adenocarcinoma** * Lepidic adenocarcinoma * Acinar adenocarcinoma * Papillary adenocarcinoma * Micropapillary adenocarcinoma * Solid adenocarcinoma * Invasive mucinous adenocarcinoma...

## LUNG TUMORS ### WHO Classification of Lung tumors (2015) **Epithelial tumors** * **Adenocarcinoma** * Lepidic adenocarcinoma * Acinar adenocarcinoma * Papillary adenocarcinoma * Micropapillary adenocarcinoma * Solid adenocarcinoma * Invasive mucinous adenocarcinoma * Mixed invasive mucinous and nonmucinous adenocarcinoma * Colloid adenocarcinoma * Fetal adenocarcinoma * Enteric adenocarcinoma * Minimally invasive adenocarcinoma * Nonmucinous * Mucinous * Preinvasive lesions * Atypical adenomatous hyperplasia * Adenocarcinoma in situ * Nonmucinous * Mucinous * **Squamous cell carcinoma** * Keratinizing squamous cell carcinoma * Nonkeratinizing squamous cell carcinoma * Basaloid squamous cell carcinoma * Preinvasive lesion * Squamous cell carcinoma in situ * **Neuroendocrine tumors** * Small cell carcinoma * Combined small cell carcinoma * Large cell neuroendocrine carcinoma * Combined large cell neuroendocrine carcinoma * Carcinoid tumors * Typical carcinoid * Atypical carcinoid * Preinvasive lesion * Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia * **Large cell carcinoma** * **Adenosquamous carcinoma** * **Pleomorphic carcinoma** * **Spindle cell carcinoma** * **Giant cell carcinoma** * **Carcinosarcoma** * **Pulmonary blastoma** * **Other and unclassified carcinomas** * Lymphoepithelioma-like carcinoma * NUT carcinoma * **Salivary gland type tumors** * Mucoepidermoid carcinoma * Adenoid cystic carcinoma * Epithelial myoepithelial carcinoma * Pleomorphic adenoma * **Papillomas** * Squamous cell papilloma * Exophytic * Inverted * Glandular papilloma * Mixed squamous and glandular papilloma * **Adenomas** * Sclerosing pneumocytoma * Alveolar adenoma * Papillary adenoma * Mucinous cystadenoma * Mucous gland adenoma **Mesenchymal tumors** * **Pulmonary hamartoma** * **Chondroma** * **PEComatous tumors** * Lymphangioleiomyomatosis * PEComa, benign * Clear cell tumor * PEComa, malignant * **Congenital peribronchial myofibroblastic tumor** * **Diffuse pulmonary lymphangiomatosis** * **Inflammatory myofibroblastic tumor** * **Epithelioid hemangioendothelioma** * **Pleuropulmonary blastoma** * **Synovial sarcoma** * **Pulmonary artery intimal sarcoma** * **Pulmonary myxoid sarcoma with EWSR1-CREB1 translocation** * **Myoepithelial tumors** * Myoepithelioma * Myoepithelial carcinoma **Lymphohistiocytic tumors** * Extranodal marginal zone lymphoma of mucosa associated lymphoid tissue (MALT lymphoma) * Diffuse large B cell lymphoma * Lymphomatoid granulomatosis * Intravascular large B cell lymphoma * Pulmonary Langerhans cell histiocytosis * Erdheim-Chester disease **Tumors of ectopic origin** * **Germ cell tumors** * Teratoma, mature * Teratoma, immature * **Intrapulmonary thymoma** * **Melanoma** * **Meningioma, NOS** **Metastatic tumors** ### ROLE OF IMAGING MODALITIES - Making diagnosis - Staging the tumor - Assessing treatment and response 1. **CXRAY** - Initial imaging modality 2. **CECT chest with upper abdomen including liver and adrenals** - imaging modality of choice 3. **PET** * Not useful in T staging * FDG uptake is less in invasive mucinous adenocarcinoma, carcinoid and small cell lung cancer (false negative) * False positive in sarcoidosis, tuberculosis, inflammatory nodes * Useful in evaluation of local and distant spread - mediastinal lymph node staging, detection of malignant effusions, detection of bone mets * Monitoring of patients undergoing non-surgical treatment * Radiotherapy planning for tumor volume - can differentiate tumor from adjacent necrosis and consolidation * Differentiate post treatment changes from recurrences 4. **MRI** - detection, characterization, TNM staging and tumor response assessment. Detection of brachial plexus involvement, chest wall, diaphragmatic pleura, great vessel and cardiac involvement ### RADIOLOGICAL CHARACTERITICS BY CELL TYPE 1. **Non-small cell lung cancer (NSCLC) (80%)** * **adenocarcinoma (35%)** * most common cell type overall * most common in women * most common cell type in non-smokers but still most patients are smokers * peripherally located * localized ground glass opacity or as solid nodule or mass * usually, <4 cm in size * cavitation is rare * associated with fibrosis * associated with enlarged hilar and mediastinal nodes, pleural effusion * **squamous cell carcinoma (30%)** * strongly associated with smoking * centrally located tumor, usually produce distal collapse due to bronchial obstruction * most common carcinoma to cavitate * poor prognosis * **large-cell carcinoma (15%)** * peripherally located * very large, usually >4 cm * rapidly growing * early metastases to mediastinum and brain 2. **Small cell lung cancer (SCLC) (20%)** * almost always in smokers * rapidly growing * metastasizes early * massive lymphadenopathy * mediastinal invasion * most common primary lung malignancy to cause paraneoplastic syndromes and SVC obstruction * worst prognosis - but radiosensitive ### BRONCHOALVEOLAR CARCINOMA Subtype of well differentiated adenocarcinoma arising beyond a grossly recognizable bronchi with tendency to spread along peripheral air spaces. * Arises from type- II alveolar epithelial cells (clara cells) * Age: 40-70 years * Male-females * 2-5% of all lung tumors * Not associated with smoking * Slow growing * Peripherally located, beyond a recognizable bronchus **Clinical features** * Often asymptomatic * Pleuritic chest pain * Non-resolving pneumonia * Cough * Hemoptysis * Weight loss * Fever EGFR and ALK mutations - important determinant in survival than anatomical location of Adenocarcinoma **Spread** * Transbronchial dissemination * Lymphatic spread * Hematogeneous * Any organ **Mets** * Skeletal - osteoblastic * Diffuse pulm. fibrosis + scars **Radiological Patterns** * **Solitary/focal** * MC presentation * 2-4 cm dia, solitary peri well defined, pulm nodule * Open Bronchus sign * Air bronchogram * Tail Sign - linear strands extending from nodule to pleura * Sunburst appearance * Spiculated margins * Lmk type a/w cavitation - alter laua Cell Ce * **Diffuse** * Diffuse consolidation * Acinar airspace conso. + air bronch * Diffuse lesion similar to interstitial fibrosis * **Multinodular** * Multiple well def is BIL nodules * Multiple poorly defined areas - ground glass attenuation * **Lobar form** * Entenswe lobar conso of I or more lobes * **Combination of nodu + consolidation** * **also be effusion - Les** **Other patterns** * **Ground glass attenuation** - early stages, Bubble like lucencies * **Collapse dit large airway involvement** **Preinvaswe** * PET - no uptake * False -ve * **Adeno Ca** * Atypical * Adenomatous * Hyperplasie * **Invasive** * AIS * MIA * TA * **Squamous** * In sili * Invasive * **Small** * Mueniratty * PSN * GGAN * GGANE * GGANT * **SN** * **PSN** **SUPERIOR SULCUS TUMOR / PANCOAST** Ca of apex of lung c/b of any cell type predominantly squamous cell ca **C/F** 1. **atrophy of ms. of 1/2 upper extremil** dlt Brachial pl. involvement 2. **Horness syndrome** dlt symp. chain involvement * Enopthalmos * Miosis * Ptosis * Anhydrosis 3. **SVC obstruction** 4. **shoulder pain** **(XR)** (a) 1/2 apical cap > 5 mm thickness (b) asymm. of BIL apical cap > 5mm (c) apical soft tissue (d) Destruction of adj ribs & trans. processess. scapula **CT** * Sup. to CXR * Disadv : • Beam hardening artifact in thorasic inlet region • Assial section dont provide information abt neurovasc. bundle. **MRI** * Superior. geves informat about * Brachial plexus * vasc strictuses * chest wall invasion * extension to SC * Bymp. ganglie **LARGE CELL LUNG CARCINOMA** * 10% bronchogenic tumors * Large peripheral masses * Usually = 4cm * Invariable plusal involvement * Irregular margin * Focal necrosi ### TNM OF CARCINOMA LUNG (8th edition) for NON-SMALL CELL CARCINOMA Size of a **solid** lesion is defined as the maximum diameter in any of the three orthogonal planes in lung window Size of a **sub-solid** lesion is defined as the maximum diameter of the solid component and not the ground glass attenuation. **Tumor size** * **Tx** * **TO** Tumor in sputum/bronchial washings but not seen on imaging or bronchoscopy * **Tis** No evidence of tumor * **T1** Tumour 3 cm or less surrounded by lung/visceral pleura, not involving main bronchus * **Timi** Minimally invasive adenocarcinoma * **T1a** Tumour 1 cm or less * **T1b** Tumour more than 1 cm but not more than 2 cm * **T1c** Tumour more than 2 cm but not more than 3 cm * **T2** Tumour more than 3 cm but not more than 5 cm; or tumour with any of the following features: * Involves main bronchus without involvement of the carina, orinvades visceral pleura or associated with atelectasis or obstructive pneumonitis (crossing of the fissure by mass is T2) * **T2a** Tumour more than 3 cm but not more than 4 cm * **T2b** Tumour more than 4 cm but not more than 5 cm * **T3** Tumour more than 5 cm but not more than 7 cm or directly invades: parietal pleura, chest wall, phrenic nerve, or parietal pericardium; or separate tumour nodule(s) in the same lobe (presence of extrapleural tumor tissue or extension into the ribs is chest wall invasion) * **T4** Tumour more than 7 cm or of any size that invades any of the following: diaphragm, mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, oesophagus, vertebral body, carina; or separate tumour nodule(s) in a different ipsilateral lobe to the primary * (Vascular invasion is complete circumferential encasement of a vessel or presence of an intravascular enhancing focus of tumor) **N Category** * **NO** No involvement * **N1** Ipsilateral peribronchial and/or hilar nodes and intrapulmonary nodes * **N2** Ipsilateral mediastinal and/or subcarinal nodes * **N3** Contralateral mediastinal or hilar; ipsilateral/contralateral scalene/supraclavicular **M Category** * **M1a** Separate tumour nodule(s) in a contralateral lobe; tumour with pleural or pericardial nodules or malignant pleural or pericardial effusion * **M1b** Single extrathoracic metastasis in a single organ * **M1c** Multiple extrathoracic metastasis in a single or multiple organs **STAGING** * **Stage IA** T1 NO MO * **Stage IA1** T1mi, T1a NO MO * **Stage IA2** T1b NO MO * **Stage IA3** T1c NO MO * **Stage IB** T2a NO MO * **Stage IIA** T2b NO MO * **Stage IIB** T1a-c, T2a,b N1 MO T3 NO MO * **Stage IIIA** T1a-c, T2a,b N2 MO T3 N1 T4 NO,N1 MO * **Stage IIIB** T1a-c, T2a,b N3 MO T3, T4 N2 MO * **Stage IIIC** T3, T4 N3 MO * **Stage IV** Any T Any N M1 * **Stage IVA** Any T Any N M1a,b * **Stage IVB** Any T Any N M1c ### METASTATIC LUNG DS Pulm. mets occur in 30% of all malig. **Route** 1. **hematogeneous** : MC via cys. veins & pulm A. 2. **Lymphatic** 3. **Endobronchial** - Rare - kidney, Breast, Colon **1° sites** * Chorio la * Hyper nephrome/wilms * Ewings * Osteosarcome * Testicular Jumors (GCT) **RADIOLOGICAL FEATURES** * **Multiple Nodules** * Usually BIL * Basal predominance * Supleural / peripheral location * fers mms - cms * spherical - well defined margins - ill defined if hage * **Solitary Nodules** * Ca colon, Kidney, Breast, Testis, Melanomя, Sarcome * **Segmental / dobar collapse** dlt endobronchial spread / mets. occluding airway * Ca colon, Kidney, Breast * **Cavitation** (Me squat) - Squamous Cell Ca - BEE Colon, melanome, Sarcomas * **calcification** - osteo carcome, chondrosarcome, mucinous adenoca - Breast, Thyroid, testis, ovary * **Hemorragic** - Kidney, chorio Ca, Ca cervin, Angio Ca, Kaposi - Melanome. * **miliary** - Thyroid, Kidney * **Lymphangitis Carcinomatosa** * results from hematogeneous metastasis invading & occluding peri pulon lymphatice * Retrograde spread to pulm. lymphatics from metastatic hilar INS * **from colon, cervin, stomach, Breast, pancreas, prostate, Lungs, Thyroid, Larynx, lung** * cancer can spread by plugging lymphat * usually BIL. U/L if Lung primary * coarse linear, rotinular nodular basal shadowing * often pl. effusion * Patchy media LNs. * nodular / lobular areas of air space shadowing * thickening of the inter- septa & thickening of centrilobular bronchovasc. Bundle * Central Dot within sec. pulm. nodul - aft thickened centrilobular bronchovasc. bundle * Pe. effusion * Hilar / mediastinal LNS. **MRI** * for nodes * Vessel involve ment ### BRONCHIAL CARCINOID Neuroendocrine Jumor, malignant arises from APUD cells **Types** * **Typical** * 90% * slow growing * Less mets * 40-60 yrs * Not a/w smoking * 80% arise in lobar bronchus * growth of tumor into bronchi may cause bronchial obstruction + collapse of lung * Recurrent bronchial obstruction rec. segmental preismonias, bronchiectasis, abscess, air trapping, Bronchoceles. * Collapse may not occur dit collateral ais drift * **Atypical** * 10% * malig * fast, invasive * more mets * M>F * > 60 yrs * a/w smoking * or main segment ### BRONCHIAL CARCINOID LOCATIONS * **Typical** * 80% - central * 20% - peripheral * **Central carcinoid** * Discrete lesion at or near the hilum * Usually <4cm * Large endobronchial component seen as intraluminal mass * Conven margin pointed towards hilum * Expansion of bronchus by mass * Local entension beyond the bronchial wall is common * So endoscopic removal not possible * Sx resection * end to end anastomosis of stump **Mets in LN** * UL collapse * **Atypical** - more aggressive Rx approach **Entra bronchial spread** → lung infiltration **CXR** * peripheral carcinoids - well circumscrib, round oval, Solitary nodules **CT** * calcifi + eccentric * Bright enhancement **CECT** * Produce (H) * Serotonm * Kalliksein: * Histamine * ACTH * ADH * Insulin * Gastoin **Radionuclide Imaging** * Somatostatin analogue (Octreotide Scan) **Mets** * Skeletal - osteoblastic dit lung primary with hepatic mets. * PET - FDG -ve, DOTA NOC +ve ### PULMONARY LYMPHOMA Refers to lung parenchymal involvement & lymphome. * accounts for <1% of all lymphomas 1. Usually NHL which is limited to the lung with or without mediastinal LN involvement & no evidence of entrathorasic dissemination for atleast 3 months after the initial diagnosis * (a) low grade B-cell lymphoma (MALToma) * (b) High grade B-cell lymphome * (c) pulmonary plasmecy toma * (d) Pulm. Intravasc. lymphome * (e) Angiocentric Immunoproliferative lesion * (2) * → NHL * → HD * Lymphome in pts : à post transplant lymphoproliferative disorders, AIDS related pulm. lymphome **Radiographic Patterns** 1. **Nodular** * solitary/multiple * U/L or BL * Indistuct mergens * Lower lobes perihilar Regioης * air bronchogram I * cavitation + 2. **Lymphangitic** * dit contigous peribronchovasc. Spread from hilor LNS * Reticulonoduler opacity radiating from hilum. * patchy opacitiis * MC form in HL 3. **Alveolar (pneumonic)** * consolidation * stable for months * not responding to Rx ### ROLE OF MRI IN LUNG CANCERS 1. Better than CT for small nodules near hila 2. Better than CT for mediastinal invasion (pericarduim, diaphragm) 3. Sup. sulcus Jumor - Brachial plexus, symp. ganglio, spenal cord, vessels 4. Diff collapsed lung vs. mass Jumos by DWI, Finding underlying lesion in completely opacified remithoran 5. Diff pleural vs. parenchymal Ds. 6. Evaluating plevral abnormalities, Fibrotic pleural Ds., Benign vs malis pleural effusion 7. Early cerest wall invasion, Loss of hyper fat plane 8. marrow space involvement. c.f. CT- Cortical Bone involvement 9. Dift adrenal adenome vs. lung mets 10. Dift enudative vs. transudative effusion by rich 11. fuyper T1, T2 vs. typer: Ta, Malignant LNS (lymph nodes) **Disadv**: peripheral pulm. vs. & Lobar fissures are not visualized making it difficult to demonstrate position of a ling mass with respect to a lobe / segment. ### ROLE OF PET IN LUNG CANCERS 1. Not useful in T-staging dit poor spatial resolution * False the - TB, Saxrid, RA, Radiation preimmitts, BAC, carcinoid, SCLC * False -ve - 2. Useful in onediastinal LN involvement 3. seff Benign vs malis effusion 4. setection of Bory mets. more accurate than Bone Scan 5. RT planning - Jarjet volume Estimation, diff viable tumor from necrotic ts. 6. Biopsy Planning * fu ←←← SUV in pastchemaRx response, more accurate than RECIST size 7. Recurrent vs. post op. changes