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| '''[[Lung]] tumours''' comes to pathology to get diagnosed. This article basically deals with core biopsies. Pulmonary cytopathology is dealt with in the ''[[pulmonary cytopathology]]'' article. | | [[Image:Small cell carcinoma (3931938372).jpg|right|thumb|300px|A lung tumour ([[small cell carcinoma of the lung]]) - centre of image. (WC/Rosen)]] |
| | '''[[Lung]] tumours''' comes to pathology to get diagnosed. |
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| | This article deals with the surgical pathology (core biopsies, lung resections). Pulmonary cytopathology is dealt with in the ''[[pulmonary cytopathology]]'' article. |
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| An introduction to lung pathology is found in the ''[[pulmonary pathology]]'' article. | | An introduction to lung pathology is found in the ''[[pulmonary pathology]]'' article. |
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| *Adenocarcinoma is the most common (primary lung cancer).<ref>{{cite journal |author=Lutschg JH |title=Lung cancer |journal=N. Engl. J. Med. |volume=360 |issue=1 |pages=87-8; author reply 88 |year=2009 |month=January |pmid=19118313 |doi=10.1056/NEJMc082208 |url=}}</ref> | | *Adenocarcinoma is the most common (primary lung cancer).<ref>{{cite journal |author=Lutschg JH |title=Lung cancer |journal=N. Engl. J. Med. |volume=360 |issue=1 |pages=87-8; author reply 88 |year=2009 |month=January |pmid=19118313 |doi=10.1056/NEJMc082208 |url=}}</ref> |
| *Adenocarcinoma is the non-smoker tumour - SCLC and squamous are more strongly associated with [[smoking]]. | | *Adenocarcinoma is the non-smoker tumour - SCLC and squamous are more strongly associated with [[smoking]]. |
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| | Children: |
| | *Most common lung tumour in children: metastasis (80-85% of lung tumours in children<ref name=pmid>{{Cite journal | last1 = Dishop | first1 = MK. | last2 = Kuruvilla | first2 = S. | title = Primary and metastatic lung tumors in the pediatric population: a review and 25-year experience at a large children's hospital. | journal = Arch Pathol Lab Med | volume = 132 | issue = 7 | pages = 1079-103 | month = Jul | year = 2008 | doi = 10.1043/1543-2165(2008)132[1079:PAMLTI]2.0.CO;2 | PMID = 18605764 }}</ref> |
| | **Most common primary tumours in children: [[inflammatory myofibroblastic tumour]], [[pleuropulmonary blastoma]], [[lung carcinoid]].<ref name=pmid26971789>{{Cite journal | last1 = Giuseppucci | first1 = C. | last2 = Reusmann | first2 = A. | last3 = Giubergia | first3 = V. | last4 = Barrias | first4 = C. | last5 = Krüger | first5 = A. | last6 = Siminovich | first6 = M. | last7 = Botto | first7 = H. | last8 = Cadario | first8 = M. | last9 = Boglione | first9 = M. | title = Primary lung tumors in children: 24 years of experience at a referral center. | journal = Pediatr Surg Int | volume = 32 | issue = 5 | pages = 451-7 | month = May | year = 2016 | doi = 10.1007/s00383-016-3884-3 | PMID = 26971789 }}</ref> |
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| ===Distribution=== | | ===Distribution=== |
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| **Adenocarcinoma is usually periperal, i.e. smaller airways. | | **Adenocarcinoma is usually periperal, i.e. smaller airways. |
| **Squamous cell carcinoma and small cell carcinoma are typically central. | | **Squamous cell carcinoma and small cell carcinoma are typically central. |
| | |
| | ===Margins in lung=== |
| | Margin in pneumonectomy specimens include: |
| | *Vessels (artery, vein). |
| | *Airway (bronchus). |
| | *Soft tissue (lymphatics, fibrous tissue and lymph nodes).<ref name=pmid21129810>{{Cite journal | last1 = Sakai | first1 = Y. | last2 = Ohbayashi | first2 = C. | last3 = Kanomata | first3 = N. | last4 = Kajimoto | first4 = K. | last5 = Sakuma | first5 = T. | last6 = Maniwa | first6 = Y. | last7 = Nishio | first7 = W. | last8 = Tauchi | first8 = S. | last9 = Uchino | first9 = K. | title = Significance of microscopic invasion into hilar peribronchovascular soft tissue in resection specimens of primary non-small cell lung cancer. | journal = Lung Cancer | volume = 73 | issue = 1 | pages = 89-95 | month = Jul | year = 2011 | doi = 10.1016/j.lungcan.2010.11.002 | PMID = 21129810 }}</ref> |
| | |
| | Notes: |
| | *The traditional teaching is there are only hollow structure margins (artery, vein, airway) - yet the bronchial margin has been divided into mucosal and extramucosal.<ref>{{Cite journal | last1 = Kaiser | first1 = LR. | last2 = Fleshner | first2 = P. | last3 = Keller | first3 = S. | last4 = Martini | first4 = N. | title = Significance of extramucosal residual tumor at the bronchial resection margin. | journal = Ann Thorac Surg | volume = 47 | issue = 2 | pages = 265-9 | month = Feb | year = 1989 | doi = | PMID = 2537610 }}</ref> |
| | *Peribronchovascular soft tissue involvement is a poor prognosticator but not an independent predictor if considered within the [[TNM staging]].<ref name=pmid21129810/> |
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| ===Management of primary lung cancer=== | | ===Management of primary lung cancer=== |
| Management is currently determined by categorization into: | | Management in the past was determined by categorization into: |
| *Small cell cancer. | | *Small cell cancer. |
| *Non-small cell cancer (includes adenocarcinoma, squamous cell carcinoma, large cell carcinoma). | | *Non-small cell cancer (includes adenocarcinoma, squamous cell carcinoma, large cell carcinoma). |
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| ===Small cell carcinoma=== | | ===Small cell carcinoma=== |
| *CD56 +ve - sensitive.<ref name=pmid16862075>{{cite journal |author=Hiroshima K, Iyoda A, Shida T, ''et al'' |title=Distinction of pulmonary large cell neuroendocrine carcinoma from small cell lung carcinoma: a morphological, immunohistochemical, and molecular analysis |journal=Mod. Pathol. |volume=19 |issue=10 |pages=1358-68 |year=2006 |month=October |pmid=16862075 |doi=10.1038/modpathol.3800659 |url=}}</ref> | | *[[TTF-1]] +ve. |
| *CK7 -ve, CK20 -ve. | | *[[CD56]] +ve - sensitive.<ref name=pmid16862075>{{cite journal |author=Hiroshima K, Iyoda A, Shida T, ''et al'' |title=Distinction of pulmonary large cell neuroendocrine carcinoma from small cell lung carcinoma: a morphological, immunohistochemical, and molecular analysis |journal=Mod. Pathol. |volume=19 |issue=10 |pages=1358-68 |year=2006 |month=October |pmid=16862075 |doi=10.1038/modpathol.3800659 |url=}}</ref> |
| | *[[CK7]] -ve, [[CK20]] -ve. |
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| Note: | | Note: |
| *CD56 - cytoplasmic.<ref>URL: [http://jcp.bmjjournals.com/content/58/9/978.full http://jcp.bmjjournals.com/content/58/9/978.full]. Accessed: 11 February 2010.</ref> | | *CD56 - cytoplasmic.<ref>URL: [http://jcp.bmjjournals.com/content/58/9/978.full http://jcp.bmjjournals.com/content/58/9/978.full]. Accessed: 11 February 2010.</ref> |
| | |
| | ===Adenocarcinoma=== |
| | *[[TTF-1]] +ve. |
| | *[[Napsin]] +ve - sensitive.<ref name=pmid22288963>{{cite journal |author=Turner BM, Cagle PT,Fukuoka J, ''et al'' |title=Napsin A, a New Marker for Lung Adenocarcinoma, Is Complementary and More Sensitive and Specific Than Thyroid Transcription Factor 1 in the Differential Diagnosis of Primary Pulmonary Carcinoma: Evaluation of 1674 Cases by Tissue Microarray |journal=Arch Pathol Lab Med. |volume=136 |issue=10 |pages=163-71 |year=2012 |month=February|pmid=22288963 |doi: 10.5858/arpa.2011-0320-OA|url=}}</ref> |
| | *[[CK7]] +ve, [[CK20]] -ve. |
| | |
| ===Squamous cell carcinoma=== | | ===Squamous cell carcinoma=== |
| *CK7 -ve, CK20 -ve. | | *[[CK7]] -ve, CK20 -ve. |
| *HMWK +ve. | | *HMWK +ve. |
| *Usually TTF-1 -ve.<ref>{{cite journal |author=Al-Zahrani IH |title=The value of immunohistochemical expression of TTF-1, CK7 and CK20 in the diagnosis of primary and secondary lung carcinomas |journal=Saudi Med J |volume=29 |issue=7 |pages=957-61 |year=2008 |month=July |pmid=18626520 |doi= |url=}}</ref> | | *Usually TTF-1 -ve.<ref>{{cite journal |author=Al-Zahrani IH |title=The value of immunohistochemical expression of TTF-1, CK7 and CK20 in the diagnosis of primary and secondary lung carcinomas |journal=Saudi Med J |volume=29 |issue=7 |pages=957-61 |year=2008 |month=July |pmid=18626520 |doi= |url=}}</ref> |
| | *[[p40]] +ve. |
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| ===Primary vs. secondary=== | | ===Primary vs. secondary=== |
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| Note: | | Note: |
| *TTF-1 - should be nuclear staining; cytoplasmic staining is non-specific.<ref name=pmid15861215>{{cite journal |author=Compérat E, Zhang F, Perrotin C, ''et al.'' |title=Variable sensitivity and specificity of TTF-1 antibodies in lung metastatic adenocarcinoma of colorectal origin |journal=Mod. Pathol. |volume=18 |issue=10 |pages=1371–6 |year=2005 |month=October |pmid=15861215 |doi=10.1038/modpathol.3800422 |url=http://www.nature.com/modpathol/journal/v18/n10/full/3800422a.html}}</ref> | | *TTF-1 - should be nuclear staining; cytoplasmic staining is non-specific.<ref name=pmid15861215>{{cite journal |author=Compérat E, Zhang F, Perrotin C, ''et al.'' |title=Variable sensitivity and specificity of TTF-1 antibodies in lung metastatic adenocarcinoma of colorectal origin |journal=Mod. Pathol. |volume=18 |issue=10 |pages=1371–6 |year=2005 |month=October |pmid=15861215 |doi=10.1038/modpathol.3800422 |url=http://www.nature.com/modpathol/journal/v18/n10/full/3800422a.html}}</ref> |
| **Image: [http://commons.wikimedia.org/w/index.php?title=File:Lung_adenocarcinoma_-_TTF-1_-_high_mag.jpg Nuclear staining with TTF-1 in a metastatic lung adenocarcinoma (WC)]. | | **Image: [http://commons.wikimedia.org/w/index.php?title=File:Lung_adenocarcinoma_-_TTF-1_-_high_mag.jpg Nuclear staining with TTF-1 in a primary lung adenocarcinoma (WC)]. |
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| ==Neuroendocrine tumours== | | ==Neuroendocrine tumours== |
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| ===Overview=== | | ===Overview=== |
| *This is a group of tumours that has benign (e.g. [[carcinoid]] tumour of the lung) to malignant (e.g. small cell lung carcinoma) behaviour.<ref>URL: [http://emedicine.medscape.com/article/426400-overview http://emedicine.medscape.com/article/426400-overview]. Accessed on: 20 January 2010.</ref> | | *This is a group of tumours that has benign (e.g. [[carcinoid]] tumour of the lung) to malignant (e.g. small cell lung carcinoma) behaviour.<ref>URL: [http://emedicine.medscape.com/article/426400-overview http://emedicine.medscape.com/article/426400-overview]. Accessed on: 20 January 2010.</ref> |
| *They are thought to arise from [[pulmonary neuroendocrine cell]]s.<ref>{{cite journal |author=Chong S, Lee KS, Chung MJ, Han J, Kwon OJ, Kim TS |title=Neuroendocrine tumors of the lung: clinical, pathologic, and imaging findings |journal=Radiographics |volume=26 |issue=1 |pages=41–57; discussion 57–8 |year=2006 |pmid=16418242 |doi=10.1148/rg.261055057 |url=}}</ref> | | *They are thought to arise from ''pulmonary neuroendocrine cells''.<ref>{{cite journal |author=Chong S, Lee KS, Chung MJ, Han J, Kwon OJ, Kim TS |title=Neuroendocrine tumors of the lung: clinical, pathologic, and imaging findings |journal=Radiographics |volume=26 |issue=1 |pages=41–57; discussion 57–8 |year=2006 |pmid=16418242 |doi=10.1148/rg.261055057 |url=}}</ref> |
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| ===Classification=== | | ===Classification=== |
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| *Typical carcinoid. | | *Typical carcinoid. |
| *Atypical carcinoid. | | *Atypical carcinoid. |
| | |
| | Notes: |
| | *[[Typical carcinoid]]-like lesions <5 mm are called [[carcinoid tumourlet]]s. |
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| ===Cytologic features=== | | ===Cytologic features=== |
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| *Small cell carcinoma: necrosis, scant cytoplasm, mitoses. | | *Small cell carcinoma: necrosis, scant cytoplasm, mitoses. |
| *Typical carcinoid: often more cytoplasm, no necrosis, low mitotic rate (MIB1: scant staining). | | *Typical carcinoid: often more cytoplasm, no necrosis, low mitotic rate (MIB1: scant staining). |
| *Atypical carcinoid: higher mitotic rate/MIB1 than ''typical carcinoid'',<ref>WG. February 2010.</ref> no [[necrosis]]. | | *Atypical carcinoid: higher mitotic rate/MIB1 than ''typical carcinoid'',<ref>Geddie, W. February 2010.</ref> no [[necrosis]]. |
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| Notes:<ref name=cancerorg_car/> | | Notes:<ref name=cancerorg_car/> |
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| =Malignant tumours= | | =Malignant tumours= |
| ==Adenocarcinoma of the lung== | | ==Adenocarcinoma of the lung== |
| *AKA ''lung adenocarcinoma''. | | *[[AKA]] ''lung adenocarcinoma''. |
| ===General===
| | {{Main|Adenocarcinoma of the lung}} |
| Treatment:
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| *Lung adenocarcinoma may be treated with [[EGFR inhibitors]] (e.g. gefitinib (Iressa), erlotinib (Tarceva)).<ref name=pmid20855837>{{cite journal |author=Sun Y, Ren Y, Fang Z, ''et al.'' |title=Lung adenocarcinoma from East Asian never-smokers is a disease largely defined by targetable oncogenic mutant kinases |journal=J. Clin. Oncol. |volume=28 |issue=30 |pages=4616–20 |year=2010 |month=October |pmid=20855837 |doi=10.1200/JCO.2010.29.6038 |url=}}</ref>
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| Patients that receive EGFR inhibitors classically are:<ref name=pmid21151896>{{cite journal |author=Job B, Bernheim A, Beau-Faller M, ''et al.'' |title=Genomic Aberrations in Lung Adenocarcinoma in Never Smokers |journal=PLoS One |volume=5 |issue=12 |pages=e15145 |year=2010 |pmid=21151896 |pmc=2997777 |doi=10.1371/journal.pone.0015145 |url=}}</ref>
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| *Non-smokers.
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| *Female.
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| *Asian.
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| **Caucasians also benefit.<ref name=pmid20973798>{{Cite journal | last1 = Rosell | first1 = R. | last2 = Moran | first2 = T. | last3 = Cardenal | first3 = F. | last4 = Porta | first4 = R. | last5 = Viteri | first5 = S. | last6 = Molina | first6 = MA. | last7 = Benlloch | first7 = S. | last8 = Taron | first8 = M. | title = Predictive biomarkers in the management of EGFR mutant lung cancer. | journal = Ann N Y Acad Sci | volume = 1210 | issue = | pages = 45-52 | month = Oct | year = 2010 | doi = 10.1111/j.1749-6632.2010.05775.x | PMID = 20973798 }}</ref>
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| ===Gross===
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| *Classically peripheral lesions.
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| *May be multifocal.
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| ===Microscopic===
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| Features:
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| *Nuclear atypia.
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| *Eccentrically placed nuclei.
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| *Abundant cytoplasm - classically with mucin vacuoles.
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| Negatives:
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| *Lack of intercellular bridges.
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| Patterns:<ref name=pmid21252716>{{cite journal |author=Travis WD, Brambilla E, Noguchi M, ''et al.'' |title=International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma |journal=J Thorac Oncol |volume=6 |issue=2 |pages=244–85 |year=2011 |month=February |pmid=21252716 |doi=10.1097/JTO.0b013e318206a221 |url=}}</ref>
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| *Lepidic.
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| *Acinar.
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| *Papillary.
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| *Solid.
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| Notes:
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| *[[Lymphovascular invasion]] is common.
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| DDx:
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| *[[Metastasis|Metastatic]] adenocarcinoma.
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| *[[Malignant mesothelioma]].
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| ====Classification====
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| Classification based on extent:<ref name=pmid21252716>{{cite journal |author=Travis WD, Brambilla E, Noguchi M, ''et al.'' |title=International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma |journal=J Thorac Oncol |volume=6 |issue=2 |pages=244–85 |year=2011 |month=February |pmid=21252716 |doi=10.1097/JTO.0b013e318206a221 |url=}}</ref>
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| #Adenocarcinoma in situ (AIS) - previously known as [[BAC]].
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| #*Subtypes: nonmucinous, mucinous, mixed mucinous/nonmucinous.
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| #Minimally invasive adenocarcinoma (MIA).
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| #*Lepidic growth with upto 5 mm of invasion.
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| #*Subtypes: nonmucinous (most common), mucinous, mixed mucinous/nonmucinous.
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| #Invasive adenocarcinoma:
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| #*Subtypes: micropapillary, mucinous (previously ''mucinous BAC''), colloid, fetal, enteric.
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| ===IHC===
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| *CK7 +ve.
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| *TTF-1 +ve.
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| *CK20 -ve.
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| ===Molecular===
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| *EGFR mutations (typically assessed by PCR) - respond to [[TKI]]s (e.g. [[gefitinib]], [[erlotinib]]) if:<ref name=pmid19680292>{{Cite journal | last1 = John | first1 = T. | last2 = Liu | first2 = G. | last3 = Tsao | first3 = MS. | title = Overview of molecular testing in non-small-cell lung cancer: mutational analysis, gene copy number, protein expression and other biomarkers of EGFR for the prediction of response to tyrosine kinase inhibitors. | journal = Oncogene | volume = 28 Suppl 1 | issue = | pages = S14-23 | month = Aug | year = 2009 | doi = 10.1038/onc.2009.197 | PMID = 19680292 }}</ref>
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| **Exon 19 deletion.
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| **Exon 21 L858R.
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| ***Natural history of mutation is suspected to have a better prognosis vs. wild-type.<ref>URL: [http://www.mycancergenome.org/mutation.php?dz=nsclc&gene=egfr&code=l858r http://www.mycancergenome.org/mutation.php?dz=nsclc&gene=egfr&code=l858r]. Accessed on: 27 April 2012.</ref>
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| **KRAS mutations are absent, i.e. ''wild-type KRAS''.<ref>{{Cite journal | last1 = Pao | first1 = W. | last2 = Wang | first2 = TY. | last3 = Riely | first3 = GJ. | last4 = Miller | first4 = VA. | last5 = Pan | first5 = Q. | last6 = Ladanyi | first6 = M. | last7 = Zakowski | first7 = MF. | last8 = Heelan | first8 = RT. | last9 = Kris | first9 = MG. | title = KRAS mutations and primary resistance of lung adenocarcinomas to gefitinib or erlotinib. | journal = PLoS Med | volume = 2 | issue = 1 | pages = e17 | month = Jan | year = 2005 | doi = 10.1371/journal.pmed.0020017 | PMID = 15696205 }}</ref>
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| *ALK [[chromosomal translocation]] (inv(2)(p21p23) -- EML4-ALK fusion).<ref name=pmid21245935>{{Cite journal | last1 = Li | first1 = Y. | last2 = Ye | first2 = X. | last3 = Liu | first3 = J. | last4 = Zha | first4 = J. | last5 = Pei | first5 = L. | title = Evaluation of EML4-ALK fusion proteins in non-small cell lung cancer using small molecule inhibitors. | journal = Neoplasia | volume = 13 | issue = 1 | pages = 1-11 | month = Jan | year = 2011 | doi = | PMID = 21245935 }}</ref>
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| **Associated with a poor prognosis.<ref name=pmid22134072>{{Cite journal | last1 = Yang | first1 = P. | last2 = Kulig | first2 = K. | last3 = Boland | first3 = JM. | last4 = Erickson-Johnson | first4 = MR. | last5 = Oliveira | first5 = AM. | last6 = Wampfler | first6 = J. | last7 = Jatoi | first7 = A. | last8 = Deschamps | first8 = C. | last9 = Marks | first9 = R. | title = Worse disease-free survival in never-smokers with ALK+ lung adenocarcinoma. | journal = J Thorac Oncol | volume = 7 | issue = 1 | pages = 90-7 | month = Jan | year = 2012 | doi = 10.1097/JTO.0b013e31823c5c32 | PMID = 22134072 }}</ref>
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| **Amenable to treatment with TKI.
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| **See ''[[lung carcinoma with ALK rearrangement]].
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| ===Sign out===
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| <pre>
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| LUNG, LEFT UPPER LOBE, LOBECTOMY:
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| - ADENOCARCINOMA WITH ACINAR, SOLID, MICROPAPILLARY AND LEPIDIC GROWTH PATTERNS IN ORDER OF PREVALENCE;
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| - PLEASE SEE TUMOUR SUMMARY.
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| </pre>
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| ====Staging note====
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| *Two small tumours in one lobe is pT3.
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| *Visceral pleural involvement upgrades small tumours.
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|
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| ==Bronchioloalveolar carcinoma== | | ==Bronchioloalveolar carcinoma== |
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| ==Squamous cell carcinoma of the lung== | | ==Squamous cell carcinoma of the lung== |
| {{Main|Squamous cell carcinoma}} | | {{Main|Squamous cell carcinoma of the lung}} |
| ===General===
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| *Strong association with smoking.
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| *May be treated with surgery.
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| ===Microscopic===
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| Features:
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| *Central nucleus.
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| *Dense appearing cytoplasm, usu. eosinophilic.
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| *+/-Small nucleolus.
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| DDx:
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| *Metastatic [[squamous cell carcinoma]].
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| *[[Adenocarcinoma of the lung]].
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| ===IHC===
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| *p63 +ve.
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| *CK5/6 +ve.
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| *TTF-1 -ve.
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| *Calponin -ve.
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| ==Small cell carcinoma of the lung== | | ==Small cell carcinoma of the lung== |
| *[[AKA]] ''small cell lung carcinoma'', abbreviated ''SCLC''.<ref name=pmid20943645/> | | *[[AKA]] ''small cell lung carcinoma'', abbreviated ''SCLC''.<ref name=pmid20943645>{{Cite journal | last1 = Travis | first1 = WD. | title = Advances in neuroendocrine lung tumors. | journal = Ann Oncol | volume = 21 Suppl 7 | issue = | pages = vii65-71 | month = Oct | year = 2010 | doi = 10.1093/annonc/mdq380 | PMID = 20943645 }}</ref> |
| | | {{Main|Small cell carcinoma of the lung}} |
| ===General===
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| *Strong association with smoking.
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| *Typically treated with chemotherapy.
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| *Poor prognosis.
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| On a spectrum of lesions (benign to malignant):<ref name=pmid20943645/>
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| *[[lung tumourlet|Tumourlet]].
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| *[[typical carcinoid|Carcinoid]].
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| *[[atypical carcinoid|Atypical carcinoid]].
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| *Small cell carinoma/large cell neuroendocrine carcinoma.
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| Precursor lesion - uncommonly seen:
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| *Pulmonary neuroendocrine cell hyperplasia.<ref name=pmid20943645>{{Cite journal | last1 = Travis | first1 = WD. | title = Advances in neuroendocrine lung tumors. | journal = Ann Oncol | volume = 21 Suppl 7 | issue = | pages = vii65-71 | month = Oct | year = 2010 | doi = 10.1093/annonc/mdq380 | PMID = 20943645 }}</ref>
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| ===Microscopic===
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| Features:
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| *Stippled chromatin.
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| *High [[NC ratio]], scant basophilic cytoplasm.
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| *Typically small cells ~2x RBC diameter.
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| *+/-Nuclear moulding.
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| *Necrosis.
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| *Mitoses.
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| Notes:
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| *There should be no nucleolus.
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| DDx:
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| *Metastatic [[small cell carcinoma]].
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| *[[Lymphoma]].
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| *[[Atypical carcinoid]].
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| *Other [[small round blue cell tumours]].
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| *Large cell neuroendocrine carcinoma {LCNEC).
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| Images:
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| *[http://commons.wikimedia.org/wiki/File:Lung_small_cell_carcinoma_%282%29_by_core_needle_biopsy.jpg SCLC - low mag. (WC)].
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| *[http://commons.wikimedia.org/wiki/File:Lung_small_cell_carcinoma_%281%29_by_core_needle_biopsy.jpg SCLC - high mag. (WC)].
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| ==Malignant mesothelioma== | | ==Malignant mesothelioma== |
| :Should '''not''' be confused with ''[[benign multicystic mesothelioma]]'' and ''[[benign papillary mesothelioma]]''. | | :Should '''not''' be confused with ''[[benign multicystic mesothelioma]]'' and ''[[benign papillary mesothelioma]]''. |
| *[[AKA]] ''mesothelioma''.
| | {{Main|Malignant mesothelioma}} |
| ===General===
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| *Prognosis sucks.
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| Locations:
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| *Lung.
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| *Primary peritoneal.
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| Epidemiology:
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| *Strong association with asbestos exposure.
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| Conditions associated with asbestos exposure (mnemonic ''PALM''):<ref name=Ref_PCPBoD8_375>{{Ref PCPBoD8|375}}</ref>
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| *Pleural plaques.
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| *[[Asbestosis]].
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| *[[Lung carcinoma]].
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| *Malignant mesothelioma.
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| Possible association with asbestos exposure:
| |
| *[[Gestational trophoblastic disease]].<ref name=pmid19900938>{{Cite journal | last1 = Reid | first1 = A. | last2 = Heyworth | first2 = J. | last3 = de Klerk | first3 = N. | last4 = Musk | first4 = AW. | title = Asbestos exposure and gestational trophoblastic disease: a hypothesis. | journal = Cancer Epidemiol Biomarkers Prev | volume = 18 | issue = 11 | pages = 2895-8 | month = Nov | year = 2009 | doi = 10.1158/1055-9965.EPI-09-0731 | PMID = 19900938 }}</ref>
| |
| | |
| ===Microscopic===
| |
| Features:<ref name=Ref_WMSP156>{{Ref WMSP|156}}</ref>
| |
| *Infiltrative atypical cells - '''key feature'''.
| |
| **+/-Epithelioid cells - may be cytologically bland, i.e. benign appearing.
| |
| ***Variable architecture: sheets, microglandular, tubulopapillary.
| |
| ***+/-[[Psammoma bodies]].
| |
| **+/-Spindle cells.
| |
| *+/-''Ferruginous body'' - '''strongly supportive'''.<ref>URL: [http://medical-dictionary.thefreedictionary.com/asbestos+body http://medical-dictionary.thefreedictionary.com/asbestos+body]. Accessed on: 4 November 2011.</ref>
| |
| ** Looks like a (twirling) baton - segemented appearance, brown colour.
| |
| ** Thin (asbestos) fiber in the core.
| |
|
| |
|
| Note:
| | ==Non-small cell lung carcinoma== |
| *''Asbestos body'' is not strictly speaking a synonym for ''ferruginous body''. | | *[[AKA]] ''poorly differentiated carcinoma of the lung''. |
| | {{Main|Non-small cell lung carcinoma}} |
|
| |
|
| DDx:<ref name=pmid15559051>{{Cite journal | last1 = Corson | first1 = JM. | title = Pathology of mesothelioma. | journal = Thorac Surg Clin | volume = 14 | issue = 4 | pages = 447-60 | month = Nov | year = 2004 | doi = 10.1016/j.thorsurg.2004.06.007 | PMID = 15559051 }}
| | ==Adenosquamous carcinoma of the lung== |
| </ref>
| | {{Main|Adenosquamous carcinoma of the lung}} |
| *[[Fibrosing pleuritis]].
| |
| *Mesothelial hyperplasia.
| |
|
| |
|
| Image:
| | ==Lung metastasis== |
| *[http://commons.wikimedia.org/wiki/File:Ferruginous_body.jpg Ferruginous body (WC)].
| | *[[AKA]] ''pulmonary metastasis''. |
| | | {{Main|Lung metastasis}} |
| ====Subtypes====
| |
| List of subtypes - mnemonic ''BEDS'':<ref name=pmid15559051/><ref name=Ref_WMSP156>{{Ref WMSP|156}}</ref>
| |
| *Biphasic mesothelioma.
| |
| **10%+ of epithelioid & 10%+ sarcomatoid.
| |
| *Epithelioid mesothelioma.
| |
| *Desmoplastic mesothelioma.
| |
| **Should be 50%+ dense tissue with storiform pattern & atypical cells.
| |
| *Sarcomatoid mesothelioma.
| |
| | |
| ===Stains===
| |
| *PASD -ve.
| |
| *Mucicarmine -ve.
| |
| **Typically +ve in adenocarcinoma.
| |
| | |
| ===IHC===
| |
| ====Mesothelioma versus mesothelial hyperplasia====
| |
| Features:<ref name=pmid20209622>{{Cite journal | last1 = Hasteh | first1 = F. | last2 = Lin | first2 = GY. | last3 = Weidner | first3 = N. | last4 = Michael | first4 = CW. | title = The use of immunohistochemistry to distinguish reactive mesothelial cells from malignant mesothelioma in cytologic effusions. | journal = Cancer Cytopathol | volume = 118 | issue = 2 | pages = 90-6 | month = Apr | year = 2010 | doi = 10.1002/cncy.20071 | PMID = 20209622 }}</ref>
| |
| *EMA +ve ~100% (vs. ~10%).
| |
| *Desmin -ve ~5% (vs. ~85%).
| |
| *GLUT1 +ve ~50% (vs. ~10%)
| |
| *p53 +ve ~50% (vs. ~2%).
| |
| | |
| ====Mesothelioma versus adenocarcinoma====
| |
| *Several panel exists - ''no agreed upon best panel''.<ref name=pmid18318582>{{cite journal |author=Marchevsky AM |title=Application of immunohistochemistry to the diagnosis of malignant mesothelioma |journal=Arch. Pathol. Lab. Med. |volume=132 |issue=3 |pages=397-401 |year=2008 |month=March |pmid=18318582 |doi= |url=http://journals.allenpress.com/jrnlserv/?request=get-abstract&issn=0003-9985&volume=132&page=397}}</ref>
| |
| **Usually two carcinoma markers + two mesothelial markers.
| |
| | |
| Panel:<ref name=pmid18318582/>
| |
| *Mesothelial markers:
| |
| **Calretinin.
| |
| **WT-1.
| |
| **D2-40.
| |
| **CK5/6.
| |
| *Carcinoma markers:
| |
| **CEA (monoclonal and polyclonal).
| |
| **TTF-1.
| |
| **Ber-EP4.
| |
| **MOC-31.
| |
| **CD15.
| |
|
| |
|
| =Malignant potential= | | =Malignant potential= |
Line 352: |
Line 184: |
| *Abbreviated ''AAH''. | | *Abbreviated ''AAH''. |
| *[[AKA]] ''atypical adenomatous hyperplasia of the lung''.<ref name=pmid11235908>{{Cite journal | last1 = Mori | first1 = M. | last2 = Rao | first2 = SK. | last3 = Popper | first3 = HH. | last4 = Cagle | first4 = PT. | last5 = Fraire | first5 = AE. | title = Atypical adenomatous hyperplasia of the lung: a probable forerunner in the development of adenocarcinoma of the lung. | journal = Mod Pathol | volume = 14 | issue = 2 | pages = 72-84 | month = Feb | year = 2001 | doi = 10.1038/modpathol.3880259 | PMID = 11235908 }}</ref> | | *[[AKA]] ''atypical adenomatous hyperplasia of the lung''.<ref name=pmid11235908>{{Cite journal | last1 = Mori | first1 = M. | last2 = Rao | first2 = SK. | last3 = Popper | first3 = HH. | last4 = Cagle | first4 = PT. | last5 = Fraire | first5 = AE. | title = Atypical adenomatous hyperplasia of the lung: a probable forerunner in the development of adenocarcinoma of the lung. | journal = Mod Pathol | volume = 14 | issue = 2 | pages = 72-84 | month = Feb | year = 2001 | doi = 10.1038/modpathol.3880259 | PMID = 11235908 }}</ref> |
| | | {{Main|Atypical adenomatous hyperplasia of the lung}} |
| ===General===
| |
| *Generally considered the precursor lesion to ''adenocarcinoma in situ''.<ref name=pmid17618248>{{Cite journal | last1 = Sakuma | first1 = Y. | last2 = Matsukuma | first2 = S. | last3 = Yoshihara | first3 = M. | last4 = Nakamura | first4 = Y. | last5 = Nakayama | first5 = H. | last6 = Kameda | first6 = Y. | last7 = Tsuchiya | first7 = E. | last8 = Miyagi | first8 = Y. | title = Epidermal growth factor receptor gene mutations in atypical adenomatous hyperplasias of the lung. | journal = Mod Pathol | volume = 20 | issue = 9 | pages = 967-73 | month = Sep | year = 2007 | doi = 10.1038/modpathol.3800929 | PMID = 17618248 }}</ref>
| |
| *Typically an incidental finding, i.e. asymptomatic.<ref name=Ref_WMSP114>{{Ref WMSP|114}}</ref>
| |
| | |
| ===Microscopic===
| |
| Features:<ref name=Ref_WMSP114>{{Ref WMSP|114}}</ref>
| |
| *Enlarged alveolar lining cells with:
| |
| **Hobnail morphology - free (luminal) surface area > attached/basal surface area.
| |
| **Hyperchromasia.
| |
| *Limited extent:
| |
| **<5 mm. †
| |
| | |
| DDx:
| |
| *Adenocarcinoma in situ.
| |
| | |
| Note:
| |
| * † [[Diagnostic size cutoff]].
| |
| | |
| Image:
| |
| *[http://www.nature.com/modpathol/journal/v20/n9/fig_tab/3800929f1.html#figure-title AAH (nature.com)].<ref name=pmid17618248/>
| |
|
| |
|
| ==Atypical carcinoid lung tumour== | | ==Atypical carcinoid lung tumour== |
| *[[AKA]] ''atypical carcinoid tumour of the lung''. | | *[[AKA]] ''atypical carcinoid tumour of the lung''. |
| ===General===
| | {{Main|Atypical lung carcinoid tumour}} |
| *Approximately 20% of lung carcinoids.<ref name=pmid20888248>{{Cite journal | last1 = Naalsund | first1 = A. | last2 = Rostad | first2 = H. | last3 = Strøm | first3 = EH. | last4 = Lund | first4 = MB. | last5 = Strand | first5 = TE. | title = Carcinoid lung tumors--incidence, treatment and outcomes: a population-based study. | journal = Eur J Cardiothorac Surg | volume = 39 | issue = 4 | pages = 565-9 | month = Apr | year = 2011 | doi = 10.1016/j.ejcts.2010.08.036 | PMID = 20888248 }}</ref>
| |
| | |
| ===Microscopic===
| |
| Features:<ref name=Ref_WMSP115>{{Ref WMSP|115}}</ref>
| |
| *Nests of cells.
| |
| **Stippled chromatin.
| |
| **Mild-to-moderate amount of cytoplasm.
| |
| *No necrosis/focal necrosis.
| |
| *Moderate mitotic rate (2-10/[[HPF]] - definition suffers from [[HPFitis]]).
| |
| | |
| DDx:
| |
| *[[Typical carcinoid lung tumour]].
| |
| *[[Small cell carcinoma of the lung]].
| |
| | |
| ===IHC===
| |
| *MIB1 moderate staining.
| |
|
| |
|
| ==Solitary fibrous tumour of the pleura== | | ==Solitary fibrous tumour of the pleura== |
| :See also: ''[[Solitary fibrous tumour]]''.
| | {{Main|Solitary fibrous tumour of the pleura}} |
| ===General===
| |
| *Common.
| |
| *Benign.
| |
| *Elderly.
| |
|
| |
|
| ===Gross/radiology=== | | =Benign tumours= |
| *Chest wall.
| | ==Pulmonary apical cap== |
| | | {{Main|Pulmonary apical cap}} |
| ===Microscopic=== | | A lesion that can mimic a lung neoplasm. |
| Features:
| |
| *Spindle cells.
| |
| *Ropy collagen.
| |
| | |
| Image:
| |
| *[http://path.upmc.edu/cases/case216/dx.html SFT (upmc.edu)].
| |
| | |
| ===IHC===
| |
| *CD34 +ve.
| |
|
| |
|
| =Benign tumours=
| |
| ==Pulmonary carcinoid tumourlet== | | ==Pulmonary carcinoid tumourlet== |
| *[[AKA]] ''carcinoid tumourlet''. | | *[[AKA]] ''carcinoid tumourlet''. |
| ===General===
| | {{Main|Pulmonary carcinoid tumourlet}} |
| *Neuroendocrine cell proliferation.<ref>{{Cite journal | last1 = Bennett | first1 = GL. | last2 = Chew | first2 = FS. | title = Pulmonary carcinoid tumorlets. | journal = AJR Am J Roentgenol | volume = 162 | issue = 3 | pages = 568 | month = Mar | year = 1994 | doi = | PMID = 8109497 | URL = http://www.ajronline.org/content/162/3/568.full.pdf }}</ref>
| |
| **Essentially a small [[typical carcinoid lung tumour|typical carcinoid]].
| |
| | |
| ===Microscopic===
| |
| Features:
| |
| *Nests of cells - classic pattern.
| |
| **Salt and pepper chromatin - '''key feature'''.
| |
| *Size criterion: <= 4 mm.<ref name=pct_ucsf>URL: [http://pathhsw5m54.ucsf.edu/case7/image75.html http://pathhsw5m54.ucsf.edu/case7/image75.html]. Accessed on: 23 January 2012.</ref>
| |
| | |
| DDx:
| |
| *[[Typical carcinoid lung tumour]].
| |
| | |
| Images:
| |
| *[http://pathhsw5m54.ucsf.edu/case7/image75.html Tumourlets - several images (ucsf.edu)].
| |
|
| |
|
| ==Typical carcinoid lung tumour== | | ==Typical carcinoid lung tumour== |
| *[[AKA]] ''carcinoid tumour of the lung''. | | *[[AKA]] ''carcinoid tumour of the lung''. |
| *[[AKA]] ''lung carcinoid''. | | *[[AKA]] ''lung carcinoid''. |
| ===General===
| | {{Main|Typical carcinoid lung tumour}} |
| *Approximately 80% of lung carcinoids.<ref name=pmid20888248>{{Cite journal | last1 = Naalsund | first1 = A. | last2 = Rostad | first2 = H. | last3 = Strøm | first3 = EH. | last4 = Lund | first4 = MB. | last5 = Strand | first5 = TE. | title = Carcinoid lung tumors--incidence, treatment and outcomes: a population-based study. | journal = Eur J Cardiothorac Surg | volume = 39 | issue = 4 | pages = 565-9 | month = Apr | year = 2011 | doi = 10.1016/j.ejcts.2010.08.036 | PMID = 20888248 }}</ref>
| |
| | |
| Presentation:<ref name=pmid16810137>{{Cite journal | last1 = Gungor | first1 = S. | last2 = Damadoglu | first2 = E. | last3 = Aybatli | first3 = A. | last4 = Yilmaz | first4 = A. | last5 = Kir | first5 = A. | last6 = Akkaya | first6 = E. | title = Typical pulmonary carcinoid tumors: presentation and outcome of 24 cases. | journal = Med Sci Monit | volume = 12 | issue = 7 | pages = CR315-8 | month = Jul | year = 2006 | doi = | PMID = 16810137 }}</ref>
| |
| *Cough.
| |
| *Hemoptysis.
| |
| | |
| ===Gross===
| |
| *Well-circumscribed, solid.
| |
| *Location - central airways (85%), remainder peripheral.<ref name=pmid22021498>{{Cite journal | last1 = Meisinger | first1 = QC. | last2 = Klein | first2 = JS. | last3 = Butnor | first3 = KJ. | last4 = Gentchos | first4 = G. | last5 = Leavitt | first5 = BJ. | title = CT features of peripheral pulmonary carcinoid tumors. | journal = AJR Am J Roentgenol | volume = 197 | issue = 5 | pages = 1073-80 | month = Nov | year = 2011 | doi = 10.2214/AJR.10.5954 | PMID = 22021498 }}</ref>
| |
| | |
| ===Microscopic===
| |
| Features:
| |
| *Nests of cells.
| |
| **Stippled chromatin.
| |
| **Moderate cytoplasm.
| |
| *No necrosis.
| |
| *Low mitotic rate.
| |
| *[[diagnostic size cutoff|Size criterion]]: > 4 mm.<ref name=pct_ucsf>URL: [http://pathhsw5m54.ucsf.edu/case7/image75.html http://pathhsw5m54.ucsf.edu/case7/image75.html]. Accessed on: 23 January 2012.</ref>
| |
| | |
| DDx:
| |
| *[[Pulmonary carcinoid tumourlet]].
| |
| *[[Atypical carcinoid lung tumour]].
| |
| *[[Lung adenocarcinoma]].<ref name=pmid22269186>{{Cite journal | last1 = Demirci | first1 = I. | last2 = Herold | first2 = S. | last3 = Kopp | first3 = A. | last4 = Flaßhove | first4 = M. | last5 = Klosterhalfen | first5 = B. | last6 = Janßen | first6 = H. | title = Overdiagnosis of a typical carcinoid tumor as an adenocarcinoma of the lung: a case report and review of the literature. | journal = World J Surg Oncol | volume = 10 | issue = | pages = 19 | month = | year = 2012 | doi = 10.1186/1477-7819-10-19 | PMID = 22269186 }}</ref>
| |
| | |
| Images:
| |
| *[http://commons.wikimedia.org/wiki/File:Lung_carcinoid_-_low_mag.jpg Lung carcinoid - low mag. (WC)].
| |
| *[http://commons.wikimedia.org/wiki/File:Lung_carcinoid_-_high_mag.jpg Lung carcinoid - high mag. (WC)].
| |
| *[http://commons.wikimedia.org/wiki/File:Lung_carcinoid_-_very_high_mag.jpg Lung carcinoid - very high mag. (WC)].
| |
| | |
| ===IHC===
| |
| *MIB1 scant staining.
| |
|
| |
|
| ==Clear cell sugar tumour of the lung== | | ==Clear cell sugar tumour of the lung== |
| *[[AKA]] ''clear cell sugar tumour''. | | *[[AKA]] ''clear cell sugar tumour''. |
| **Abbreviated ''CCST''. | | **Abbreviated ''CCST''. |
| ===General===
| | {{Main|Clear cell sugar tumour of the lung}} |
| *A [[PEComa]].
| |
| *Benign.<ref name=pmid19119463>{{Cite journal | last1 = Kim | first1 = WJ. | last2 = Kim | first2 = SR. | last3 = Choe | first3 = YH. | last4 = Lee | first4 = KY. | last5 = Park | first5 = SJ. | last6 = Lee | first6 = HB. | last7 = Chung | first7 = MJ. | last8 = Jin | first8 = GY. | last9 = Lee | first9 = YC. | title = Clear cell "sugar" tumor of the lung: a well-enhanced mass with an early washout pattern on dynamic contrast-enhanced computed tomography. | journal = J Korean Med Sci | volume = 23 | issue = 6 | pages = 1121-4 | month = Dec | year = 2008 | doi = 10.3346/jkms.2008.23.6.1121 | PMID = 19119463 | PMC = 2610653 | URL = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2610653/?tool=pubmed }}</ref>
| |
| | |
| ===Microscopic===
| |
| Features:<ref name=pmid19119463/>
| |
| *Sheets or trabeculae.
| |
| *Irregular epithelioid cells with:
| |
| **Focally clear cytoplasm.
| |
| | |
| Images:
| |
| *[http://www.surgicalpathologyatlas.com/glfusion/mediagallery/media.php?f=0&sort=0&s=20080802170404452 Clear cell sugar tumour of the lung (surgicalpathologyatlas.com)].
| |
| *[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2610653/figure/F3/ CCST (nih.gov)].<ref name=pmid19119463/>
| |
| | |
| ===IHC===
| |
| *HMB-45 +ve (nuclear & cytoplasmic).
| |
|
| |
|
| =See also= | | =See also= |
Line 496: |
Line 218: |
| *[[Basics]]. | | *[[Basics]]. |
| *[[Heart]]. | | *[[Heart]]. |
| | *[[Missed endobronchial biopsy]]. |
|
| |
|
| =References= | | =References= |