LUNG TUMORS

Dr WIWIT ADE, M.BIOMED, SpPA

 Degenerative
Inflammatory
Neoplastic and Pleura

WEIGHT

LOBES
SEGMENTS
BRONCHI

ARTERIES,
pulmonary
ARTERIES,
bronchial
VEINS
PLEURA, visceral

PLEURA, parietal
NERVES

Bronchi
Bronchioles
Terminal
bronchioles
Alveolar ducts
Alveoli
Type 1
pneumocytes
Type 2
pneumocytes
Macrophages
Capillaries

N
O
R
M
A
L

LUNG TUMORS
Benign, malignant, epithelial, mesenchymal, but
90% are CARCINOMAS
BIGGEST USA killer. Only 15% 5 year survival.
Prevalence not as high as prostate or breast but
mortality higher.

TOBACCO has polycyclic aromatic hydrocarbons,

such as benzopyrene, anthracenes, radioactive
isotopes
Radiation, asbestos, radon
C-MYC, K-RAS, EGFR, HER-2/neu

PATHOGENESIS
NORMAL BRONCHIAL MUCOSA
METAPLASTIC/DYSPLASTIC MUCOSA
CARCINOMA-IN-SITU (squamous,
adeno)
INFILTRATING : cancer

Morphology
Primary carcinomas of the lung arise in the periphery
of the lung substance from the alveolar septal cells or
terminal bronchioles.
(>> adenocarcinomas, bronchioloalveolar type)
Squamous cell carcinoma of the lung begins as an area
of in situ cytologic dysplasia ( small area of thickening
or piling up of bronchial mucosa -small focus, usually
less than 1 cm2 in area
-> fungate into the bronchial lumen to produce an
intraluminal mass
->penetrate the wall of the bronchus- infiltrate along
the peribronchial tissue into the adjacent region of the
carina or mediastinum.

TWO TYPES
NON-SMALL CELL
SQUAMOUS CELL CARCINOMA
ADENOCARCINOMA
LARGE CELL CARCINOMA
The NON-small cell cancers behave and are treated
similarly

SMALL CELL CARCINOMA

the SMALL cell carcinomas are WORSE than the nonsmall cell carcinomas, but respond better to
chemotherapy .

Squamous cell carcinoma

Small cell carcinoma
Combined small cell carcinoma
Adenocarcinoma: Acinar, papillary, bronchioloalveolar, solid,
mixed subtypes
Large cell carcinoma
Large cell neuroendocrine carcinoma
Adenosquamous carcinoma
Carcinomas with pleomorphic, sarcomatoid, or sarcomatous
elements
Carcinoid tumor: Typical, atypical
Carcinomas of salivary gland type
Unclassified carcinoma

Lung carcinoma. The

gray-white tumor tissue
is seen infiltrating the
lung substance.
Histologically, this large
tumor mass was
identified as a squamous
cell carcinoma

Histologic appearance of lung carcinoma. A, Well-differentiated squamous cell carcinoma showing keratinization. B,
Gland-forming adenocarcinoma. C, Small cell carcinoma with islands of small deeply basophilic cells and areas of
necrosis. D, Large cell carcinoma, featuring pleomorphic, anaplastic tumor cells and absence of squamous or
glandular differentiation.

Bronchioloalveolar carcinoma with characteristic growth along pre-existing

alveolar septa, without invasion

TNM, Lung
T1

TNM
ALWAYS
relates
to
BIOLOGIC
BEHAVIOR!
Tumor <3 cm without pleural or main stem bronchus involvement

T2

Tumor >3 cm or involvement of main stem bronchus 2 cm from carina,

visceral pleural involvement, or lobar atelectasis

T3

Tumor with involvement of chest wall (including superior sulcus tumors),

diaphragm, mediastinal pleura, pericardium, main stem bronchus 2 cm from
carina, or entire lung atelectasis

T4

Tumor with invasion of mediastinum, heart, great vessels, trachea,

esophagus, vertebral body, or carina or with a malignant pleural effusion

N0

No demonstrable metastasis to regional lymph nodes

N1

Ipsilateral hilar or peribronchial nodal involvement

N2

Metastasis to ipsilateral mediastinal or subcarinal lymph nodes

N3

Metastasis to contralateral mediastinal or hilar lymph nodes, ipsilateral or

contralateral scalene, or supraclavicular lymph nodes

M0

No (known) distant metastasis

M1

Distant metastasis present

LOCAL effects of LUNG CANCER

Clinical Feature

Pathologic Basis

Pneumonia, abscess, lobar

collapse

Tumor obstruction of airway

Lipid pneumonia

Tumor obstruction; accumulation of cellular

lipid in foamy macrophages

Pleural effusion

Tumor spread into pleura

Hoarseness

Recurrent laryngeal nerve invasion

Dysphagia

Esophageal invasion

Diaphragm paralysis

Phrenic nerve invasion

Rib destruction

Chest wall invasion

SVC syndrome

SVC compression by tumor

Horner syndrome

Sympathetic ganglia invasion

Pericarditis, tamponade

Pericardial involvement

SVC, superior vena cava.

METASTATIC TUMORS
LUNG is the MOST COMMON site for all
metastatic tumors, regardless of site of origin
It is the site of FIRST CHOICE for metastatic
sarcomas.

PLEURA
PLEURITIS
PNEUMOTHORAX
EFFUSIONS
HYDRO-THORAX
HEMO-THORAX
CHYLO-THORAX
MESOTHELIOMAS

MESOTHELIOMAS
Benign vs. Malignant differentiation does not matter,
but a self limited localized nodule can be regarded as
benign, and a spreading tumor can be regarded as
malignant
Visceral or parietal pleura, pericardium, or peritoneum
Most are regarded as asbestos caused or asbestos
related

Typical growth appearance of a malignant

mesothelioma, it compresses the lung from
the OUTSIDE

Mesothelial cells have MANY more microvilli than most

epithelial cells and express a protein called CALRETININ, which
epithelial cells do NOT.
The differentiation between mesothelioma and carcinoma
may be crucially important!

A, Malignant mesothelioma, epithelial type.

B, Malignant mesothelioma, mixed type, stained for
calretinin (immunoper-oxidase method). The epithelial
sarcomatoid compocomponent iss trongly positive (dark
brown)

H&E, IMMUNOCHEMISTRY

ASPEK PATOLOGI
KANKER PARU

Bahan pemeriksaan paru

PROFESI TERKAIT PENANGANAN KANKER

PARU

Spesialis Paru
Spesialis Radio-diagnostik
Spesialis Patologi Anatomik
Spesialis Bedah thoraks
Spesialis Radio-terapi
Spesialis PD KHOM

Faktor yang berpengaruh pada diagnosis

keganasan paru
Ketrampilan klinisi
mendapatkan bahan
pemeriksaan

Sitologi: sputum; bilas

dan sikat bronkhus;
TBNA; TTNA; BAL
Histopatologi: TBLB;
biopsi core; biopsi insisi;
biopsi eksisi; operasi

Ketrampilan diagnostik
SpPA

Diagnostik: sitologi;
histopatologi

Peran pemeriksaan PA utk penanganan

Kanker Paru
Sitologi

Histo-path

Diagnosa

Staging pra/pst

Bedah

Radiasi

Kemoterapi

Monoklonal

Potong beku

Molekular
X

MODAL TERAPI Kanker Paru

BEDAH
RADIASI
KEMOTERAPI
MONOKLONAL

stadium I-III

stadium III-IV
1st & 2nd lines
1st line & maintain

Klasifikasi Kanker Paru menggunakan

Klasifikasi WHO 2004
WHO 1999

WHO 2004

SQUAMOUS CELL Ca
SMALL CELL Ca
ADENOCARCINOMA
Adenoca, mixed type
Acinar Adenoca
Papillary Adenoca
Bronchioloalveolar Ca
Solid Adenoca mucin prod
LARGE CELL Ca

SQUAMOUS CELL Ca
SMALL CELL Ca
ADENOCARCINOMA
LARGE CELL Ca

Klasifikasi Kanker Paru menggunakan

Klasifikasi WHO 2004
Bronchioloalveolar Ca
Nonmucinous
Mucinous
Mixed nonmucinous
and mucinous or
indeterminate

Solid adenocarcinoma with

mucin production
fetal adenocarcinoma
mucinous/coloid ca
mucinous cyst ad.ca
signet ring adeno ca
clear cell ca

Karsinoma sel skuamosa (SCC)

Histologi

Sitologi

Karsinoma sel kecil(SCLC)

Histologi

Sitologi

Adenokarsinoma(Adeno)
Histologi

Sitologi

Karsinoma sel besar(LCC)

Histologi

Sitologi

Carcinoid
tipik

atipik

Frekuensi jenis histologi keganasan

epitelial paru
Squa
%

Adeno
%

Large
%

Small
%

38

26.5

9.3

19.2

Suemasu, 1978

32.9

41.8

Hayata, 1980

40.8

39.8

9.6

8.7

Endardjo, 1990

32.3

38.9

1.5

5.6

Vincent, 1977

12.7

Pola gambaran sitologi keganasan paru

(2000-2001 Sept). S. Endardjo 2001
Gambaran sitologi

TTB(459)

Bronkhus(834)

Adenokarsinoma

100

74

72

79

Ka sel skuamosa

33

24

18

20

Ka sel besar
Ka sel kecil

2
-

1
-

Karsinoid

135

91

Total

Perspectives in lung cancer

1. Estimated 1.3 million new cases will be
diagnosed annually
2. Adenocarcinoma is the major histological
subtype
3. Increasing the incidence of typical &
atypical carcinoid and large cell
neuroendocrine tumors
4. Decreasing the incidence of small cell
carcinoma
Hansen: 2nd International Chicago Symposium on Malignacies of Chest and
Head & Neck, October 2001.

Saluran napas bawah

Apusan sputum

Apusan sputum

Apusan Bilasan Bronkhus

Apusan Bilasan Bronkhus

Karsinoma Sel Skuamosa

SITOLOGI
- nekrosis dan sel debris
- sel terisolasi
- inti sentral ireguler
hiperkromatik
- anak inti kecil 1-2
- sitoplasma lebar
- bentuk sel bizarre

IMUNOHISTO
- MW Keratin
- Sitokeratin 5/6
- CEA

Karsinoma Sel Skuamosa

Karsinoma Sel Kecil

SITOLOGI
- streaks/baluran sel
- sebaran sel ireguler,
sinsitial, berderet
- N/C rasio tinggi
- nuclear moulding
- inti ovoid, ireguler
- kromatin salt and
pepper
- mitosis

IMUNOHISTO
- CD 56
- chromogranin
- synaptophysin

Karsinoma Sel Kecil

Adenokarsinoma
SITOLOGI
- sel tunggal, morula,
asini, papiler
- inti bulat/oval ditepi,
kromatin halus, anak
inti menonjol besar
- sitoplasma lebar,
translusen, vakuol,
musin

IMUNOHISTO
- AE1/AE3
- Cam 5.2
- EMA
- CEA
- CK 7

Adenokarsinoma

Karsinoma Bronkioloalveolar

Karsinoma Bronkioloalveolar

Karsinoma Bronkioloalveolar

Karsinoma Sel Besar

SITOLOGI
- gambaran tidak spesifik
- sel bergerombol atau
tersebar
- batas selular tidak jelas,
kolompokan tidak teratur
- inti bulat sp tak teratur,
kromatin tdk teratur
- anak inti sangat menonjol
- sitoplasma sedikit dan
basofilik

IMUNOHISTO
- petanda neroendokrin
- seperti NSCLC

Karsinoma Sel Besar

Peran Sp Patologi Anatomik

mendatang dalam upaya deteksi dini
Kanker Paru

SEKRINING KANKER PARU

Positivity of sputum cytology

Method

Endardjo
1990
Astowo
1995
Titin M S
2002

Direct
%

Inhalation
%

Saccomano
%

5.2
16

26

4.3

18.3

Relative survival of lung cancer. England and Wales,

1971-2001
Cancer research UK
30

25

Relative survival(%)

20

men - 1 yr
women - 1 yr

15

men - 5 yr
women - 5 yr
10

1971-75

1976-80

1981-85

1986-90

1991-95

Period of diagnosis

1996-99

2000-01*

Ringkasan
Diagnosa patologi sedapat mungkin
mencantumkan jenis, karena terkait jenis
terapi yang akan diberikan
Mengenal gambaran prakanker guna
membantu menurunkan angka kanker paru