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LUNG TUMORSDr WIWIT ADE, M.BIOMED, SpPA

DegenerativeInflammatoryNeoplastic and Pleura

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WEIGHTLOBESSEGMENTSBRONCHIARTERIES, pulmonaryARTERIES, bronchialVEINSPLEURA, visceralPLEURA, parietalNERVES3

BronchiBronchiolesTerminal bronchiolesAlveolar ductsAlveoliType 1 pneumocytesType 2 pneumocytesMacrophagesCapillaries

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NORMAL 6 LUNG TUMORSBenign, malignant, epithelial, mesenchymal, but 90% are CARCINOMASBIGGEST 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 isotopesRadiation, asbestos, radonC-MYC, K-RAS, EGFR, HER-2/neu7PATHOGENESISNORMAL BRONCHIAL MUCOSAMETAPLASTIC/DYSPLASTIC MUCOSACARCINOMA-IN-SITU (squamous, adeno)INFILTRATING : cancer

8MorphologyPrimary 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 TYPESNON-SMALL CELLSQUAMOUS CELL CARCINOMAADENOCARCINOMALARGE CELL CARCINOMAThe NON-small cell cancers behave and are treated similarly

SMALL CELL CARCINOMAthe SMALL cell carcinomas are WORSE than the non-small cell carcinomas, but respond better to chemotherapy .

10 Squamous cell carcinomaSmall cell carcinomaCombined small cell carcinomaAdenocarcinoma: Acinar, papillary, bronchioloalveolar, solid, mixed subtypesLarge cell carcinomaLarge cell neuroendocrine carcinomaAdenosquamous carcinomaCarcinomas with pleomorphic, sarcomatoid, or sarcomatous elementsCarcinoid tumor: Typical, atypicalCarcinomas of salivary gland typeUnclassified carcinoma11

Lung carcinoma. The gray-white tumor tissue is seen infiltrating the lung substance. Histologically, this large tumor mass was identified as a squamous cell carcinoma12

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.13 Bronchioloalveolar carcinoma with characteristic growth along pre-existing alveolar septa, without invasion

T1Tumor 3 cm or involvement of main stem bronchus 2 cm from carina, visceral pleural involvement, or lobar atelectasisT3Tumor with involvement of chest wall (including superior sulcus tumors), diaphragm, mediastinal pleura, pericardium, main stem bronchus 2 cm from carina, or entire lung atelectasisT4Tumor with invasion of mediastinum, heart, great vessels, trachea, esophagus, vertebral body, or carina or with a malignant pleural effusionN0No demonstrable metastasis to regional lymph nodesN1Ipsilateral hilar or peribronchial nodal involvementN2Metastasis to ipsilateral mediastinal or subcarinal lymph nodesN3Metastasis to contralateral mediastinal or hilar lymph nodes, ipsilateral or contralateral scalene, or supraclavicular lymph nodesM0No (known) distant metastasisM1Distant metastasis presentTNM, Lung TNM ALWAYS relates to BIOLOGIC BEHAVIOR!15Clinical FeaturePathologic BasisPneumonia, abscess, lobar collapseTumor obstruction of airwayLipid pneumoniaTumor obstruction; accumulation of cellular lipid in foamy macrophagesPleural effusionTumor spread into pleuraHoarsenessRecurrent laryngeal nerve invasionDysphagiaEsophageal invasionDiaphragm paralysisPhrenic nerve invasionRib destructionChest wall invasionSVC syndromeSVC compression by tumorHorner syndromeSympathetic ganglia invasionPericarditis, tamponadePericardial involvementSVC, superior vena cava.LOCAL effects of LUNG CANCER16METASTATIC TUMORSLUNG is the MOST COMMON site for all metastatic tumors, regardless of site of origin

It is the site of FIRST CHOICE for metastatic sarcomas.17PLEURAPLEURITIS PNEUMOTHORAXEFFUSIONSHYDRO-THORAX HEMO-THORAX CHYLO-THORAX MESOTHELIOMAS 18MESOTHELIOMASBenign 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

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Typical growth appearance of a malignant mesothelioma, it compresses the lung from the OUTSIDE20

H&E, IMMUNOCHEMISTRYMesothelial 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)21ASPEK PATOLOGIKANKER PARU

Bahan pemeriksaan paruPROFESI TERKAIT PENANGANAN KANKER PARU Spesialis ParuSpesialis Radio-diagnostikSpesialis Patologi AnatomikSpesialis Bedah thoraksSpesialis Radio-terapiSpesialis PD KHOMFaktor yang berpengaruh pada diagnosis keganasan paruKetrampilan klinisi mendapatkan bahan pemeriksaan

Ketrampilan diagnostik SpPASitologi: sputum; bilas dan sikat bronkhus; TBNA; TTNA; BALHistopatologi: TBLB; biopsi core; biopsi insisi; biopsi eksisi; operasi

Diagnostik: sitologi; histopatologiPeran pemeriksaan PA utk penanganan Kanker ParuSitologiHisto-pathPotong bekuMolekular Diagnosa XXXStaging pra/pstXXBedahXXRadiasi XXKemoterapi XXMonoklonal XXXMODAL TERAPI Kanker ParuBEDAH stadium I-IIIRADIASI stadium III-IVKEMOTERAPI 1st & 2nd linesMONOKLONAL 1st line & maintainKlasifikasi Kanker Paru menggunakan Klasifikasi WHO 2004 WHO 1999SQUAMOUS CELL CaSMALL CELL CaADENOCARCINOMALARGE CELL CaWHO 2004SQUAMOUS CELL CaSMALL CELL CaADENOCARCINOMA Adenoca, mixed type Acinar Adenoca Papillary Adenoca Bronchioloalveolar Ca Solid Adenoca mucin prodLARGE CELL CaKlasifikasi Kanker Paru menggunakan Klasifikasi WHO 2004 Bronchioloalveolar Ca Nonmucinous Mucinous Mixed nonmucinous and mucinous or indeterminateSolid adenocarcinoma with mucin production fetal adenocarcinoma mucinous/coloid ca mucinous cyst ad.ca signet ring adeno ca clear cell caKarsinoma sel skuamosa (SCC) Histologi

Sitologi30 Karsinoma sel kecil(SCLC)Histologi

Sitologi

31 Adenokarsinoma(Adeno)Histologi

Sitologi

32 Karsinoma sel besar(LCC)Histologi

Sitologi

33 Carcinoid tipik atipik

34 Frekuensi jenis histologi keganasan epitelial paruSqua %Adeno%Large% Small%Vincent, 19773826.59.319.2Suemasu, 197832.941.812.7Hayata, 198040.839.89.68.7Endardjo, 199032.338.91.55.6Pola gambaran sitologi keganasan paru (2000-2001 Sept). S. Endardjo 2001Gambaran sitologiTTB(459)Bronkhus(834)n%n%Adenokarsinoma100747279Ka sel skuamosa33241820Ka sel besar2111Ka sel kecil--Karsinoid--Total13591Perspectives in lung cancer1.Estimated 1.3 million new cases will be diagnosed annually2.Adenocarcinoma is the major histological subtype3.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 SkuamosaIMUNOHISTO - MW Keratin - Sitokeratin 5/6 - CEASITOLOGI - nekrosis dan sel debris - sel terisolasi - inti sentral ireguler hiperkromatik - anak inti kecil 1-2 - sitoplasma lebar - bentuk sel bizarreKarsinoma Sel Skuamosa

Karsinoma Sel KecilSITOLOGI - 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 - synaptophysinKarsinoma Sel Kecil

AdenokarsinomaSITOLOGI - sel tunggal, morula, asini, papiler - inti bulat/oval ditepi, kromatin halus, anak inti menonjol besar - sitoplasma lebar, translusen, vakuol, musinIMUNOHISTO - AE1/AE3 - Cam 5.2 - EMA - CEA - CK 7Adenokarsinoma

Karsinoma Bronkioloalveolar

Karsinoma Bronkioloalveolar

Karsinoma Bronkioloalveolar

Karsinoma Sel BesarSITOLOGI - 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 basofilikIMUNOHISTO - petanda neroendokrin - seperti NSCLCKarsinoma Sel Besar

Sekrining Kanker ParuPeran Sp Patologi Anatomik mendatang dalam upaya deteksi dini Kanker ParuPositivity of sputum cytologyMethodDirect%Inhalation%Saccomano%Endardjo19905.2Astowo19951626Titin M S20024.318.3Relative survival of lung cancer. England and Wales, 1971-2001 Cancer research UKPeriod of diagnosisRelative survival(%)

RingkasanDiagnosa patologi sedapat mungkin mencantumkan jenis, karena terkait jenis terapi yang akan diberikanMengenal gambaran prakanker guna membantu menurunkan angka kanker paruTERIMAKASIH