Lung tumor: Difference between revisions

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{{Top
<noinclude>{{Top
|author1=[[User:Mikael Häggström|Mikael Häggström]]
|author1=[[User:Mikael Häggström|Mikael Häggström]]
|author2=
|author2=
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*'''[[Lung wedge resection or lobectomy]]'''
*'''[[Lung wedge resection or lobectomy]]'''
*'''[[Lung autopsy]]'''
*'''[[Lung autopsy]]'''
 
</noinclude>
==Gross processing==
==Gross processing==
In tumor resection:<ref>{{cite web|url=https://www.uclahealth.org/pathology/workfiles/Education/Residency%20Program/Gross%20Manual/Wedge%20Resection.pdf|title=Pulmonary pathology grossing guidelines|accessdate=2021-03-17}}</ref>
As per presentation above.
*'''Measure''' the specimen in 3 dimensions.
*Describe any included '''pleural surface''', including color, and any presence of granularity, adhesions, retraction, or tumor.
*{{Moderate-begin}}[[Ink]] the surgical margin.{{Moderate-end}}
*Serially '''section''' the specimen. Describe the cut surface, including color and consistency, and any focal lesions.
*Measure '''tumor size''' as a maximum diameter {{Moderate-begin}}or 3 dimensions{{Moderate-end}}
*Determine '''location''': Which lobe if applicable, and if it is peripheral, central or hilar.
*'''Margin''' length to pleura and hilum/surgical margin.
*Any '''involvement''' of major bronchi or blood vessels.
*Any abnormal '''lymph nodes''', including hilar ones if available.
Photograph all tumors.
 
===Gross report===
{{Report-begin|fresh=yes|intraop=yes}} a wedge-shaped piece of lung which measures __ cm and has a staple line along one aspect measuring __ cm in length. The stapled surgical margin is inked black. The visceral pleura is mottled tan-pink and slightly puckered in the center. Cut sections show a tan, soft, tumor measuring __ cm in greatest dimension, located __ cm from the visceral pleura and __ cm from the surgical margin.  The remaining parenchyma is pink and spongy.{{Report-end}}
 
<gallery mode=packed heights=190>
File:Squamous cell carcinoma involving a subsegmental bronchus.jpg|'''Squamous cell carcinoma''' involving a subsegmental bronchus with distal chronic obstructive pneumonia. The tumor is seen as a rounded nodule, approximately 2 cm in diameter, proximal to a more irregular focus of chronic obstructive pneumonia with fibrosis.
[[File:Large cell carcinoma of the lung.jpg|thumb|'''Large cell carcinoma''', with a large multilobulated tumor adjacent to the hilum. A metastatically involved lymph node is present next to the bronchus.]]
</gallery>


==Microscopic evaluation==
==Microscopic evaluation==
[[File:Pie chart of lung cancers.svg|thumb|Lung cancers by relative incidence.]]
Medical imaging provides a major clue as to whether a lung tumor is benign or malignant, where lesions smaller than 2 cm are likely to be benign, whereas lesions larger than 2 cm are malignant (that is, lung cancer) in 85% of cases.<ref name=Borczuk2008>{{cite journal|author=Alain C. Borczuk|year=2008|title=Benign Tumors and Tumorlike Conditions of the Lung|journal=Archives of Pathology & Laboratory Medicine|volume=132|issue=7|url=https://www.archivesofpathology.org/doi/full/10.1043/1543-2165%282008%29132%5B1133%3ABTATCO%5D2.0.CO%3B2}}</ref>
Medical imaging provides a major clue as to whether a lung tumor is benign or malignant, where lesions smaller than 2 cm are likely to be benign, whereas lesions larger than 2 cm are malignant (that is, lung cancer) in 85% of cases.<ref name=Borczuk2008>{{cite journal|author=Alain C. Borczuk|year=2008|title=Benign Tumors and Tumorlike Conditions of the Lung|journal=Archives of Pathology & Laboratory Medicine|volume=132|issue=7|url=https://www.archivesofpathology.org/doi/full/10.1043/1543-2165%282008%29132%5B1133%3ABTATCO%5D2.0.CO%3B2}}</ref>


===Benign tumors===
Subsequently distribution of benign tumors and lung cancers, respectively, are as follows:<ref name=Borczuk2008/>
Subsequently distribution of benign tumors and lung cancers, respectively, are as follows:<ref name=Borczuk2008/>
[[File:Pie chart of lung cancers.svg|thumb|Lung cancers by relative incidence.]]
[[File:Histopathology of a minute pulmonary meningothelial-like nodule (MPMN).jpg|thumb|'''Minute pulmonary meningothelial-like nodules''' (MPMNs) are interstitial nodular proliferations of small oval or spindle-shape cells in nests,<ref name="KurokiNakata2002">{{cite journal|last1=Kuroki|first1=Masaomi|last2=Nakata|first2=Hiroshi|last3=Masuda|first3=Toshifumi|last4=Hashiguchi|first4=Norihisa|last5=Tamura|first5=Shozo|last6=Nabeshima|first6=Kazuki|last7=Matsuzaki|first7=Yasunori|last8=Onitsuka|first8=Toshio|title=Minute Pulmonary Meningothelial-like Nodules: High-Resolution Computed Tomography and Pathologic Correlations|journal=Journal of Thoracic Imaging|volume=17|issue=3|year=2002|pages=227–229|issn=0883-5993|doi=10.1097/00005382-200207000-00008}}</ref> and do not need reporting.{{MH}}]]
Benign lung tumors:
Benign lung tumors:
*Hamartomas - 76%
*Hamartomas - 76%
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*Other - 3.3%
*Other - 3.3%


===Gallery of lung cancers===
===Lung cancers===
<gallery mode=packed heights=190>
<gallery mode=packed heights=190>
File:Lung adenocarcinoma with lepidic growth - low magnification.jpg|'''Lung adenocarcinoma''', with lepidic pattern shown, wherein tumors cells cover alveolar walls.
File:Lung adenocarcinoma with lepidic growth - low magnification.jpg|'''[[Lung adenocarcinoma]]''', with lepidic pattern shown, wherein tumors cells cover alveolar walls.
File:Large cell carcinoma of the lung .jpg|'''Large cell carcinoma''' of the lung: neoplastic cells with abundant pale eosinophilic cytoplasm
File:Histopathology of lung adenocarcinoma with solid pattern.jpg|'''[[Lung adenocarcinoma]]''', with solid pattern.
File:Histopathology of squamous-cell carcinoma of the lung.jpg|'''[[Squamous-cell carcinoma of the lung]]'''. Typical squamous-cell carcinoma cells are large with abundant eosinophilic cytoplasm and large, often vesicular, nuclei.<ref>{{cite web|url=https://dermnetnz.org/topics/squamous-cell-carcinoma-pathology/|title=Squamous cell carcinoma pathology|website=DermNetz|author=Dr Nicholas Turnbull, A/Prof Patrick Emanual|date=2014-05-03}}</ref>
File:Large cell carcinoma of the lung .jpg|'''Large cell carcinoma''' of the lung: neoplastic cells with abundant pale eosinophilic cytoplasm.
File:Histopathology of squamous-cell carcinoma of the lung.jpg|'''[[Squamous-cell carcinoma of the lung|Squamous-cell carcinoma (SCC) of the lung]]'''. Typical squamous-cell carcinoma cells are large with abundant eosinophilic cytoplasm and large, often vesicular, nuclei.<ref>{{cite web|url=https://dermnetnz.org/topics/squamous-cell-carcinoma-pathology/|title=Squamous cell carcinoma pathology|website=DermNetz|author=Dr Nicholas Turnbull, A/Prof Patrick Emanual|date=2014-05-03}}</ref>
File:Histopathology of small cell carcinoma, annotated.png|'''Small-cell carcinoma''', with typical findings.<ref>Image by Mikael Häggström, MD. Source for findings: {{cite web|url=https://www.pathologyoutlines.com/topic/lungtumorsmallcell.html|title=Lung - Small cell carcinoma|website=Pathology Outlines|author=Caroline I.M. Underwood, M.D., Carolyn Glass, M.D., Ph.D.}} Last author update: 20 September 2022}}</ref>
</gallery>
</gallery>
[[File:Immunohistochemistry of adenocarcinoma with cytoplasmic versus nuclear staining for TTF-1.jpg|thumb|220px|TTF-1 needs to have nuclear staining on immunohistochemistry to count as positive. Cytoplasmic staining is disregarded for diagnostic purposes.<ref>Image by Mikael Häggström, MD. Source for significance: {{cite journal| author=Bejarano PA, Mousavi F| title=Incidence and significance of cytoplasmic thyroid transcription factor-1 immunoreactivity. | journal=Arch Pathol Lab Med | year= 2003 | volume= 127 | issue= 2 | pages= 193-5 | pmid=12562233 | doi=10.5858/2003-127-193-IASOCT | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12562233  }} </ref>]]
===Diagnostic immunohistochemistry===
Whereas large cell carcinoma is more often histologically distinct, adenocarcinoma and SCC may look alike. In such cases, an [[immunohistochemistry]] panel of TTF1, CK5/6, and p63 can be used to distinguish the two.<ref name="pmid29538329">{{cite journal| author=Inamura K| title=Update on Immunohistochemistry for the Diagnosis of Lung Cancer. | journal=Cancers (Basel) | year= 2018 | volume= 10 | issue= 3 | pages=  | pmid=29538329 | doi=10.3390/cancers10030072 | pmc=5876647 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29538329  }} </ref><ref name="pmid30235512">{{cite journal| author=Affandi KA, Tizen NMS, Mustangin M, Zin RRMRM| title=p40 Immunohistochemistry Is an Excellent Marker in Primary Lung Squamous Cell Carcinoma. | journal=J Pathol Transl Med | year= 2018 | volume= 52 | issue= 5 | pages= 283-289 | pmid=30235512 | doi=10.4132/jptm.2018.08.14 | pmc=6166010 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30235512  }} </ref>
In case of adenocarcinoma, in order to distinguish primary lung cancer from a gastrointestinal metastasis, the best panel, in addition to CK7 and TTF-1, may be CDX2 and/or GPA33 plus MUC2, or all of the following GI markers: CDH17, CDX2, CK20, GPA33, MUC2, and SATB2 with four positive GI markers supporting metastasis.<ref name="pmid37349623">{{cite journal| author=Malmros K, Lindholm A, Vidarsdottir H, Jirström K, Nodin B, Botling J | display-authors=etal| title=Diagnostic gastrointestinal markers in primary lung cancer and pulmonary metastases. | journal=Virchows Arch | year= 2023 | volume=  | issue=  | pages=  | pmid=37349623 | doi=10.1007/s00428-023-03583-w | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=37349623  }} </ref>


==Further workup==
{{NSCLC molecular workup}}
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