Elsevier

Clinics in Chest Medicine

Volume 32, Issue 4, December 2011, Pages 669-692
Clinics in Chest Medicine

Pathology of Lung Cancer

https://doi.org/10.1016/j.ccm.2011.08.005Get rights and content

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Classification

Worldwide, lung cancer is the most common cause of major cancer incidence and mortality in men, whereas in women it is the third most common cause of cancer incidence and the second most common cause of cancer mortality.1 In 2010 the American Cancer Society estimated that lung cancer would account for more than 222,520 new cases in the United States during 2010 and 157,300 cancer deaths.2 Although lung cancer incidence in the United States began to decline in men in the early 1980s,3 it seems

Preinvasive lesions

The pathology of preinvasive lesions for lung cancer has attracted increasing interest in recent years because of the growing importance of early detection of lung cancer using screening of high-risk patients by fluorescence bronchoscopy30, 31 and by spiral or helical computed tomography (CT).32, 33 In addition, the concepts of preinvasive lesions have evolved over the past several decades, with none mentioned in the 1967 WHO classification of lung tumors34 and only bronchial squamous dysplasia

Squamous cell carcinoma

Squamous cell carcinoma accounts for approximately 20% of all lung cancers in the United States.63 Historically, two-thirds of squamous cell carcinomas presented as central lung tumors, whereas many among the remaining third are peripheral.64, 65 However, recent reports document that an increasing percentage of squamous cell carcinomas are found in the periphery, exceeding 50% in some studies.66 The morphologic features that suggest squamous differentiation include intercellular bridging,

Adenocarcinoma

Adenocarcinomas represent 38% of all lung cancers in the United States.63, 75 The 2011 IASLC/ATS/ERS lung adenocarcinoma classification recommends multiple major changes (see Box 1).5, 7, 9, 19 First, it is recommended to no longer use the term BAC because the tumors formerly classified under this term are now classified into 5 different tumors. Second, there are new concepts of AIS (see preinvasive lesions) and MIA. Third, it is recommended to no longer use the term mixed subtype, but rather

MIA

MIA was introduced as a lepidic predominant tumor measuring 3 cm or less that has 5 mm or less of an invasive component (Fig. 5).5 Limited data suggest patients with MIA have a near 100% 5-year disease-free survival.5, 59 Although few articles use the same criteria,59, 76 multiple studies support this concept77, 78 Most of these cases are nonmucinous, but rarely mucinous cases may occur.5 By CT nonmucinous MIA typically shows a ground-glass nodule with a solid component measuring 5 mm or less.

Adenocarcinoma classification in small biopsies and cytology

For the first time in lung cancer classification formal criteria for diagnosis of lung cancer in small biopsies and cytology were proposed by the new IASLC/ATS/ERS lung adenocarcinoma classification (see Table 1).5 Because 70% of lung cancers present in advanced stages and are unresectable, they are diagnosed in these small specimens. These new criteria were driven by the need to separate adenocarcinoma from squamous cell carcinoma because of the therapeutic implications based on histology.

Small cell carcinoma

SCLC comprises 14% of all lung cancers, and more than 30,000 new cases are diagnosed per year in the United States.63, 75 Approximately two-thirds of SCLC present as a perihilar mass. SCLC typically are situated in a peribronchial location with infiltration of the bronchial submucosa and peribronchial tissue. Bronchial obstruction is usually caused by circumferential compression, although rarely endobronchial lesions can occur. Because the diagnosis is usually established on transbronchial

Large cell carcinoma

Large cell carcinoma comprised 3% of all lung carcinomas in a recent report of the US National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results (SEER) data.75 This finding is a decrease from 9% reported in the SEER monograph for 1983 to 1987.63 The SEER data include unresectable tumors that would have been diagnosed on small biopsies or cytology as well as resected tumors; other recent surgical series also report a frequency of approximately 3%.123, 124 These tumors are mostly

Adenosquamous carcinoma

Adenosquamous carcinoma accounts for 0.6% to 2.3% of all lung cancers153, 154, 155, 156, 157 and it is defined as a lung carcinoma having at least 10% squamous cell and adenocarcinoma by light microscopy.36 Similar to large cell carcinoma enormous confusion has been introduced by use of immunostains. The current WHO definition recognizes this tumor if the 10% of squamous and adenocarcinoma components are diagnosable by light microscopy. This diagnosis should be made only if the adenocarcinoma

Carcinomas with pleomorphic, sarcomatoid, or sarcomatous elements

Sarcomatoid carcinomas comprise 0.3% of all invasive lung malignancies.63 This group of lung carcinomas is poorly differentiated and expresses a spectrum of pleomorphic, sarcomatoid, and sarcomatous elements.158 Pleomorphic carcinomas tend to be large, peripheral tumors that often invade the chest wall and are associated with a poor prognosis.158 Because of the prominent histologic heterogeneity of this tumor, adequate sampling is important and should consist of at least 1 section per

Typical and atypical carcinoid

Carcinoid tumors account for 1% to 2% of all invasive lung malignancies.63 Approximately 50% of patients are asymptomatic at presentation.96, 112, 159 Typical carcinoid (TC) and atypical carcinoid (AC) occur at any age, with an average of 45 to 55 years, and there is no sex predilection. They are the most common lung tumor in childhood.160 Symptoms include hemoptysis in 18%, postobstructive pneumonitis in 17%, and dyspnea in 2% of patients. Paraneoplastic syndromes include the carcinoid

Summary

This article reviews current concepts in pathologic classification of lung cancer based on the 2004 WHO classification of lung tumors and the 2011 IASLC/ATS/ERS classification of lung adenocarcinoma. AIS is now added to the other preinvasive lesions that include squamous dysplasia/CIS, AAH, and DIPNECH. Major changes in lung disease diagnosis have now resulted from the new IASLC/ATS/ERS classification including: (1) the term BAC is no longer used because tumors formerly classified under this

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