TUMOR PARU - lung tumor neoplasm Copy.pptx

TUMOR PARU - lung tumor neoplasm Copy.pptx
TUMOR PARU - lung tumor neoplasm Copy.pptx
TUMOR PARU - lung tumor neoplasm Copy.pptx
TUMOR PARU - lung tumor neoplasm Copy.pptx
TUMOR PARU - lung tumor neoplasm Copy.pptxTUMOR PARU - lung tumor neoplasm Copy.pptxTUMOR PARU - lung tumor neoplasm Copy.pptx
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1. SOLITARY PULMONARY NODUL D idefinisikan sebagai opasitas paru soliter , berbatas tegas tanpa kelainan paru, pleura, atau mediastinum. Ukuran diameter < 3 cm . Banyak ditemukan secara kebetulan (40% mungkin ganas) . <10% disebabkan oleh metastasis paru . Nodul dengan kalsifikasi , biasanya jinak .

2. Benign intrapulmonary lymph node s ( subpleural nodules / Perifissural nodules ) : <15 mm dari permukaan pleura, berbentuk elips , terhubung ke permukaan pleura dengan opasitas linier halus . Ground-glass nodules / subsolid nodules : Bentuk awal adenokarsinoma . Ground glass density : peningkatan atenuasi paru fokal , dimana struktur normal masih dapat dilihat . Pure ground glass nodule : tidak mengandung komponen jaringan lunak . Part solid ground-glass nodul e : komponen solid yang menutupi struktur paru-paru . Nodul ground glass ( atau nodul mix- solid dan ground glass) lebih ganas dibandingkan nodul solid.

3. Typical perifissural nodule (blue arrow) attached to the oblique fissure (yellow arrows). 

4. Partly solid lesions with ground-glass components had a malignancy rate of 63%. Nonsolid - only ground-glass lesions had a malignancy rate of 18%. Only solid lesions had a malignancy rate of only 7%.

5. The lesion on the far left has a spicuated margin and has lucencies within it. The lesion next to it is lobulated in contour and has some spicules radiating to the pleura. It is however homogeneous in attenuation. Based on these findings we should be most concerned that the lesion on the far left is malignant. It proved to be an adenocarninoma , while the other one was a fungal infection. The lucencies and frank air bronchograms should not mislead you in thinking that it probably is infection.

6. Partly solid nodule containing ground-glass component most likely to be malignant

7. Differential diagnosis N EOPLASTIC Malignant bronchogenic carcinoma solitary pulmonary metastasis lymphoma carcinoid tumors bronchial carcinoid tumor peripheral pulmonary carcinoid tumor B enign pulmonary hamartoma pulmonary chondroma primary pulmonary meningioma - rare I NFLAMMATORY granuloma lung abscess rheumatoid nodule Pulmonary inflammatory Pseudotumor: Plasma cell granuloma small focus of pneumonia: round pneumonia C ONGENITAL arteriovenous malformation lung cyst bronchial atresia with mucoid impaction M ISCELLANEOUS pulmonary infarct intrapulmonary lymph node mucoid impaction pulmonary hematoma pulmonary amyloidosis normal confluence of pulmonary veins Mimics nipple shadow cutaneous lesion (e.g. wart, mole) rib fracture or other bone lesion

8. BENIGN MALIGNANT Rate of growth/ stability over time benign lesions invariably have a doubling time of > 18 months bronchial carcinomas usually have a doubling time of between 1 and 18 months bronchoalveolar carcinomas are an exception in that they may have very slow growth rates) Attenuation/ enhancement a dense central nidus or lamellated calcification indicates a granulomatous process (e.g. tuberculosis, histoplasmosis) a lack of enhancement (<15HU) following IV contrast medium is indicative of benignity irregular ‘popcorn’ calcification suggests a pulmonary hamartoma, is benign. Intra- lesional fat , suggestive of hamartoma or lipoid granuloma, is benign. Granular calcification is seen on CT in up to 7% of carcinomas (and can represent either tumour calcification or a granuloma engulfed by tumour ) A mixture of soft tissue and ground-glass attenuation nodules is more likely to be malignant than soft tissue nodules alone Calcification, which is eccentric or stippled within an area of soft-tissue density, may be seen in malignancy DIFFERENTIATION BETWEEN BENIGN AND MALIGNANT MASSES

9. BENIGN MALIGNANT P atient’s age carcinoma is only seen in < 1% of patients < 35 years old patients > 35 years old Size Small nodules are usually benign. most benign nodules are <2 cm Large size is the single most important risk factor for malignancy . A nodule <3 mm has a 0.2% chance of being cancer and a 4–7 mm nodule is malignant in 2.7% of cases. regardless of morphology: 0.8 to 3 cm nodules have 18% risk of being lung cancer and masses >3 cm have a very high chance of being malignant. Margins/Shape a well-defined mass with a smooth pencil sharp margin is likely to be benign Non-round shape, including oblong, polygonal, triangular, or geometric is probably benign. carcinomas typically have ill-defined margins which are irregular, spiculated , or lobulated and may exhibit umbilication or a notch – unfortunately all these features can be seen with benign disease Round shape (as opposed to oblong) is suggestive of malignancy.

10. BENIGN MALIGNANT M orphology Central, laminated, and diffuse calcification are almost always benign. Lobulated nodules are more likely to be malignant Suggestion Subpleural location is often benign. Clustering of nodules suggests an infectious process. A nodule that has not changed in size over 2 years is very likely, but not definitely, benign. A cavitary nodule or nodule containing small cystic spaces is suspicious for malignancy . Any interval nodule growth is suspicious. Doubling time for lung cancers ranges from 42 days in very aggressive tumors to over 4 years in indolent lesions such as bronchioloalveolar carcinoma.

11. Japanese screening studies showed that a polygonal shape and a three-dimensional ratio > 1.78 was a sign of benignity. A peripheral subpleural location was also a sign of benignity in this study. The three-dimensional ratio is measured by obtaining the maximal transverse dimension and dividing it by the maximal vertical dimension. A large three-dimensional ratio indicates that the lesion is relatively flat, which is a benign sign.

12. Recent studies have showed that an air bronchogram is more commonly seen in malignant pulmonary nodules. It is most commonly seen in BAC (bronchoalveolar cell carcinoma) and adenocarcinoma.

13. Hamartoma Are benign neoplasms composed of cartilage, connective tissue, muscle, fat, and bone. It is one of the most common benign tumors of the lung Patients usually present in the 4 th and 5 th decades of life and they are very uncommon in children. There is a recognized male predilection (M:F = 2.5:1). Most lesions are diagnosed incidentally. The vast majority of pulmonary hamartomas are located peripherally within the lungs (>90%), with endobronchial hamartomas representing only ~5% (range 1.4-10%) of such lesions

14. Bronchial carcinoid Most (~60%) tend to be central within the tracheobronchial tree ; the vast majority of which arise from the central bronchi, rarely from the trachea. Typically affects patients from 3 rd to 7 th decades with the mean age around 45 years Associated with Cushing syndrome. Typical (90%): these commonly arise within the central airways ▸ they demonstrate benign behaviour . Atypical (10%): these usually arise within the lung periphery ▸ their histological and clinical features are intermediate between a typical bronchial carcinoid and a small cell carcinoma of the lung.

15. A circumscribed density is seen projected over the right main bronchus on the frontal view. The margins of the mass are clearly seen indicating that it is in contact with air and is likely to be endobronchial (silhouette sign).  An ovoid well-circumscribed polypoidal endobronchial mass is seen within the right main bronchus, bulging slightly into the right upper lobe bronchus. No internal calcification, fat density, or necrosis is seen. It shows mild homogeneous enhancement on post contrast scans. There is no associated atelectasis or collapse of the right lung.

16. Granulomas Tuberculosis and histoplasmosis usually produce calcifed nodules less than 1 cm in size, although tuberculomas and histoplasmomas can reach up to 4 cm. When calcifed , they are clearly benign. Tuberculous granulomas are usually homogeneously calcifed . Histoplasmomas may contain a central or “target” calcification or may have a laminated calcifcation , which is diagnostic.

17. Kanker Paru Kanker paru-paru adalah keganasan fatal yang paling umum pada pria dan wanita. Di Amerika Serikat, kanker paru-paru menyumbang 13% sampai 15% dari semua kanker baru dan 26% hingga 30% dari semua kematian akibat kanker. Jumlah kanker paru-paru yang didiagnosis setiap tahun kemungkinan akan meningkat karena skrining CT tersedia secara luas dan lebih banyak kanker terdeteksi . SCLC: small cell lung carcinoma =15% Berasal dari sel neuroendokin submukosa Menyebar cepat secara hematogen dan ke kelenjar getah bening . Sebagai penyakit sistemik NSCLC: non-small cell lung cancer = 85% Squamous cell carcinomas: berasal dari epitel proksimal saluran nafas . Large cell carcinomas: sel atipikal yang berukuran besar pada mikroskop , usually >4 cm Adenocarcinoma: tipe yang paling sering , berasal dari kelenjar bronkial .

18. Faktor risiko Merokok menyebabkan 80-90% kanker paru-paru. Hampir semua kasus Squamous cell carcinomas dan small cell carcinoma terjadi pada perokok. Adenokarsinoma juga dikaitkan dengan merokok . Tetapi karsinoma bronkogenik primer yang timbul pada bukan perokok dan tanpa riwayat pajanan rokok hampir selalu terjadi pada kasus adenokarsinoma. Paparan pekerjaan dan lingkungan, termasuk berilium, radon, arsenik, dll., merupakan faktor risiko penting untuk kanker paru-paru. Paparan asbes meningkatkan risiko kanker paru-paru sebanyak 5x . Fibrosis paru meningkatkan risiko kanker paru-paru sebanyak 10x . Jaringan parut paru, seperti dari TB sebelumnya, juga meningkatkan risiko kanker paru-paru.

19. Gejala Klinis Asimptomatik (25%): tumor perifer tanpa gejala lebih mungkin ditemukan secara kebetulan dan dapat dioperasi Gejala : Pneumonia berulang , Batuk , Hemoptisis Sindrom paraneoplastik: gangguan sekresi ADH ( Sindrom Cushing (ACTH) , sindrom karsinoid , hiperkalsemia (PTH) Fitur prognostik yang buruk: suara serak , nyeri dada , neuropati pleksus brakialis atau sindrom Horner (karena tumor Pancoast) , Obstruksi SVC , Disfagia

20. Schema of central and peripheral locations. This diagram showed definition of central, peripheral and apical location of lung tumor. Tumors located at proximal bronchial tree (according to the Radiation Therapy Oncology Group) defined as centrally located tumor, tumor located above aortic arch defined as apically located tumor, and others defined as peripherally located tumor.  Clinical outcome of fiducial-less CyberKnife radiosurgery for stage I non-small cell lung cancer

21. Central tumours Peripheral tumours Collapse or consolidation can be seen peripheral to the tumour (due to bronchial narrowing ± hilar enlargement) ▸ any peripheral collapsed lung will enhance more than a central tumour . The majority are spherical or oval in shape ▸ lobulated masses can occur due to uneven growth rates ▸ there may be a ‘corona radiata’ due to numerous fine strands radiating into the lung Golden S’ sign : a fissure may show a central bulge due to collapse around a central tumor Cavitation with irregular thick walls (≥8 mm) ± fluid levels (particularly squamous tumors) Air bronchograms are rare but can be seen with adenocarcinoma

22. Small cell lung carcinoma (SCLC), juga dikenal sebagai oat cell lung cancer , adalah subtipe karsinoma bronkogenik yang dipisahkan dari non-small cell lung cancer (NSCLC) karena memiliki presentasi, penampilan pencitraan, pengobatan, dan prognosis yang unik. Small cell lung carcinoma adalah tumor neuroendokrin paru-paru yang tumbuh dengan cepat, sangat ganas, bermetastasis luas, dan, meskipun menunjukkan respons awal terhadap kemoterapi dan radioterapi, memiliki prognosis yang buruk dan biasanya tidak dapat direseksi. Metastasis yang paling umum 19-38% ke tulang , 17-34% ke liver, 10-17% ke kelenjar adrenal dan 14% ke otak .

23. Karena 90% -95% SCLC muncul dari lobar atau bronkus utama, manifestasi SCLC yang paling umum adalah massa besar , central di dalam parenkim paru (atau massa mediastinum yang melibatkan setidaknya satu hilus. SCLC yang berlokasi di central dapat menyebabkan atelektasis baik lobus atau seluruh paru-paru . Sebagian besar SCLC terletak di bagian tengah paru dan bermanifestasi sebagai limfadenopati mediastinum (92% kasus) atau hilus (84%). CT dengan kontras dapat berguna untuk melihat tingkat invasi mediastinum T rakea, esofagus, jantung , dan pembuluh darah, termasuk vena cava superior ditemukan pada sekitar 68% pasien. Kalsifikasi intratumoral telah dilaporkan hingga 23% pasien .

24. CXR demonstrates a large opacity in the right upper zone consistent with collapse of the right upper lobe  secondary to a hilar mass . Note the hyperlucency of the hyperexpanded right lower and middle lobe, and elevation of the right hemidiaphragm, either due to volume loss or less likely phrenic nerve paralysis . Juxtaphrenic peak sign also present. Although not particularly S shaped, the collapse of the right upper lobe and a hilar mass are the components of Golden's S sign . 

25. SCLC involving the left chest wall in a 69-year-old woman. (a) Well-collimated contrast-enhanced CT image shows a large tumor in the left upper lobe (arrows) invading the adjacent chest wall ( * ). (b) Well-collimated contrast-enhanced CT image shows pathologic left hilar l ymphadenopathy (arrow) and occlusion of the left upper lobe bronchus (arrowhead).

26. 1. Low cervical, supraclavicular and sternal notch nodes Superior mediastinal nodes 2. Upper Paratracheal : above the aortic arch, but below the clavicles. 3A. Pre-vascular : nodes not adjacent to the trachea like the nodes in station 2, but anterior to the vessels. 3P. Pre-vertebral : nodes not adjacent to the trachea, but behind the esophagus, which is prevertebral (3P). 4. Lower Paratracheal (including Azygos Nodes): below upper margin of aortic arch down to level of main bronchus. 5. Subaortic (A-P window): nodes lateral to ligamentum arteriosum. These nodes are not located between the aorta and the pulmonary trunk, but lateral to these vessels. 6. Para-aortic (ascending aorta or phrenic): nodes lying anterior and lateral to the ascending aorta and the aortic arch. Subcarinal nodes 7. Subcarinal . 8. Paraesophageal (below carina). 9. Pulmonary Ligament : nodes lying within the pulmonary ligaments. 10-14. N1-nodes : these are located outside of the mediastinum.

27. N1-nodes are ipsilateral nodes within the lung up to hilar nodes. N2-nodes represent ipsilateral mediastinal or subcarinal lymphadenopathy. N3-nodes represent contralateral mediastinal or contralateral hilar lymphadenopathy or scalene or supraclavicular nodes.

28. For a tumor in the right lung the N-stages are: N1: Ipsilateral peribronchial and/or hilar lymph nodes 10R-14R N2: Ipsilateral mediastinal and/or subcarinal lymph nodes 2R, 3aR, 3p, 4R, 7, 8R, 9R N3: Contralateral mediastinal and/or hilar, as well as any supraclavicular lymph nodes 1, 2L, 3aL, 4L, 5, 6, 8L, 9L, 10L-14L For a tumor in the left lung the N-stages are: N1: Ipsilateral peribronchial and/or hilar lymph nodes 10L-14L N2: Ipsilateral mediastinal and/or subcarinal lymph nodes 2L, 3aL, 4L, 5, 6, 7, 8L, 9L N3: Contralateral mediastinal and/or hilar, as well as any supraclavicular lymph nodes 1, 2R, 3aR, 3pR, 4R, 8R, 9R, 10-14R

29. THANK YOU