{ بسم الله الرحمن الرحيم }

1. { بسم الله الرحمن الرحيم }

2. Non-Malignant Lung Tumors.(Surgical point and cases) Dr.Yasserahmedelsaid ; M.D. Cardiothoracic surgery Air Force Hospital

3. Classification can be confusing :- • Many tumors go by different names • Difficult to define benign vs. malignant • Many benign lesions not truly neoplasms • Classify based on: • Cell Type. • Anatomical location. • Malignant potential.

4. Predominantly located in : *airways. *Parenchyma. *pleura.

5. Carcinoid (bronchial adenoma) Cylindroma (adenoid cystic carcinoma) Mucous gland adenoma Granular cell myoblastoma Mucoepidermoid Carcinoma Papilloma/papillomatosis Bronchial mucous gland adenoma Peripheral nerve sheath tumors Granular cell tumor (Abrikossoff’s tumor) Predominantly located in airways:

6. Papillary adenoma Alveolar adenoma Neurofibroma Meningioma Fibroma Glomus tumor Endometrioma Pseudolymphoma Chondromas (Carney’s triad) Teratoma Pulmonary tumorlets Pulmonary mucinous cystadenoma Pulmonary sugar tumor (epithelioid myomelanocytoma) Primary pleuropulmonary thymoma Heterotopic meningeal proliferations Chemodectoma (paragonglionoma) Minute pulmonary chemodectomas Predominantly located in parenchyma:

7. Hamartoma Leiomyoma/leiomyomatous hamartoma/BML Glomus tumor/glomangioma Chondroma/myxoma/fibromyxoma Pneumocytoma Angiomyolipoma Myelolipoma Cystic fibrohistiocytic tumor Hemangioma/hemangiomatosis Lipoma/lipoblastoma Found in airways or parenchyma:

8. Predominantly located on the pleura: • Adenomatoid tumor of the pleura. • Calcifying fibrous pseudotumor of the pleura. • Solitary fibrous tumor of the pleura.

9. *Pseudotumors.*Pseudoneoplastic pleural changes*

10. Tracheopathiaosteochondroplastica. Inflammatory pseudotumor. Mycobacterialpseudotumor. Post-traumatic pseudotumor. Nodular sarcoidosis. Nodular amyloidosis. Hematoma. Lipoid pneumonia. Rheumatoid granuloma. Wegener’s granulomatosis. Loculated interlobular pleural effusion. Pulmonary infarct. Lymphoid hyperplasia. Pseudotumors:

11. *Pseudoneoplastic pleural changes: • Reactive mesothelial proliferations. • Hyaline pleural plaques. • Diffuse pleural fibrosis.

12. Predominantly located in airways: Papilloma/papillomatosis Bronchial mucous gland adenoma Peripheral nerve sheath tumors Granular cell tumor (Abrikossoff’s tumor) Carcinoid (bronchial adenoma) Cylindroma (adenoid cystic carcinoma) Mucous gland adenoma Granular cell myoblastoma Mucoepidermoid Carcinoma Benign/Borderline Tumors

13. Predominantly located in parenchyma: • Pulmonary mucinous cystadenoma • Pulmonary sugar tumor (epithelioid myomelanocytoma) • Primary pleuropulmonary thymoma • Heterotopic meningeal proliferations • Chemodectoma (paragonglionoma) • Minute pulmonary chemodectomas • Papillary adenoma • Alveolar adenoma • Neurofibroma • Meningioma • Fibroma • Glomus tumor • Endometrioma • Pseudolymphoma • Chondromas (Carney’s triad) • Teratoma • Pulmonary tumorlets

14. Predominantly located on the pleura: • Adenomatoid tumor of the pleura Calcifying fibrous pseudotumor of the pleura • Solitary fibrous tumor of the pleura • Found in airways or parenchyma: • Hamartoma • Leiomyoma/leiomyomatoushamartoma/BML • Glomus tumor/glomangioma • Chondroma/myxoma/fibromyxoma • Pneumocytoma • Angiomyolipoma • Myelolipoma • Cystic fibrohistiocytic tumor • Hemangioma/hemangiomatosis • Lipoma/lipoblastoma

15. Pseudotumors: • Tracheopathia osteochondroplastica • Inflammatory pseudotumor • Mycobacyterial pseudotumor • Post-taumatic pseudotumor • Nodular sarcoidosis • Nodular amyloidosis • Hematoma • Lipoid pneumonia • Rheumatoid granuloma • Wegener’s granulomatosis • Loculated interlobular

16. Classification can be confusing :- • Many tumors go by different names • Difficult to define benign vs. malignant • Many benign lesions not truly neoplasms • Classify based on: * Cell Type. * Anatomical location. * Malignant potential.

17. Some Cases with your kind suggestion for diagnosis..

18. Case #1 • 63 y/old m with a 2 pk/D. for 10 Y. of smoking. • referred for incidental finding on CXR. • Denies cough, sputum, hemoptysis, with non specific, wt loss. • Vitals, exam, and labs are normal.

19. Plain X ray

21. Hamartoma

23. What is the diagnosis?

24. Hamartoma.

25. What is the name of the syndrome characterized by multiple hamartomatous neoplasm's of ectodermal, mesodermal, and endodermal origin? • Carney syndrome • Meigs syndrome • Cowden syndrome • Sill syndrome

26. What is the name of the syndrome characterized by multiple hamartomatous neoplasm's of ectodermal, mesodermal, and endodermal origin? • Carney syndrome • Meigs syndrome • Cowden syndrome • Sill syndrome

27. Hamartoma • Most common benign pulmonary tumor • 5-8% of all Solitary pul. Nodules. • Rarely can have multiple lesions (Cowden syndrome) • >60 yrs • M>F (2-3:1) • Small, well circumscribed, Most < 4 cm • “Popcorn” calcification (25%) • Fat, cartilage, muscle • Any lung zone - 5% endobronchial • Tx: observation – surgical resection. • Sarcomatous transformation has been reported .

28. Case #2 • 37 y/old female non-smoker was referred for hemoptysis. • Intermittent blood-streaked sputum for 2 mo • 2 weeks ago developed foul and purulent sputum • CXR obtained. • Patient was started on antibiotics and referred to us.

29. Past Medical History of 2nd Pneumonia in 4 months, otherwise PMH are unremarkable. • Vital Sing Stable, A febrile. • By exam . There is only dullness to percussion on the right side . • Labs – leukocytosis 13.5; . • otherwise normal.

33. What is the diagnosis?

34. Carcinoid.

35. Which paraneoplastic syndrome is most commonly associated with this tumor? • Lambert-Eaton Myasthenic syndrome • Carcinoid syndrome • Myasthenia gravis • Cushing syndrome • Dooley-Powers syndrome

36. Which paraneoplastic syndrome is most commonly associated with this tumor? • Lambert-Eaton Myasthenic syndrome • Carcinoid syndrome • Myasthenia gravis • Cushing syndrome • Dooley-Powers syndrome

37. Carcinoid • <3% of all pulmonary tumors • Neuroendocrine tumor derived from Kulchitsky cells • Mean age 45 yrs; slightly more common in females • Pulmonary tumors 1-2% of all carcinoids (90% GI) • 80% central – lobar or subsegmental • 20% peripheral – SPNs • Often asymptomatic • Central tumors – hemoptysis, cough, wheezing, atelectasis

38. Carcinoid • Typical carcinoid – low grade • 15% will metastasize. • Atypical carcinoid – intermediate grade • <10% of pulmonary carcinoids • Often locally invasive • Mets to LNs and distant sites in >50% • Small cell carcinoma – high grade

39. Carcinoid • Can produce serotonin, ACTH, somatostatin, bradykinin • Cushing syndrome (ACTH) – 2% • Most common cause of ectopic ACTH secretion • Carcinoid syndrome (serotonin) – rare in pulm tumors • Acromegaly (GH ) • Zollinger-Ellison syndrome in pts with MEN and carcinoids

40. Carcinoid • Approx 25% have areas of calcification on CT • Vascularity not a contraindication to biopsy • Tx: Surgical removal for limited disease • Bronchoscopic removal insufficient • Chemo/XRT limited efficacy • 10 yr survival • Typical 82% • Atypical 56%

41. Case #3 • 10 y/o m was referred for hoarseness slowly progressive over several months • 2 episodes of blood tinged hemoptysis over the last week • PMH is unremarkable • Vitals, exam, labs, and CXR are normal

44. SCC from Papilloma

46. What is the diagnosis?

47. Respiratory Papillomatosis

48. With regards to respiratory papillomatosis, which of the following is true? • The pulmonary nodules associated with this condition frequently demonstrate cavitations • It has been linked to infection with herpes simplex virus. • Most patients with laryngeal papillomatosis will go on to develop lower respiratory lesions • Local recurrence after removal of a lesion is rare

49. With regards to respiratory papillomatosis, which of the following is correct? • The pulmonary nodules associated with this condition frequently demonstrate cavitations • It has been linked to infection with HSV1 • Most patients with laryngeal papillomatosis will go on to develop lower respiratory lesions • Local recurrence after removal of a lesion is rare

50. Papillomatosis • Multiple, recurrent, coarsely lobulated tumors • On epithelial surfaces • Predilection for ciliated/squamous junction • Can present with hoarseness, hemoptysis, airway compromise/atelectasis