Lung cancer is the leading cause of cancer-related death worldwide. Smoking is accepted as the major risk factor, responsible for 70-90% of all cancer cases, although the etiology of lung cancer appears multifactorial with both environmental and genetic factors playing a role. One important reason for the poor outcome of patients with lung cancer is that the disease is commonly diagnosed in advanced stages and therefore often not resectable by surgery. Symptoms of lung cancer are unspecific and dependent on anatomical site and include persistent coughing, hemoptysis, repeated pneumonia and signs of respiratory distress.
Lung cancer can principally be divided into non-small cell carcinoma and small cell carcinoma:
The histology-based classification has gained a significant clinical impact, as molecular testing as well as chemotherapy are guided by the histological subtype.
Non-small cell carcinomas are classified as adenocarcinoma or squamous cell carcinoma based on morphology and the expression of markers of differentiation. In the absent of specific histology and marker expression, the tumor may be classified as large cell carcinoma. Other rare entities include large cell neuroendocrine carcinomas, pleomorphic carcinoma and mixed tumors. Necrosis, hemorrhage and abundant mitotic figures are common features in non-small cell lung carcinomas. As in several other forms of cancer, the infiltration of various inflammatory cells can be prominent and is linked to patient prognosis.
Small cell carcinoma represents the end of the spectrum of poorly differentiated neuroendocrine tumors and is a highly aggressive tumor with an extremely poor clinical outcome independent of stage. Signs of neuroendocrine differentiation can be difficult to visualize and the diagnosis is mainly based on morphological appearance. These tumors are characterized by the proliferation of primitive-appearing relatively small tumor cells of about double or triple the size of an ordinary lymphocyte. The tumor grows in randomly arranged sheets of a homogeneous population of tumor cells separated by thin fibrous septa. Necrosis is extensive and a common feature of these tumors.
Diagnostics of lung cancer subtypes is principally based on morphology, although immunohistochemistry markers are important in the absence of clear features of differentiation. In adenocarcinoma the expression of TTF1 or napsin A is common, whereas squamous cell carcinomas are positive for cytokeratin 5 and 6, p63 as well as p40. Immunohistochemistry also plays an important role to distinguish primary lung carcinomas from lung metastases from other organs.