Lung ca


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Lung ca

  1. 1. Management of Lung Neoplasms Mizan Kidanu Mar.04/2013
  2. 2. Outline  Introduction  Risk factors  Classification  Clinical features  Diagnosis  Management  Benign neoplasms
  3. 3. Introduction  lung ca is the leading cancer killer in USA (30% of all ca deaths/year)  the 2nd most frequently diagnosed ca in USA  most patients are diagnosed at an advanced stage of disease (80%) - Rx is rarely curative  survival depends on several factors: positive (female sex, younger age, and white race)
  4. 4. Risk factors  Smoking 10 cause of lung cancer risk increases with the number of cigarettes, number of years, & use of unfiltered cigarettes ~25% of all lung ca are not related to smoking > 3000 chemicals in tobaccos but the main carcinogens are polycyclic aromatic hydrocarbons  Age older age
  5. 5.  Industrial compounds asbestos, arsenic, mustard & chromic compounds have multiplicative effect with smoking  Pre-existing lung disease  tuberculosis (scar formation) and COPD  Family Hx  Viral factors (HPV)
  6. 6. Classification (Invasive)  broadly divided into two main groups: (I) Non-small cell ca squamous cell ca adenocarcinoma large cell ca bronchoalveolar ca (II) Neuroendocrine carcinoma (NEC)  typical carcinoid (grade-I NEC) atypical carcinoid (grade-II NEC) large cell type (grade-III NEC) small cell type (grade-III NEC)
  7. 7. Non-Small Cell Lung Carcinoma I. Squamous cell cancer 30-40% of lung cancer most frequently found in men highly correlated with smoking 10 located centrally (peripherally-pulmonary scar) Sx: hemoptysis, dyspnea, bronchial obstruction with atelectasis and pneumonia central necrosis is frequent (air-fluid level)
  8. 8. II. Adenocarcinoma 25-40% of all lung cancer most common type to occur in non-smokers occurs more frequently in females than in males most often located peripherally frequently discovered incidentally on CXR Sx: chest wall invasion or malignant pleural effusion dominate destruction of contiguous lung architecture
  9. 9. III. Bronchoalveolar Carcinoma 5% of all lung cancers (subtype of adenoca) tumor cells multiply and fill the alveolar spaces no evidence of destruction of surrounding lung parenchyma can aerogenously seed other parts radiographic presentations: single nodule, multiple nodules or a diffuse form bronchograms can be seen, unlike with other ca
  10. 10. IV. Large cell carcinoma 10 - 20% of lung cancers may be located centrally or peripherally often admixed with other cell types such as squamous cells or adenocarcinoma can be confused with a large cell variant of neuroendocrine carcinoma (immunohistochemical staining for diagnostic distinction)
  11. 11. Neuroendocrine carcinoma Small cell lung carcinoma 25% of all lung cancers is the most malignant NEC centrally located high mitotic and areas of extensive necrosis immunohistochemical staining (if necessary) leading producer of paraneoplastic syndromes
  12. 12. Clinical Presentation • Manifestation depends on: 1. Histological features 2. Specific tumor location in the lung & relation to adjacent structures 3. Biological features and production of paraneopslastic syndrome 4. Metastasis
  13. 13. Tumor histology  Squamous cell and SCLC frequently arise in main, lobar or 1st segmental bronchi  Adenocarcinomas are often peripheral  Bronchoalveolar ca - solitary nodule, multiple nodules or a diffuse infiltrate mimicking an infective pneumonia
  14. 14. Tumor location  Sx related to the local intrathoracic effects of the 10 tumor can be divided in to 2 groups 1. Pulmonary Sx Cough …… bronchial irritation/obstruction Dyspnea … Wheezing … > 50% of airway obstruction Hemoptysis …. tumor erosion / irritation Pneumonia …. airway obstruction
  15. 15. 2. Non – pulmonary thoracic Pleuritic pain … parietal plural irritation/invasion  Local chest wall pain …. rib and/or muscle invasion  Radicular chest pain …… IC nerve involvement  Hoarseness ……. RLN invasion  Dysphagia …… Esophageal invasion  SVC synd. ........... SVC compression  Hornor’s synd …. ……. Sympathetic ganglion  Pancoast’s synd. ……. C8 - T2 invasion  Pericarditis/ Tamponade … pericardial invasion  Diaphragmatic paralysis …. Phrenic N. involvement 
  16. 16. Biological features  NSCLC & SCLC can produce paraneoplastic syndrome  Most often from tumor production and release of biologically active compounds  SX usually abate following treatment of the tumor
  17. 17. Metastatic disease  Lung cancer metastases occur most commonly to: CNS bone liver adrenal glands lungs skin, and soft tissues • Non specific  anorexia, wt loss, fatigue, malaise – metastasis
  18. 18. Diagnostic workup  Assessment of primary tumors 1. Hx and P/E questions regarding presence/absence of pulmonary, nonpulmonary thoracic Sx,… cervical / supraclavicular LAP,…. 2. Laboratory CBC LFT and RFT Serum electrolyte
  19. 19. 3. Sputum cytology  least invasive  together with bronchoscopy guided bronchial brushing and lavage - specific Dx in 90% of pts  bigger and central tumors - positive Dx
  20. 20. 4. PA and lateral CXR tumor <1cm not visible on CXR finding on CXR atelectasis discrete mass / multiple nodules mediastinal, hilar and paratracheal masses raised diaphragm pleural effusion osteolytic vertebral / rib lesion
  21. 21. 5. Chest CT scan assessment of the I0 tumor and its relationship to the surrounding structures mediastinal and chest wall involvement metastatic spread to the mediastinal lymph nodes 6. Bronchoscopy visualization of the bronchial tree dx tissue collection by brushing and washing for cytology direct forceps biopsy of visualized lesion FNAC
  22. 22. 7. Transthoracic needle biopsy ideally used for peripheral tumors under imaging guidance (CT, U/S or fluoroscope) I0 complication is pneumothorax (50% patients) 8. MRI little advantage over CT used to define tumor relation to major vascular structures
  23. 23. 9. Thoracoscopy, mediastinoscopy & mediastinotomy 10.Thoracotomy  in < 5% of pts  a deep seated lesion with an indeterminate needle biopsy result or can’t be biopsied due to technical reasons
  24. 24. Assessment   of distant metastasis found in 40% of newly diagnosed lung cancer may imply inoperability Hx  Presence of: recent bone pain neurological Sx new skin lesions constitutional Sx P/E G/A with wt loss + muscle wasting cervical & supraclavicular LNs skin lesions
  25. 25. CT and multiorgan scanning adrenal enlargements, nodules, or masses-by MRI and S/times by needle biopsy multiorgan scanning – not routinely indicated regionally advanced ds (stage II, IIIa and IIIb) pts with a positive clinical sign
  26. 26. Assessment of functional status Hx can the pt walk on a flat surface indefinitely? can the pt walk up 2 flights of stairs ? current smoking status and sputum production P/E signs of COPD or air flow limitation use of accessory muscles. fullness of breath sounds
  27. 27. Pulmonary Function Test  routinely performed when any resection other than wedge resection is considered >2.0 L can tolerate pneumonectomy >1.0 L can tolerate lobectomy
  28. 28. TNM description for staging of non-small cell lung cancer Primary tumor (T) T0 – No evidence of primary tumor Tis – Carcinoma insitu T1 – Φ ≤ 3 cms T2 – Φ > 3cms or any size with invasion of visceral pleura, athelectasis or obst. Pneumonia T3 – Extension to pleura, chest wall, diaphragm, pericardium, within zone of carina or total atelectasis T4 – Invasion of the mediastinal organs (e.g. esophagus, trachea, great vessels, heart); malignant pleural effusion, or satellite modules with in the primary tumor lobe
  29. 29. Nodal involvement (N) N0 – no demonstrable metastasis to regional LN. N1 – Ipsilateral bronchopulmonary or hilar LN involvment. N2 – Ipsilateral mediastinal or subcarinal LN. N3 – contra lateral modiastinal, hilar, and ipsilat or contra lateral scale or supraclavicular LNS Distant metastasis (m) M0 - No metastasis M1 - metastasis in distant sites.
  30. 30. Stage grouping Stage IA IB IIA IIB IIIA IIIB IV T1N0M0 T2N0M0 T1NIM0 T2NIM0 or T3 N0M0 T1 – 3 N2M0 or T3NIM0 T4 Any NM0 or AnyT N3M0 Any T, Any N M1
  31. 31. Staging for small cell lung cancer  Limited stage disease confined to one hemithorax, includes involvement of madiastinal, contra lateral hilar, and/or supraclavicular and scalene LN, malignant pleural effusion is excluded.  Disseminated (extensive) stage disease has spread beyond the definition of a limited stage or malignant pleural effusion is present
  32. 32. Treatment of lung cancer : NSCLC I. Early Stage disease    stages I and II represents a small proportion of pts diagnosed with lung cancer each year (15%) current standard treatment is surgical resection by lobectomy, or pneumonectomy depending on T location
  33. 33. Pancoast’s Tumor (apical) • resection preceded by mediastinoscope • Rx is multimodal approach with radiation playing a central role • Induction radiation followed by surgery after 4-5 weeks.  For pts deemed medically unfit for major pulmonary resection options include - Limited surgical resection - Definitive radiation (30% survival for stage I disease)  Role of chemotherapy in early stage NSCLC is evolving
  34. 34. II. Locoregional advanced disease • Stage IIIa disease • Surgical resection as a sole Rx has a limited use • T3N1 can be Rx with surgery alone (5 yr survival • • 25%) Definitive Rx of stage III ds (when surgery is not feasible). A combi of chemo and radiotherapy. 2 strategies for delivery • “Sequential” – full dose chemo (i.e. ci splatinum combined with a 2nd agent) followed by radiation therapy. • Improves survival 17% Vs 6% with radiotherapy alone) • “ concurrent” chemo radiation” adm. at the same time.
  35. 35. Preop (induction) chemotherapy for NSCHC • Chemotherapy before surgical resection has a number of potential:  Advantages  the Ts blood supply is still intact  10 tumor may be down staged with high respectability.  better tolerated by pts before surgery  responders are identified thereby add treatment is tailored.  systemic micro metastases are Rx ed.  Disadvantages   high periop complication rate definitive surgical Rx may be delayed.
  36. 36. III. Advanced (metastasis) diseases inoperable  cisplatinum based chemo + radiotherapy  Indications of radiotherapy early lung cancer in unfit pts.  advanced lung ca  Pancoast’s tumor  postop adjuvant therapy  palliation of hemoptysis inoperable cases  bone metastasis 
  37. 37. Management of small cell carcinoma  95% of pts SCLC are treated – non – surgically  Management of limited stage SLLC = chemotherapy + radiotherapy  It pts achieve complete remission = prophylactic cranial irradiation.  Extensive stage SCLC remains incurable with current + Mx options pts treated with combination chemotherapy
  38. 38. Prognosis Median survival is only a little over 1year  Prognosis following resection depends on disease stage and cell type  5 year and 1year survival  Disease stage Stage I  Stage II  Stage IIIa  5 year survival 55 – 80 % 35 – 50 % 5 – 35 % 1 year survival Stage IIIb  Stage IV  < 20% < 15%
  39. 39. Cell type • 5 year survival according to cell type: Cell type squamous cell ca  adenocarcinoma  adenosquamous carcinoma  undifferentiated carcinoma  small cell carcinoma  5 year survival 35 - 50 % 25 - 45 % 20 - 35 % 15 - 25% 0-5%
  40. 40. Benign pulmonary tumors  Primary or metastatic cancers make up ~ 97% of all pulmonary tumor.  Benign tumors, are therefore, a relatively small fraction (2-5%) of all lung tumors  Their exact incidence is not known because benign tumors are often asymptomatic and are only detected during autopsy.  The significance of these tumors is almost exclusively related to their differential diagnosis from malignancies.
  41. 41.  Affect men more frequently than women.  Mean age of 56.2 years for all types.  Etiology: unknown.  Adenomas and hamartomas constitute the largest group (90%) of benign lung tumors.  The diagnostic and treatment approach of all benign tumors is basically the same.
  42. 42. Presentation  Mode of presentation depends on location and size.  Most lesions are peripheral, hence are asymptomatic.  When central (in a major bronchus): they may cause obstruction and present with the effects of chronic infection, atelectasis or hemoptysis.
  43. 43. Diagnosis ◦ ◦ ◦ ◦ ◦ CXR CT scan Bronchoscopy for central lesions Peripheral lesions- Needle biopsy Thoracoscopy / open biopsy
  44. 44. Radiology: Benign lung tumors  A lung mass with: ◦ Symmetrical Calcification ◦ Absence of growth ◦ "Popcorn" type ◦ Well defined margins and Lobulation COMPARE WITH OLD X/RAYS.
  45. 45. Non-surgical management  A solitary asymptomatic benign pulmonary tumor in a young non-smoking patient can be monitored with serial radiographs as long as the solitary nodule does not: ◦ Double in size in less than a year ◦ Significantly increase in the pattern of calcification or shape consistent with a malignancy.
  46. 46. Surgical intervention: Indication • The purpose of surgical intervention for benign lung tumors is: • to avoid missing potentially malignant lesions. • To treat significant symptomatology. • indicated by the presence of complications such as pneumonia, atelectasis, and/or severe hemoptysis.
  47. 47. Surgical options  The extent is usually determined at surgery and is as conservative as possible. 1. 2. Simple endoscopic resection Thoracotomy with ◦ local wedge excision ◦ segmental resection, or ◦ lobectomy.
  48. 48. References 1. Schwartz’s: Principles of surgery, 9th ed 2. Washington: Manual of Oncology, 1st ed 3. Sabiston: Text book of surgery, 18th ed 4. Bailey & Love’s: Short practice of surgery, 25th 5. Shield: General Thoracic surgery