The document provides an overview of lung neoplasms (tumors), including risk factors, classification, clinical features, diagnosis, and management. Some key points include: - Lung cancer is the leading cause of cancer death in the US, with most patients diagnosed at an advanced stage. Survival depends on several factors like sex, age, and race. - Major risk factors include smoking, age, industrial compounds, pre-existing lung diseases, family history, and viruses. Lung cancers are broadly classified into non-small cell carcinomas and neuroendocrine carcinomas. - Clinical features vary depending on tumor type and location. Diagnosis involves imaging like CT scans, biopsies, and

1. Management of
Lung Neoplasms
Mizan Kidanu
Mar.04/2013

2. Outline
 Introduction
 Risk
factors
 Classification
 Clinical features
 Diagnosis
 Management
 Benign neoplasms

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. 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. 
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

32. 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

33. 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

34. 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

35. 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.

36. 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.

37. 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


38. 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

39. 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%

40. 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%

41. 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.

42. 
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.

43. 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.

44. Diagnosis
◦
◦
◦
◦
◦
CXR
CT scan
Bronchoscopy for central lesions
Peripheral lesions- Needle biopsy
Thoracoscopy / open biopsy

45. 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.

46. 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.

47. 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.

48. 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.

49. 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