Lung cancer is the most common malignant disease and cause of cancer deaths. Smoking is the primary risk factor, with cigarette smokers 8-20 times more likely to develop lung cancer than non-smokers. Other occupational exposures like asbestos, radon, and chemicals used in mining and metal refining can also increase lung cancer risk. Symptoms often do not appear until the cancer has spread, with cough, breathlessness, and chest pain being common complaints at diagnosis. Treatment depends on the cancer type and stage but may involve surgery, chemotherapy, radiation therapy, or a combination of these. Prognosis is generally poor but prevention through smoking cessation can significantly reduce lung cancer risk.

1. Dr. Manu Mohan. K
Asst. Professor
Pulmonary Medicine

2.  Most common form of malignant diseases
 40,000 new patients per year
 8% male deaths and 4% of all female
deaths
 Men > women, middle age

3.  Tobacco smoking
 Cigarette smokers are 8-20 times more
likely to develop lung cancer than life
long non smokers.
 Squamous and small cell carcinoma
have clear association with smoking.
 Adenocarcinoma is commonest
histological type in a non smoker

4.  Controversial
 Radon - radiation

5.  Asbestos – mining, processing, usage.
 Radioactivity – metal ore mining, uranium
mining.
 Nickel – refining.
 Chromium salt – extraction, production,
usage.
 Arsenic – metal refining, chemical industry,
insecticides.

6.  Localised areas of pulmonary scarring
 Diffuse pulmonary fibrosis
 Cryptogenic fibrosing alveolitis is
associated with adenocarcinoma
 Tuberculosis – scar carcinoma,
adenocarcinoma
 Bronchioloalveolar carcinoma also occur
in areas of scarring

7. 1. Squamous cell carcinoma (epidermoid
carcinoma)
2. Small cell carcinoma
a. oat cell carcinoma
b. intermediate cell type
c. combined oat cell
carcinoma

8. 3. Adenocarcinoma
a. acinar
b. papillary adenocarcinoma
c. bronchioloalveolar
d. solid carcinoma with mucous
4. Large cell carcinoma
5. Adenosquamous carcinoma

9. 6. Carcinoid tumours
7. Bronchial gland carcinoma
a. adenoid cystic carcinoma
b. mucoepidermoid carcinoma
c. others

10.  Polypeptides that take part in the control of
cell differentiation and proliferation
 Bombesin/gastrin releasing peptide –
growth factor for small cell carcinoma
 Non small cell carcinoma – few growth
factors are recognized, EGF, TGF

11.  Loss of short arm of chromosome in small
cell carcinoma (p14, p23)
 CDKN2 gene on chromosome 9 – Non
small cell lung carcinoma

12.  myc genes – small cell lung carcinoma
 Kras – adenocarcinoma

13.  Substances produced by tumour cells
that are released in to blood stream.
 Neuron specific enolase, creatinine
phophokinase BB, CEA

14.  Worsening of preexisting respiratory state.
 No symptoms, detected by the chance
of finding an opacity.
 Nonspecific symptoms of malignancy like
malaise, anorexia, and weight loss
 Metastatic disease

15.  Cough – most common symptom
 New cough that persists longer than 2
weeks in a patient of 40 years who is a
smoker.
 Hemoptysis – usually streaky
 Breathlessness – due to central airway
narrowing, partial or total collapse of a
distal segment
 Chest pain – deep chest discomfort, due
to peribronchial and perivascular nerve
involvement.

16.  Cough and hemoptyis
 Bronchorrhoea
 Dyspnoea
 Chest pain

17.  Skeletal metastasis – bone pain,
pathological fractures
 Cerebral metastasis – progressive
neurological symptoms

18.  Frequently no abnormal findings
 Hoarseness
 Bovine cough
 Clubbing
 HPOA

19.  Lymphatic involvement – scalene and
supraclavicular
 Axillary lymph nodes due to chest
invasion
 Stridor, wheezes

20.  Atelectasis
 Pleural effusion
 SVC obstruction
 Diaphragm palsy
 Enlarged liver
 Raised intracranial pressure
 Dysphagia

21.  Chest radiography
 Nearly always abnormal

22.  Collapse
 Pleural effusion
 Elevated hemi diaphragm
 Widening of mediastinum
 Lymphangitis carcinomatosa
 Pneumonic shadow – bronchioloalveolar
carcinoma
 Pancoast tumour

23.  Opacity of less than 3 cm without
surrounding atelectasis and or
adenopathy.
 Doubling time
 Calcification

24. Solitary pulmonary nodule

25.  Sputum cytology – more yield in
central tumours
 60-70% positive yield in experienced
hands
 Single sample – 40%
 4 samples – 80%

26.  Bronchoscopy – most useful for central
tumours
 Tumours beyond bronchoscopic view
– Transbronchial needle biopsy, blind
brushing and washing

27.  Percutaneous needle biopsy
 Aspiration of subcutaneous swelling
 Pleural fluid study
 Thoracoscopic lung biopsy
 Mediastinoscopy
 Thoracotomy

28.  TNM staging
 Primary tumour (T)
 Tx, T0, T1s, T1, T2, T3, T4
 Nodal involvement (N)
 N0, N1, N2, N3.
 Distant metastasis (M)
 M0, M1

29. Small cell lung carcinoma
 Limited
 Extensive

30. Non small cell lung carcinoma
 Surgery – best result, but only a small
minority
 Types of surgery
 Pneumonectomy
 Lobectomy
 VATS – segmentectomy
 5 year survival rate overall 35%

31. Radiotherapy
Stage I&II – inoperable due to medical
contraindications
Indications
 Hemoptysis, pain, cough, dyspnoea due
to large bronchus obstruction,
mediastinal compression, symptoms due
to intracranial metastasis, symptoms due
to spinal cord compression.

32. Endobronchial treatment
 Laser therapy
 Endobronchial radiotherapy
 Photodynamic therapy
Chemotherapy
 Poor response to chemotherapeutic
agents
 Combined modalities

33.  At presentation 70% have extensive
disease
 Chemotherapy
 More sensitive to chemotherapy
 Combined therapy preferred than
monotherapy

34.  Radiotherapy
 Primary tumour control
 Prophylatic cranial irradiation
 Surgery

35.  Non metastatic
metabolic/neuromuscular
manifestations
 Hypercalcemia
 SIADH
 Ectopic ACTH
 HPOA

36.  Gynaecomastia – large cell and adeno
carcinoma
 Eaton-Lambert syndrome,
polymyositis/dermatomyositis
 Peripheral neuropathy
 Cerebellar ataxia

37.  Small cell carcinoma
 Diagnosis – swelling of face and upper
torso and distension of veins across the
chest, upper arms and neck.
 Treatment – chemotherapy,
radiotherapy and stenting

38.  Pancoast
 Pain in lower part of shoulder and
inner aspect of the arm (C8, T1 and T2)
 Sympathetic ganglion involvement –
stellate
 Diagnosis
 Treatment - radiotherapy and surgery

39.  Primary prevention
 Stop smoking

40. Mediastinum lies centrally within the
chest and spans the region vertically
from the thoracic inlet to the
diaphragmatic hiatus, transversally
between the parietal pleura, and
coronally between the sternum and
vertebral column.

41. 3 compartments
Anterior compartment
Middle compartment
Posterior compartment

45. Structures Common
lesions
Rare lesions
Ascending
aorta
Thymomas Vascular
lesions
Superior
vena cava
Lymphomas Mesenchymal
tumors
Azygos vein Germ cell
tumours
Endocrine
tumours

46. Thymus
gland
Lymph
nodes
Transverse
and great
vessels
Connective
tissue

47. Structures Common
lesions
Rare
lesions
Heart and
Pericardium
Foregut cysts Pleural and
pericardial
cysts
Trachea and
bronchi
Lymphatic
tumours
Neuroenteric
and
gastroenteric
cysts

48. Structures Common
lesions
Rare
lesions
Sympathetic
chain
Tumours of
Neurogenic
origin
Vascular
tumour
Vagus nerves Mesenchyma
l tumours

49. Thoracic
duct
Lymphatic
lesions
Lymph
nodes
Descending
aorta
oesophagus

50. Symptoms Mechanisms
cough Airway narrowing,
compression
Chest pain Chest wall invasion,
neural invasion
Dyspnoea Airway compromise,
pericardial tamponade,
pleural effusions,
pulmonary stenosis,
heart failure.

51. Hemoptysis Bronchogenic
carcinoma, airway
invasion, pulmonary
stenosis, heart failure
Dysphagia Oesophageal
narrowing/obstruction,
oesophageal motor
dysfunction
Hoarseness Vocal cord paralysis
Facial swelling Superior vena cava
syndrome

52.  Adults
65% in Anterosuperior, 10% in the
middle and 25% in the posterior
compartments
 Children
28% Anterosuperior, 10% in middle,
62% in the posterior compartment

53. • Noninvasive diagnostic procedures
• Computed tomography
• Magnetic resonance imaging
• Ultrasonography
• Radio nuclides

54. Biochemical Markers
AFB, HCG – nonseminomatous germ cell
tumour, Teratoma, Carcinoma
 CEA
 Catecholamines,vanillylmandelic acid,
homovanillic acid –
Pheochromocytoma
 Nor epinephrine, epinephrine –
paraganglioma,ganglioneuroma,
neuroblatoma

55. Invasive biopsy procedures
FNAB
Surgical procedures

56. • Substernal Goiter
• Cystic Hygroma
• Lesions originating from thoracic
skeleton
• Vascular lesions
• Oesophageal lesions
• Pulmonary lesions
• Sub diaphragmatic Lesions

57. Well established
 Myasthenia gravis
 Pure red cell aplasia
 Acquired hypogammaglobulinemia
 Non Thymic cancers

58. Less well established
 Pancytopenia
 Lambert-Eaton
 Peripheral neuropathies
 CNS changes
 Multiple endocrine defects
 Multiple rheumatologic disorders
 Nephrotic syndrome

59.  Thymoma is the most common primary
neoplasm of the mediastinum
 15% of Thymic lesions
 Equal frequency in male and female
 40-60 years
 75% in anterior mediastinum
 More than 90% are visible on chest
radiograph

60.  Surgical resection
 Radiotherapy
 Unresectable, recurrent or metastatic
Thymoma- chemotherapy

61.  Lymphomas
› 10-14% of mediastinal tumours
› rare in posterior mediastinum
› Hodgkin’s and Non Hodgkin’s
› 20-30% asymptomatic
› 60-70% symptoms of local invasion
› 30-35% systemic symptoms

62.  Non-Hodgkin’s lymphoma
› 5% with mediastinal involvement
› Large irregular anterior and superior
mediastinal involvement
› Radiation therapy effective in low grade
lymphoma
› chemotherapy

63.  Benign and malignant

64.  Constitute 70% of the lesions in children
and 60% in adults.
 Contain multiple tissues that are foreign
to the part of the body in which they
develop.
 Symptomatic only when infected

65.  Malignant mediastinal teratoma
 Mediastinal seminoma
 Nonseminomatous tumours-
embryonal carcinoma,
choriocarcinoma, endodermal sinus
tumours, teratocarcinoma
 Chemotherapy and radiotherapy,
surgery

66.  Bronchogenic cysts
 Mediastinal cysts form 20% of
mediastinal tumours
 60% of mediastinal cysts are
bronchogenic cyst
 Oesophageal cysts
 Neuroenteric cysts
 Mesothelial cysts
 Pericardial or pleuropericardial
cysts
 Thoracic duct cyst

67. • Neurogenic tumours
• Most common malignancy in children
• In children 50% malignant, adults 10%
• Dumbbell tumours – intraspinal extension
• CT, MRI, myelography
 Tumours of nerve sheath origin
› Benign – neurilemoma or neurofibroma
› Malignant tumours-incidence of
malignancy more in von
Recklinghausen’s disease
› Poor prognosis
Posterior mediastinal tumours

68.  Tumours of autonomic nervous system
› Neuroblatoma, ganglioneuroblastoma
rare in adults

69.  Mediastinal pheochromocytoma
 Parathyroid adenoma