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Lung mediastinal tumors_mbbs
This document discusses lung and mediastinal tumours. It covers the epidemiology, etiological factors like smoking, histological classifications, clinical presentation, investigations including imaging and biopsies, staging, treatments such as surgery, chemotherapy and radiation, and complications. It also discusses tumours that can occur in the different mediastinal compartments and associated conditions.
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Lung mediastinal tumors_mbbs
- 1. Lung and Mediastinal Tumours Dr.Manu Mohan. K Associate Professor Pulmonary Medicine
- 2. Epidemiology Most common formof malignant diseases 40,000 new patients per year 8% male deaths and 4% of all female deaths Men > women, middle age
- 3. Etiological factors Tobacco smoking Cigarettesmokers 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.
- 5. Occupational factors Asbestos –mining, processing, usage. Radioactivity – metal ore mining, uranium mining. Nickel – refining. Chromium salt – extraction, production, usage. Arsenic – metal refining, chemical industry, insecticides.
- 6. Pulmonary scarring Localised areasof pulmonary scarring Diffuse pulmonary fibrosis Cryptogenic fibrosing alveolitis is associated with adenocarcinoma Tuberculosis – scar carcinoma, adenocarcinoma Bronchioloalveolar carcinoma also occur in areas of scarring
- 8. Histological classification 1. Squamouscell carcinoma (epidermoid carcinoma) 2. Small cell carcinoma a. oat cell carcinoma b. intermediate cell type c. combined oat cell carcinoma
- 9. 3. Adenocarcinoma a. acinar b.papillary adenocarcinoma c. bronchioloalveolar d. solid carcinoma with mucous 4. Large cell carcinoma 5. Adenosquamous carcinoma
- 10. 6. Carcinoid tumours 7.Bronchial gland carcinoma a. adenoid cystic carcinoma b. mucoepidermoid carcinoma c. others
- 11. Growth factors Polypeptides thattake 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
- 12. Genetic abnormalities Loss ofshort arm of chromosome in small cell carcinoma (p14, p23) CDKN2 gene on chromosome 9 – Non small cell lung carcinoma
- 13. Oncogenes myc genes –small cell lung carcinoma Kras – adenocarcinoma
- 14. Tumour markers Substances producedby tumour cells that are released in to blood stream. Neuron specific enolase, creatinine phophokinase BB, CEA
- 15. Modes of presentation Worseningof 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
- 16. Central tumours 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.
- 17. Peripheral tumours Cough andhemoptyis Bronchorrhoea Dyspnoea Chest pain
- 18. Distant spread Skeletal metastasis– bone pain, pathological fractures Cerebral metastasis – progressive neurological symptoms
- 19. Clinical features Frequently noabnormal findings Hoarseness Bovine cough Clubbing HPOA
- 20. Lymphatic involvement – scaleneand supraclavicular Axillary lymph nodes due to chest invasion Stridor, wheezes
- 21. Atelectasis Pleural effusion SVC obstruction Diaphragmpalsy Enlarged liver Raised intracranial pressure Dysphagia
- 22.
- 23. Collapse Pleural effusion Elevated hemidiaphragm Widening of mediastinum Lymphangitis carcinomatosa Pneumonic shadow – bronchioloalveolar carcinoma Pancoast tumour
- 24. Solitary pulmonary nodule(SPN) Opacity of less than 3 cm without surrounding atelectasis and or adenopathy. Doubling time Calcification
- 25.
- 26. Sputum cytology –more yield in central tumours 60-70% positive yield in experienced hands Single sample – 40% 4 samples – 80%
- 27. Bronchoscopy – mostuseful for central tumours Tumours beyond bronchoscopic view – Transbronchial needle biopsy, blind brushing and washing
- 28. Other investigations Percutaneous needlebiopsy Aspiration of subcutaneous swelling Pleural fluid study Thoracoscopic lung biopsy Mediastinoscopy Thoracotomy
- 29. Staging Non small cellcarcinoma TNM staging Primary tumour (T) Tx, T0, T1s, T1, T2, T3, T4 Nodal involvement (N) N0, N1, N2, N3. Distant metastasis (M) M0, M1
- 30. Staging Small cell lungcarcinoma Limited Extensive
- 31. Treatment Non small celllung carcinoma Surgery – best result, but only a small minority Types of surgery Pneumonectomy Lobectomy VATS – segmentectomy 5 year survival rate overall 35%
- 32. Radiotherapy StageI&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.
- 33. Endobronchial treatment Lasertherapy Endobronchial radiotherapy Photodynamic therapy Chemotherapy Poor response to chemotherapeutic agents Combined modalities
- 34. Small cell carcinoma Atpresentation 70% have extensive disease Chemotherapy More sensitive to chemotherapy Combined therapy preferred than monotherapy
- 35. Radiotherapy Primary tumour control Prophylaticcranial irradiation Surgery
- 36. Paraneoplastic syndrome Nonmetastatic metabolic/neuromuscular manifestations Hypercalcemia SIADH Ectopic ACTH HPOA
- 37. Gynaecomastia –large cell and adeno carcinoma Eaton-Lambert syndrome, polymyositis/dermatomyositis Peripheral neuropathy Cerebellar ataxia
- 38. Superior venacava obstruction 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
- 39. Superior sulcus tumour Pancoast Painin lower part of shoulder and inner aspect of the arm (C8, T1 and T2) Sympathetic ganglion involvement – stellate Diagnosis Treatment - radiotherapy and surgery
- 40.
- 41. Mediastinum lies centrally withinthe 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.
- 42. Mediastinal Compartments 3 compartments Anteriorcompartment Middle compartment Posterior compartment
- 46. Symptoms and Mechanisms SymptomsMechanisms cough Airway narrowing, compression Chest pain Chest wall invasion, neural invasion Dyspnoea Airway compromise, pericardial tamponade, pleural effusions, pulmonary stenosis, heart failure.
- 47. Hemoptysis Bronchogenic carcinoma, airway invasion,pulmonary stenosis, heart failure Dysphagia Oesophageal narrowing/obstructio n, oesophageal motor dysfunction Hoarseness Vocal cord paralysis Facial swelling Superior vena cava syndrome
- 48. Incidence 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
- 49. Investigations • Noninvasive diagnosticprocedures • Computed tomography • Magnetic resonance imaging • Ultrasonography • Radio nuclides
- 50. Biochemical Markers CEA AFB, HCG – nonseminomatous germ cell tumour, Teratoma, Carcinoma Catecholamines,vanillylmandelic acid, homovanillic acid – Pheochromocytoma Nor epinephrine, epinephrine – paraganglioma,ganglioneuroma, neuroblatoma
- 51. Invasive biopsy procedures FNAB Surgicalprocedures
- 52. Lesions masquerading as mediastinaltumours • Substernal Goiter • Cystic Hygroma • Lesions originating from thoracic skeleton • Vascular lesions • Oesophageal lesions • Pulmonary lesions • Sub diaphragmatic Lesions
- 53. Paraneoplastic syndromes associated withThymoma Well established Myasthenia gravis Pure red cell aplasia Acquired hypogammaglobulinemia Non Thymic cancers
- 54. Less well established Pancytopenia Lambert-Eaton Peripheralneuropathies CNS changes Multiple endocrine defects Multiple rheumatologic disorders Nephrotic syndrome
- 55. Thymoma is themost 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
- 56. Surgical resection Radiotherapy Unresectable, recurrentor metastatic Thymoma- chemotherapy
- 57. Tumours of lymphnodes 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
- 58. Non-Hodgkin’s lymphoma 5% withmediastinal involvement Large irregular anterior and superior mediastinal involvement Radiation therapy effective in low grade lymphoma chemotherapy
- 59. Germ cell tumours Benignand malignant
- 60. Benign germ celltumours (Teratoma) 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
- 61. Malignant germ celltumours Malignant mediastinal teratoma Mediastinal seminoma Nonseminomatous tumours- embryonal carcinoma, choriocarcinoma, endodermal sinus tumours, teratocarcinoma Chemotherapy and radiotherapy, surgery
- 62. Middle mediastinal tumours Bronchogeniccysts Mediastinal cysts form 20% of mediastinal tumours 60% of mediastinal cysts are bronchogenic cyst
- 63. Oesophageal cysts Neuroentericcysts Mesothelial cysts Pericardial or pleuropericardial cysts Thoracic duct cyst
- 64. • Neurogenic tumours •Most common malignancy in children • In children 50% malignant, adults 10% • Dumbbell tumours – intraspinal extension • CT, MRI, myelography Posterior mediastinal tumours
- 65. Tumours of nervesheath origin Benign – neurilemoma or neurofibroma Malignant tumours-incidence of malignancy more in von Recklinghausen’s disease Poor prognosis
- 66. Tumours of autonomicnervous system Neuroblatoma, ganglioneuroblastoma rare in adults
- 67.