lung tumours

8/8/2019 Lung Tumours

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Lung TumoursBronchogenic carcinoma

Bronchial carcinoid and other tumoursMetastatic tumours


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Classification

Bronchogenic carcinoma from epithelium of airways

Small cell

Non-Small cellAdenocarcinoma Bronchioalveolar carcinoma

Squ amo us cell carcinomaLarge cell carcinoma

MixedCarcinoidMesothelioma


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Bronchogenic CarcinomaCarcinomas constitute 90-95% of tumours of thelung, they are the most common cause of cancerdeath in men

Most important risk factor is smoking , otherfactors include asbestos exposure, air pollution,and radiation especially radonPrecursor lesions; squamous dysplasia and

carcinoma in situ , atypical adenomatoushyperplasia and diffuse idiopathic pulmonaryneuroendocrine hyperplasia


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SymptomsNon- Specific

Fatigue Malaise Anorexia & weight loss

Respiratory Haemoptysis Cough Chest pain Recurrent infections Dyspnoea Hoarseness & dysphagia

SVC sy ndrome : SOB, headache, swelling of face and neck (due to obstruction of SVC)H orner s sy ndrome (myosis, ptosis, anhidrosis decreased sweating on affected side of face, sometimesenopthalmos ) due to Pancoast tumour at lung apexP araneopla stic sy ndrome

Eaton lambert Cerebellar degeneration Clubbing G eneral; night sw eat s, fever s ..

Prognosis is dependent at stage of carcinoma at diagnosis Overall 5yr survival rate is 15%


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Bronchogenic Carcinoma Clinical

FeaturesCough 41%Chest pain 22%Cough + Pain 15%

Coughing blood 7%Chest InfectionDyspneaHoarseness

Malaise, Weight lossMetastatic


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Squamous Cell CarcinomaArise from squamous cells in bronchiMore common in menAssociated with smokingPrecancerous lesions; sq metaplasia / dysplasia carcinoma in situ cancerPrecancerous lesion may be identified in sputum

Sputum smear Bronchial lavage fluid

Tumour mass tend to arise centrally in major bronchi with eventualspread to hilar nodesLarge lesions show central necrosis which gives rise to cavitationOften tumour masses obstruct lumen of bronchi causing atelectasisand infection - most common presentationLocal spread is common, but widespread metastases occurs late


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This chest radiographdemonstrates a large 5cm diametersquamous cellcarcinoma of the rightlower lobe. The 1.5 cmbright opacity in themiddle of the mass isa calcified granulomathat was seen onlateral view to bebehind the neoplasm.Additional calcifiedgranulomatous areasare medial to themass. The sternal wireloops are from aprevious coronaryartery bypassprocedure.


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One method for diagnosis of pulmonary neoplasms is fine needle aspiration(FNA ) in which cells from a mass are sampled, often under radiologicguidance, for cytologic diagnosis. Seen here are cells from a squamous cellcarcinoma that have enlarged, angular, hyperchromatic nuclei and orange-staining keratinized cytoplasm.


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AdenocarcinomaMost common type of lung carcinoma among women and non-smokers

10% of all bronchial carcinomas Is now the most common lung cancer

Arise from bronchioalveolar stem cells (BA SCs)

Typically peripherall y locatedSlow growing but invasive pleura and mediastinal LNThey metastasize widely at an early stage; brain, adrenal glands andboneThe precursor of adencarcinomas are atypical adenomatoushyperplasia (AAH )


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Bronchioloalveolar Carcinomas (BA Cs)

Subtype of adenocarcinomaTypically at peripher yShow lepidic growth growth along existing structures

without invasion or destruction of alveolar septaThere are two subtypes, mucinous and nonmucinousOccasionally associated with expectoration of very largevolumes of mucoid sputumHas ground glass appearance on CXR


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Large Cell CarcinomaU ndifferentiated malignant epithelialtumoursAccount for 25% of all lung cancersTend to metastasize earlyPossibly represent SCC or Adenocarcinomathat are so undifferentiated they can no

longer be recognisedCells have large nuclei, prominent nucleoli,moderate cytoplasm


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Small Cell Lung CarcinomaDerived from neuroendocrine cells as suchexpress various neuroendocrine markersAccounts for 20-30% of all lung cancers

Tend to be centrall y locatedSpreads early (hilar LN ), almost alwaysinoperableRapidly growing, highly malignant

Necrosis is common and often extensive


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Pancoast tumourThese are apical neoplasms that invade brachialplexus causing pain in distribution of ulnar nerve(shoulder and inner surface of arm ) PancoastTumourIf involves sympathetic ganglion then Hornerssyndrome

Enopthalmos sunken eye Ptosis drooping upper eyelid Miosis constriction of pupil Anhidrosis decreased sweating

Often accompanied by destruction of first andsecond ribs


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Direct SpreadHilar tumours may involve left rec u rrent lar yngeal nerve

Hoarseness Bovine cough

Direct invasion of phrenic nerve Ipsilateral paralysis of hemidiaphragm

Invasion of Oesophagus Dysphagia

Pericardium Pericardial effusion Malignant dysrhytmias

Su perior Vena Cava ob stru ction Early morning headache Facial congestion Oedema of upper limbs Distention of veins; jugular and chest


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Metastatic Complications

Bone Severe pain Pathological featuresLiverBrain

Personality changes Epilepsy Focal neurological signs Spinal cord compression


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Non-metastatic extrapulmonary

manifestationsMetabolic (Universal at some stage ) Loss of weight Anorexia

Endocrine (10% - Usually small cell )

Ectopic adrenocorticotrophin syndrome SIADH Hypercalcaemia

Neurological Encephalopathy Myelopathy Neuropathy

Skeletal Clubbing (30% ) Hypertrophic osteoarthropathy


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Bronchogenic Carcinoma -

InvestigationsCXR Detects mass >1cm Lateral view to asses hilum and post to heart Secondary

PneumoniaPleural effusionCollapseRaised hemidiaphragm

CT Detection of small tumours or tumour in mediastinum, spread Alw ays incl u de liver , adrenal s and brain Nodal involvement (LN >2cm )

PET or PET- CT Investigation of choice for assesement of mediastinum, use FDG Can visualise primaries, secondaries and affected LN

Fibreoptic B roncho scop y Tumours confined to central airways or mediastinum easily seen (missed on CXR) Biopsy and cytology specimens

Percutaneous aspiration and biopsy For peripheral lung lesions under CT guidance Pneumothorax a common complication CXR

Lab; CBC, U&E, LFTs


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M ediastinoscopy

This procedure is performed under generalanaesthesiaA transverse incision 2 cm above the sternalnotch.A mediastinoscope is introduced for directvisualisation and biopsy

Complications include pneumothorax andhaemorrhage.


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M ediastinotomy

An incision is made through the second intercostal space to gainaccess to some of the mediastinal lymph nodes on the affectedside (Fig. 52.18; see also Fig. 52.3, page 877). Damage to theinternal mammary artery and the phrenic nerve must be avoided.

M ediastinal extension of tumour can also be assessed.These techniques may also be used in the diagnosis of othermediastinal conditions, including:

lymphoma; anterior mediastinal tumours;

thymoma; sarcoid, tuberculosis or any other cause of lymphadenopathy.


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Thoracotomy The standard route into the thoracic cavity is through a p osterolateralthoracotomy. The incision is used for access to the:

lung and major bronchi; thoracic aorta; oesophagus; posterior mediastinum.

A double-lumen endotracheal tube is used to allow ventilation of one lung whilethe other is collapsed, to facilitate surgery and to protect the non-operated lungand retain control of ventilationThe patient is turned to the lateral position with the affected side upThe incision passes 1 2 cm below the tip of the scapula, and extends posteriorlyand superiorly between the medial border of the scapula and the spine.The anaesthetist is now able to deflate the affected lung to allow a better view of the intrathoracic structures.In an emergency thoracotomy for penetrating wounds of the heart, a moreanterior approach is used and no specialised supporting equipment is required(Fig. 52.22).


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S taging

S taging is according to TN M

Tumours staged up to and including T2 N1 M0

are considered for surgery and have a betterprognosis


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StagingPrimary tumour (T)

TX Tumour prove n by th e prese nce of m alignant cells and bro nchial secre ti ons, bu t not visualised byradiograph y or bro nchoscopy

T0 No ev idence of pr imary t umour TI S Carcinoma in sit u T1 A t umour that is 3 cm or less in gre at es t dimension, surrou nded by lung or viscer al pleur a and with out

evidence of invasion prox imal t o a lobar bro nchus at bro nchoscopy T2 A t umour of more than 3 cm in gre at es t dimension or a t umour of an y size that eith er invades th e viscer al

pleur a or has associat ed at electa sis or obs t ructi ve pneumonitis, which ex t ends t o th e hilar re gion, but does not involve an enti re lung; at bro nchoscopy, th e prox imal ex t ent of demonst rable t umour must be within a lobarbro nchus or at least 2 cm distal t o th e car ina

T3 A t umour of an y s ize, with dire ct ex t ension int o th e ches t wall (including super ior su lcus t umours),diaphragm, mediastinal pleur a or per icardium, with out involving th e hear t , gre at vesse ls, t rach ea, oesop hagus orver t ebr al bod y, or a t umour in th e main bronchus within 2 cm of th e car ina with out involving th e car ina

T4 A t umour of an y s ize, with invasion of th e mediastin um or involving th e hear t , gre at vesse ls, t rach ea,oesop hagus, ver t ebr al bod y or car ina, or th e prese nce of m alignant pleur al effus ion

N odal involvement ( N ) N0 No demonst rable me ta sta sis or re gional l ymph node N1 Meta sta sis t o l ymph nodes in th e per ibro nchial or th e ipsilat er al hilar re gion, or bo th , including dire ct

ex t ension N2 Me ta sta sis t o th e ipsilat er al, mediastinal and subcar inal l ymph nodes N3 Me ta sta sis t o th e cont ralat er al mediastinal l ymph nodes, cont ralat er al hilar l ymph nodes, ipsilat er al or

cont ralat er al scalene or supr aclavicular l ymph nodesD istant metastasis (M)

M0 No known distant meta sta sis M1 Distant meta sta sis prese nt


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Bronchogenic Carcinoma Tx optionsSurgery

I f tu mo u r is w ithin fir st 2cm of either main bronch us then i s inoperable Only 5-10% of cases suitable for surgery Can be curative in non small cell lung cancer Rarely appropriate in >65

Radiation High dose radiotherapy Radiation pneumonitis develops in 10-15% Radiation fibrosis occurs to varying degrees in all cases

ChemotherapyPalliative

Laser therapy Endobronchial irradiation Tracheobronchial stents Radiotherapy bone pain, cough, haemoptysis

Prednisolone daily (upto 15mg ) improves appetite Morphine or Diamorphine

Laxatives to combat constipation caused by opiatesCounselling


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PrognosisOften lung carcinomas are silent until they havemetastasized making prognosis very poorSCLC has virtually always metastasized at time ofdiagnosis and surgical resection is not a viable option,despite responding well to chemotherapy recurrence isthe norm and average survival with treatment is 1year(10yr survival rate is 5% )If NSLC is detected before spread or significant invasionthen lobectomy or pneumonectomy is an optionParaneoplastic syndromes occur in 3-10%

Hypercalcaemia, cushings syndrome, SIADH, neuromuscularsyndromes, clubbing of the fingers, DI C


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S urgery

Principle remove cancer and affected LN swhilst preserving as much lung as possible

Types of surgery Lobectomy Pneumonectomy


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Pneumonectomy

A surgical procedure in which an entire lung isremoved.A pneumonectomy is most oftendone for cancer of the lung that cannot betreated by removal of a smaller portion of thelung. A pneumonectomy is an open chesttechnique (thoracotomy).


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Lobectomy

Also called a pulmonary lobectomy, it is acommon surgical procedure that removes onelobe of the lung that contains cancerous cells.Removal of two lobes is called bilobectomy.


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Sleeve Lobectomy

Removal of affected lobe plus part of bronchus

Remaining lobe is reconnected to remainingbronchus (broncho-bronchoanastomosis) thuspreserving lung tissue ( an alternative topneumonectomy)


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Wedge Resection

Removal of wedge shaped portion of lung containingcancerous cells plus healthy margin

Used to remove small tumours or in diagnosis, can also be analternative to lobectomy in patients who would not toleratethe procedure due to poor lung function

Can be performed by minimally invasive techniques; videoassisted thoracoscopic surgery (VAT S )

Or by open surgery - thoracotomy


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Segment Resection (Segmentectomy)

A segment resection removes a larger portionof the lung lobe than a wedge resection, butdoes not remove the whole lobe


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S urgery

When considering a patient for surgery onehas to carefully evaluate lung function

Obviously patients with poor lung functionwill be poor candidates for pneumonectomy.

Other issues are location of tumour, centrallylocated and adherent to aorta, heart oroesophagus imply iresectability


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Complications of S urgery

Bleeding especially if there are adhesionsPersistent air leak chest drains should be placed to dealwith thisBasal colapse & hypoxaemiaRespiratory InfectionBronchopleural fistula high morbidity & mortality,requires special management. Patient should be sat upPost op pain; important to deal with as pain interferes withbreathing

PCA (patient controlled analgesia) Paravertebral, extrapleural catheter-delivered local anaesthetic Background oral analgesia with paracetamol


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Bronchial Carcinoid

Arise from neuroendocrine cells liningbronchial mucosa (kulchitsky cells )

They may secrete hormonally activepolypeptides, occasionally they occur aspart of MEN syndromeAccount for 5% of all pulmonary tumours,occur typically at 40yrsThey are often resectable and curable


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Bronchial CarcinoidOriginate in main bronchi, and show one of two growthpatterns

Obstuctive, polypoid intraluminal mass Mucosal plaque penetrate bronchial wall and invade

underlying tissueMucosal plaques although invasive are still reasonablywell demarcated5-15% have spread to local hilar nodes, but distantmetastasis is rareNeoplsams appear as nests of cells, with regular roundnuclei and salt & pepper chromatin. Mitoses andpleomorphism are not commonAtypical carcinoid higher mitotic rate, pleomorphism,focal necrosis, p53 mutations, worse prognosis


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Bronchial Carcinoid

Presentation is usually due to bronchialobstruction, some are even asymptomatic

Rarely present as carcinoid syndrome(flushing, diarrohea, cyanosis )Typical carcinoid has 10yr survival rate of85%, but only 56% or lower for atypical


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Other tumoursHamartomas are the most common benign lesion of thelung, they are small spherical lesions (3-4cm ) consistingmainly of cartilage often admixed with fat, fibrous tissueand blood vessels

Granulomas TB, HistoplasmosisMetastatic tumours; very common, occurs throughcontigous spread, lymphatic or hematogenous

Superior mediastinum; lymphoma, thymoma Anterior mediastinum; thymoma, teratoma, lymphoma Posterior mediastinum; neurogenic tumours, lymphoma Middle mediastinum; bronchogenic cyst, pericardial cyst,

lymphoma


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Lung SurgeryOther conditions which may require lung surgeryincludeBronchiectasis:

Irreversible dilatation of medium sized bronchi Resection (unless generalised) can be very effectiveLung abscess

CXR: cavity with fluid level

TX: ATB s and postural drainageTB Rarely requires surgery

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