Tumors of The Lung &Surgery of Mediastinum

Prof. Ahmed DeebisHead of Cardiothoracic Surgery Department -

Zagazig University

Tumors of The Lung

Objetives:I) Bronchogenic CarcinomaII)Low-grade Malignant TumorsIII)Benign lung tumors

Bronchogenic Carcinoma

The most common cancer all over the world

The most common cause of cancer-related mortality.

Bronchogenic CarcinomaRisk factors:-

• Smoking, and passive smoking: The exact mechanism is unknown, Many studies suggest that it promotes mutations and

paralyzes cellular repair.• Occupational :

Asbestos, uranium (in miners), arsenical fumes, nickel, radon gas ects.

• Air pollutions, ionizing radiation.• Tuberculosis:

Nowadays, it is reported that tuberculosis is associated with a higher incidence of lung cancer.

• Genetic: Early work with genetic mapping suggests that certain

families are at risk to develop lung cancer.

Pathology

Histologic classification:• A- Non small cell lung cancer (NSCLC)• B- Small cell carcinoma (SCLC)

Pathology, cont.

A- Non small cell lung cancer (NSCLC):- More common and less aggressive

• 1- Adenocarcinoma: The most common lung cancer type( recently, its incidence precedes that of squamous cell carcinoma) Usually peripherally located, not related to smoking.

• 2- Squamous carcinoma: Usually centrally located, related to smoking, cavitation can occur to the distal of obstructing mass.

• 3- Large cell carcinoma:. Usually peripherally located.

• 4- Adenosquamous carcinoma: There are definite features of adenocarcinoma and squamous cell carcinoma.

Pathology ,cont.

B- Small cell carcinoma (SCLC):-• It is less common (20%), • More aggressive (early metastases) • Usually centrally located. • SCLC belongs in a group of tumors derived

from neuroendocrine cells that are responsible for the production and secretion of specific peptide product that may related to paraneoplastic syndrome.

Clinical presentation

One or more of the following pictures:• 1- Asymptomatic: 5-15 %• 2- Due to primary lesions:

Cough, dyspnea, hemoptysis, wheezing, weight loss, fever, pneumonia

Clinical presentation, cont.• 3- Due to local extension or regional spread to hilar

and mediastinal nodes: Infilteration of parietal pleura, chest wall &nerves

Chest pain, Recurrent laryngeal nerve involvement hoarseness Superior vena cava compression SVC syndrome Sympathetic nerve involvement Horner’s syndrome Esophageal compression, dysphagiaphrenic nerve involvement diaphragm paralysis pericardium or pleura pericardial effusion, or

pleural effusion,

Clinical presentation, cont.

• 4- Superior sulcus, or pancoast’s tumor:Lung cancer located in apex of the lungManifests itself with shoulder pain radiating to

forearmMay involve the brachial plexus, resulting in a

C7-T2 neuropathy with pain, numbness, and weakness of the arm.

Clinical presentation, cont.

• 5- Paraneoplastic syndromes: Remote effects of the tumor. They lead to metabolic and neuromuscular

disturbances unrelated to the primary tumor or metastases.

They include: hypertrophic pulmonary osteoarthropathy, hypercalcemia, inappropriate antidiuretic hormone secretion syndrome, polymyositis, peripheral neuropathies and cushing’s syndrome.

Clinical presentation, cont.

• 6- Metastatic manifestations eg; Neurologic manifestations, Aplastic anemia, Obstructive jaundice, Distal lymph nodal invasion, etc...

Diagnosis of bronchogenic carcinomaThis requires: i) detecting the tumor, ii) establish the cell type, and iii) define the stage of the tumor.Determine cell type is the most important because it influences the treatment.

• These can be done using the following investigations:- A) imaging B) Pathological diagnosis

Diagnosis of bronchogenic carcinoma A) imaging

• 1) Chest X-Ray: The most important method to find lung cancer.

The most frequent findings: Mass in the lung field with irregular border. Secondary manifestations include:

lobar collapse, pleural effusion, pneumonitis, elevation of the hemidiaphragm, hilar & mediastinal adenopathy, & erosion of ribs or vertebrae may be encountered.

Diagnosis of bronchogenic carcinoma A) imaging , cont.

• 2) CT and MRI : Allowing better assessment of the

tumor, and its spread Guide for transthoracic needle biopsy

(T.T.N.B) .

Diagnosis of bronchogenic carcinoma A) imaging , cont.

• 3) Positron Emission Tomography (PET): With a PET scan, a small amount of radioactive sugar

is injected into the bloodstream. Rapidly growing cells such as cancer cells take up the sugar and can be seen on 3-dimensional imaging.

PET more accurate than CT in the distinction between benign and malignant lesions.

Diagnosis of bronchogenic carcinoma B) Pathological diagnosis• 1) Sputum cytology. • 2) Pleural effusion cytology. • 3) Transthoracic needle biopsy (T.T.N.B)• 4) Endoscopic Biopsy :

bronchoscopic, thoracoscopic, or mediastinoscopic

• 5) Diagnostic thoracotomy.

Staging of lung cancer

• Non-small cell lung cancer :Classified according to TNM classification to 4

stages, stage I, II, III, and IV.• Small cell lung cancer :

Often metastasized at the time of diagnosis.TNM staging is not suited to small cell lung cancer. Small cell lung cancer is divided into limited and

extensive stage disease.

Treatment• A) Non-small cell lung cancer:

1- Surgery: Indicated for Stage I and II .Lobectomy or pneumonectomy is the surgical

treatment for operable cases. Segmentectomy and limited resection may be

used in special situations.

2- Radiotherapy: more prominent role than chemotherapy for

NSCLC.

Treatment, cont

B) Small cell lung cancer : Chemotherapy is the standard treatment for

small-cell lung cancer (SCLC).

II) Low-grade Malignant Tumors (Bronchial Adenomas)

Bronchial Adenoma

• Collective description for numerous neoplasms, including :

Carcinoid tumorsTumors of salivary gland origin

adenoid cystic carcinomamucoepidermoidoncocytomaacinic cell carcinoma

Carcinoid Tumors

• Carcinoid tumors arise in the tracheobronchial tree • 1-2% of lung tumors. • Not associated with cigarette smoking.• Carcinoid syndrome is present in 2% of cases.• Slowly-growing tumor.• Although these tumors are less aggressive, they are

cancerous lesions with potential to metastasize to regional lymph nodes as well as distally.

Treatment of Carcinoid Tumors

• Complete excision with conserving as much lung parenchyma as possible.

Lobectomy or Sleeve resections the commonest

procedures.

III) Benign lung tumors

Benign lung tumors Usually present with solitary pulmonary nodule on

routine chest X-ray. Often asymptomatic Usually diagnosed after removal for suspicion of

CancerHamartomas

Abnormal combination of normal tissues in the lung, they composed of cartilage, gland like structure and fat.Treatment:

according to location, but wedge resection is appropriate.

Surgery of Mediastinum

Surgery of Mediastinum

Objectives:• I) Mediastinal masses & tumors• II) Myasthenia Gravis

Anatomy of Mediastinum The mediastinum lies between the right and left pleura & extends from the sternum in front to the vertebral column behind.Contains all the thoracic viscera except the lungs.Anterior mediastinum in front of the pericardium, Middle mediastinum containing the pericardium and its contents.Posterior mediastinum behind the pericardium.

Mediastinal masses & tumors

Treatment of Mediastinal tumors

Depends on the type of tumor and its location• Thymic tumors surgical resection,

may followed by radiation or chemotherapy. • Lymphomas chemotherapy followed by

radiation. • Neurogenic tumors surgical excision.

II) Myasthenia Gravis

Definition: Myasthenia Gravis (MG) is an autoimmune disease caused by anti-acetylcholine receptor (anti-AChR) antibodies, characterized by muscle weakness or ocular signs .

Myasthenia Gravis

Diagnosis: • The clinical diagnosis of MG:

Muscular weakness that affect ocular, facial, oropharyngeal, and limb muscles. Fatigability on exertion

• Diagnosis of MG : Characteristic history or physical findings, or both As well as two positive diagnostic tests.

Diagnostic testing for MG includes pharmacologic, serologic, and electrodiagnostic studies.

Diagnostic tests

Pharmacologic testsEdrophonium (Tensilon test)Serologic:Anti-acetylcholine receptor antibodyAnti-striated muscleElectrodiagnostic studies Repetitive nerve stimulation Single fiber electromyography

Pharmacological testing

Before & after Edrophonium Pharmacological testing

Treatment of Myasthenia Gravis

1-Depending on the disease severity, patients with MG may require medical optimization before surgery by some combination of cholinesterase inhibitors, steroids, gamma globulin, and plasmapheresis.2-Surgical TreatmentComplete removal of the thymus gland through sternotomy approach (thymectomy) is the optimal management for improvement in MG.

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