Management of Lung Neoplasms

Mizan Kidanu Mar.04/2013

Outline

Introduction Risk factors Classification Clinical features Diagnosis Management Benign neoplasms

Introductionlung 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)

Risk factors

Smoking10 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

Ageolder age

Industrial compounds asbestos, arsenic, mustard & chromic

compoundshave multiplicative effect with smoking

Pre-existing lung disease tuberculosis (scar formation) and COPD

Family Hx

Viral factors (HPV)

Classification (Invasive)broadly divided into two main

groups:(I) Non-small cell ca

squamous cell caadenocarcinomalarge cell cabronchoalveolar 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)

Non-Small Cell Lung CarcinomaI. 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)

II. Adenocarcinoma

25-40% of all lung cancer most common type to occur in non-smokers occurs more frequently in females than in

malesmost often located peripherally frequently discovered incidentally on CXRSx: chest wall invasion or malignant pleural

effusion dominatedestruction of contiguous lung architecture

III. Bronchoalveolar Carcinoma

5% of all lung cancers (subtype of adenoca)tumor cells multiply and fill the alveolar

spacesno evidence of destruction of surrounding

lung parenchymacan aerogenously seed other partsradiographic presentations: single nodule,

multiple nodules or a diffuse formbronchograms can be seen, unlike with

other ca

IV. Large cell carcinoma

10 - 20% of lung cancers may be located centrally or peripherallyoften admixed with other cell types such

as squamous cells or adenocarcinomacan be confused with a large cell variant

of neuroendocrine carcinoma (immunohistochemical staining for diagnostic distinction)

Neuroendocrine carcinoma

Small cell lung carcinoma

25% of all lung cancersis the most malignant NEC centrally locatedhigh mitotic and areas of extensive necrosis immunohistochemical staining (if necessary) leading producer of paraneoplastic

syndromes

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

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

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

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

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

Metastatic disease

Lung cancer metastases occur most commonly to:

CNS boneliveradrenal glandslungsskin, andsoft tissues

• Non specific anorexia, wt loss, fatigue, malaise –

metastasis

Diagnostic workup

Assessment of primary tumors

1. Hx and P/Equestions regarding presence/absence of

pulmonary, nonpulmonary thoracic Sx,…cervical / supraclavicular LAP,….

2. Laboratory CBC LFT and RFT Serum electrolyte

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

4. PA and lateral CXR

tumor <1cm not visible on CXRfinding on CXR

atelectasis discrete mass / multiple nodulesmediastinal, hilar and paratracheal

massesraised diaphragm pleural effusion osteolytic vertebral / rib lesion

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 treedx tissue collection by

brushing and washing for cytology direct forceps biopsy of visualized lesion

FNAC

7. Transthoracic needle biopsy

ideally used for peripheral tumorsunder imaging guidance (CT, U/S or

fluoroscope) I0 complication is pneumothorax (50%

patients)

8. MRI

little advantage over CTused to define tumor relation to major

vascular structures

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

Assessment of distant metastasis

found in 40% of newly diagnosed lung cancer may imply inoperability

Hx Presence of:

recent bone painneurological Sxnew skin lesionsconstitutional Sx

P/E G/A with wt loss + muscle wasting

cervical & supraclavicular LNs skin lesions

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

Assessment of functional status

Hxcan 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

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

TNM description for staging of non-small cell lung cancer

Primary tumor (T)

T0 – No evidence of primary tumorTis – Carcinoma insitu T1 – Φ ≤ 3 cmsT2 – 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 atelectasisT4 – Invasion of the mediastinal organs (e.g. esophagus, trachea, great vessels, heart); malignant pleural effusion, or satellite modules with in the primary tumor lobe

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.

Stage grouping

Stage IA T1N0M0

IB T2N0M0

IIA T1NIM0

IIB T2NIM0 or T3 N0M0

IIIA T1 – 3 N2M0 or T3NIM0

IIIB T4 Any NM0 or AnyT N3M0

IV Any T, Any N M1

Staging for small cell lung cancerLimited 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) stagedisease has spread beyond the

definition of a limited stage or malignant pleural effusion is present

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

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

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.

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.

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

Management of small cell carcinoma95% 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

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 5 year survival

Stage I 55 – 80 % Stage II 35 – 50 % Stage IIIa 5 – 35 %

1 year survival Stage IIIb < 20% Stage IV < 15%

Cell type

• 5 year survival according to cell type:

Cell type 5 year survival squamous cell ca 35 - 50 % adenocarcinoma 25 - 45 % adenosquamous carcinoma 20 -

35 % undifferentiated carcinoma 15 -

25% small cell carcinoma 0 - 5 %

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.

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.

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.

Diagnosis

◦CXR◦CT scan ◦Bronchoscopy for central lesions

◦Peripheral lesions- Needle biopsy

◦Thoracoscopy / open biopsy

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.

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.

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.

Surgical options

The extent is usually determined at surgery and is as conservative as possible.

1. Simple endoscopic resection2. Thoracotomy with

◦ local wedge excision◦ segmental resection, or◦ lobectomy.

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

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