LUNG TUMORS

ERWIN ARIEF
M. JUNUS PATAU
Pulmonary Department
Medical Faculty-Hasanuddin University
Lung Tumors
Classification
A. Origin
1. Primary lung tumor/cancer
2. Secondary (Metastase process)
B. Histopatology (malignancy)
1. non small cell lung ca (NSCLC)
2. small cell lung ca (SCLC)
Ad.1 NSCLC
-Squamous cell lung ca
-Adenocarcinoma
-Large cell ca/broncho-alveolar
Ad.2 SCLC
•~ oat cell carcinoma
•Prevalence <<
•Relatively more sensitive to chemoth/

Pleural origin : Mesothelioma

Predisposition Factors :
1. Smoking/cigarette
2. Carsinogenic
- Asbes - Arsenikum
- Nikel - klorometil eter, biklorometil eter.
3. Immunologic and genetic
4 others (scars from TB).
 Clinical Manifestation
• 1. intrapulmoner.
• 2. intrathoracis extrapulmoner.
• 3. extrathoracis metastatic.
• 4 extrathoracis non-metastatic
(paraneoplastic syndr)
Symptoms: according to
1. localization
2. tumor size
3. metastasis or not

1. Intrapulmonal
- Chronic cough – 75%
- Hemoptysis
- Chest pain
- Shortness of breath , atelectasis, pneumonitis.
Physical sign:
-May not found
-~ COPD Breath sound (-)
-Larger size  consolidation dullness

-Bronchostenosis Partial  Stridor

-Bronchostenosis Total  Atelectasis
2.Intrathoracis extrapulmonal
1. Pancoast Tumor :  apex
- shoulder pain /ipsilateral arm pain
- muscle atrophy
- Horner’s syndr Miosis/Enophtalmus /Ptosis
2. VCSS ( Vena Cava Superior Syndrome )
3. Hoarseness, swallowing disturbance
4. N. phrenicus paralysis  diaphragma ↑ (elevation)
paradoxal movement
5. Pleura eff, pericard eff, pneumothorax.
 3. Extrathorac metastasis
• CNS  intracranial press ↑  head ache, blur
vision, diplopia, vomiting, ↓ conciousness
• Bone metast  columna vertebr,pelvis, femur.
• Liver metast  hepatomegali, liver enzyme,
icterus, ascites.
• Adrenal  adrenal hypofunction (abdominal pain,
vomiting, electrolite imbalance.
• Gastrointestinal  abdominal limph metastases.
• Dermis  very rare (sub cutaneus nodes).
4. Extrapulmonal non-metastatic
(Paraneoplastic syndr)
Divided into:
a. endocrin metabolic manifestation.
b. bone & connective tissues
c. neuromuscular.
d. vascular & hematologic
a. Endocrin metabolic
- ADH production  Cushing syndr -
Hiperparatiroid w/ hipercalsemia
- Insulin  hipoglikemia
- Gonadotropin  gynecomastia
- Carsinoid syndr.
- Hyponatremia.
 b. Connective and bones
Hypertrophic pulmonary osteo-
arthropathy (HPOA)
- Severe pain: knees
- Inf extremities ~ edema
- clubbing fingers
- Gynecomastia
- Ro: new periosteal development
 c. Neuromuscular.
Neuropatia carsinomatosa syndr: myopatia,
perifer neuropatia, subacute cerebellar
degenerative , ensefalomyopatia and
necrotic myopati

• da. Vascular and hematologic

Anemia, purpura dan trombophlebitis
RADIOLOGY
A.Thorax X-ray: PA/Lateral position
-” Coin Lesion”
- Hilar enlargement
- Atelectasis
- Pneumonia on distal of stenosis
- Pleural effusion – Hemorrhagis
- elevated diafraghm
B. TOMOGRAPHY
C. BRONKOGRAPHY
D. ANGIOGRAPHY  tumors vascularization
E. CT-SCAN
Other assesment:
1. SPUTUM CITOLOGY Location
2. BRONCHOSCOPY Spreading
Operability
3. BIOPSY
Cell type
4. MEDIASTINOSCOPY
5. LFT : LOBECTOMY/PNEUMONECTOMY
FEV1>50% VC
MBC > 50% MBC PRED
RV/TLC < 50%
DIAGNOSIS
•Clinical Signs
- Early  no symptoms
- Late  various manifestasions  to seek medical
attention
•+ Laboratory and other assesment
* Thorax x-ray * Br.copy
* Tomography * Bronchography
* Thorax CT * Biopsy
 How to detect the “early stage”

High Risk Group  screening recommended:

• > 40 years
• cigarette smoker
• high risk environment
Assesment:
-Sputum citology
-Thorax x-ray
CLINICAL SUSPICION :
- Age > 40 yrs
- Smoker > 10 cigaret/day (10 yrs)
- + cronic cough
↓ BW > 4 kgs /6 months
Pleural eff  Hemorrhagis
Lung “ INFILTRAT” w/ therapy 1 month 
no improvement
RADIOLOGICAL SUSPICION
- RADIOPAQUE MASS
- + ATELECTASIS
- + PNEUMONIA
- HILAR ENLARGEMENT
- CAVITY W/ THICK WALL
- PROGRESSIVE PLEURAL EFF
- DIAFRAGMA.
THERAPY
According to:
1. Staging  TNM
2. Performance status (PS)
3. Histology
* SCLC
* NSCLC
 Treatment
• Surgery
• Radiotherapy
• Chemotherapy
• Immunotherapy
• Hormontherapy
• Gentherapy
 Surgery
• Indication : NSCLC stage I& II,
neoajuvant chemotherapy for stage III A ,
neoajuvant radiotherapy for V.Cava
superior syndrom
• Lung function test FEV1 > 60% ,FVC
normal contralateral.
 Radiotherapy
• Emergency case for Pancoast tumor w/
VCSS
• Preradiaton : Hb> 10gr%,
platelet >100.000/dl
WBC > 3000/dl
• Unfavourable group : PS < 70, LFT
abnormal, loss of BW > 5% / 2 months
• Tumor inoperable: combination radio &
chemotherapy (concurrent ch.therapy)
 Chemotherapy
1. Pre-requirement for chemotherapy:
- PS > 70-80 (Karnofsky)
- Hb >10 g%
- Granulocyte >1500/mm3
- Trombocyte > 100.000/mm3
- Normal liver function
- Normal renal function (ccr > 70/mnt)
 Chemotherapy con.
2. Histopathology
3. Chemoterapy regiment requires
4. Knowledge of mechanism and side effects
5. Knowledge how to administer the regiments
6. Knowledge how to handle the side effects
 Targetted therapy
• Signal-transduction inhibitor
• Apoptosis-inducing drugs
• Monoclonal antibodies
• Cancer vaccines
• Angiogenesis inhibitor
 Evaluation of treatment
• Subjective response : -performance
-BW increase
• Objective response : - complete response
- partial renponse
- stable disease
- progressive disease
• Side effect of chemotherapy
 Medical rehabilitation
Operable :
* Before surgery treatment
* After surgery treatment
Non operable :
* Improve performance status
REGIMENT FOR NSCLC
- CAP II ( Cisplatin, Andriamisin, Ciclophosfamide )
- PE ( Cisplatin or Carboplatin + Etoposide)
- Paclitaxel + Cisplatin or Carboplatin
- Gemcitabine + Cisplatin or Carboplatin
- Docetaxel + Cisplatin or Carboplatin

REGIMENT FOR SCLC

= Cisplatin + Etoposide
PALLIATIVE RADIATION
TUMOR INOPERABEL
-VCSS
-PANCOAST TUMOR
-PAIN DUE TO BONE METASTASE
-SUFFOCATION DUE TO BR STENOSIS
ADVERSE REACTION OF
RADIATION
-CNS DEPRESSION
-SKIN IRRITATION
-ESOPHAGITIS
- RAD. PNEUMONIE/FIBROSIS
- INF OPPORTUNITY (TB, MYCOSIS)
Cc: File IDA
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