Lung Neoplasm

LUNG NEOPLASM
PREINVASIVE LESIONS
Three precancerous lesions of the respiratory tract
1. Squamous dysplasia and carcinoma in situ
• Cigarette smoking
• transformation of the tracheobronchial pseudostratified epithelium to metaplastic
squamous mucosa, with subsequent evolution to dysplasia
• Carcinoma in situ represents carcinoma still confined by the basement membrane
2. Atypical adenomatous hyperplasia (AAH)
• lesion smaller than 5.0 mm, comprising epithelial cells lining the alveoli that are similar
to type II pneumocytes
• beginning stage of a stepwise evolution to adenocarcinoma in situ and then to
adenocarcinoma
PREINVASIVE LESIONS
Three precancerous lesions of the respiratory tract
3. Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia

• rare lesion represents a diffuse proliferation of neuroendocrine cells, but without
invasion of the basement membrane
• Lesions over 5.0 mm in size or that breach the basement membrane are carcinoid
tumors
INVASIVE MALIGNANT LUNG
LESIONS
NON-SMALL CELL LUNG CARCINOMA
a. ADENOCARCINOMA
• Most common lung cancer

• accounting for 30% of lung cancers in male smokers and 40% lung cancers in female smokers
• histologic subtype for 80% and 60% of lung cancers in nonsmoking females and males,
respectively
• most frequent histologic subtype in women, patients who are under 45 years of age, and Asian
populations
• Often peripherally located and frequently discovered incidentally on routine chest
radiographs
• Symptoms occur due to pleural or chest wall invasion (pleuritic or chest wall pain) or pleural
seeding with malignant pleural effusion
LESIONS
a. ADENOCARCINOMA
Histological Subtyping
1. Adenocarcinoma in situ (AIS)
• small (≤3 cm) solitary adenocarcinomas that have pure lepidic growth (tumor growth within the
alveolar spaces)
• not invasive into the stroma, vascular system, or pleura and do not have papillary or
micropapillary patterns or intra-alveolar tumor cells
• very rarely mucinous, consisting of type II pneumocytes or Clara cells
• appear as a pure ground-glass neoplasm; occasionally it will present as part of a solid or part-
solid nodule
• 100% disease- specific survival with complete surgical resection
LESIONS
a. ADENOCARCINOMA
2. Minimally Invasive Adenocarcinoma (MIA)
• Solitary tumor less than 5 mm of invasion within a predominantly lepidic growth
pattern with near 100% survival when the lesion is completely resected
• Invasive component histologically is acinar, papillary, micropapillary, and/or solid and
shows tumor cells infiltrating into the surrounding myofibroblastic stroma.
• On CT scan, appears as a part-solid nodule (≤5 mm) with a predominant ground-glass
component
LESIONS
a. ADENOCARCINOMA
3. Lepidic Predominant Adenocarcinomaa (LPA)

• Lymphovascular invasion, pleural invasion, tumor necrosis, or more than 5 mm of
invasion are noted in a lesion that has lepidic growth as its predominant component
LESIONS
a. ADENOCARCINOMA
3. Invasive adenocarcinoma
• solid by CT scan, but can also be part-solid and even a ground-glass nodule
• Bubble-like or cystic lucency on CT scan in small (≤2 cm) adenocarcinomas or extensive
associated ground-glass components correlate with slow growth and well-differentiated
tumors
• Intratumoral air bronchograms are usually indicative of well-differentiated tumor
• Spiculations that are coarse and thick (≥2 mm) is a sign of vascular invasion and nodal
metastasis and are associated with decreased survival following complete surgical resection
• Pleural retraction is also a poor prognostic indicator
LESIONS
a. ADENOCARCINOMA
5. Other Histological Variants
• colloid adenocarcinoma (formerly mucinous cystadenocarcinoma)
• fetal adenocarcinoma,
• enteric adenocarcinoma.
LESIONS
b. SQUAMOUS CELL CARCINOMA
• 30% to 40% of lung cancers
• most frequent cancer in men and highly correlated with cigarette smoking
• Arise primarily in the main, lobar, or first segmental bronchi, which are collectively
referred to as the central airways
• Presentation:
a) cough,
b) hemoptysis,
c) wheezing (due to high-grade airway obstruction)
d) dyspnea (due to bronchial obstruction with or without postobstructive atelectasis)
e) pneumonia (caused by airway obstruction with secretion retention and atelectasis).
LESIONS
b. SQUAMOUS CELL CARCINOMA
• Histologically, cells develop a pattern of clusters with intracellular bridges and keratin
pearls.
• radiographic findings of a cavity (possibly with an air-fluid level)- due to frequent
central necrosis
• Such pulmonary cavities may become infected, with resultant abscess formation
LESIONS
c. Large Cell Carcinoma
• 10% to 20% of lung cancers
• may be located centrally or peripherally
• cell diameters of 30 to 50 μm, which are often admixed with various other
malignant cell types.
LESIONS
SALIVARY GLAND-TYPE NEOPLASMS
• Adenoid cystic carcinoma and Mucoepidermoid carcinoma
• Salivary-type submucosal bronchial glands throughout the tracheobronchial tree can
give rise to tumors that are histologically identical to those seen in the salivary glands
• occur centrally
• Adenoid cystic carcinoma is a slow-growing tumor that is locally and systemically
invasive, growing submucosally and infiltrating along perineural sheaths
• Mucoepidermoid carcinoma consists of squamous and mucous cells and is graded as

low or high grade, depending on mitotic rate and degree of necrosis
LESIONS
NEUROENDOCRINE NEOPLASMS
• classified into neuroendocrine hyperplasia and three grades of
neuroendocrine carcinoma (NEC)
• Immunohistochemical staining for neuroendocrine markers (including
chromogranins, synaptophysin, CD57, and neuron-specific enolase) is
essential to accurate diagnosis
LESIONS
Grade I Neuroendocrine Carcinoma (classic or typical carcinoid)
• low-grade NEC,
• 80% arise in the central airway epithelium
• Occur primarily in younger patients.
• Hemoptysis, with or without airway obstruction and pneumonia is the most common
presentation
• Histologically, tumor cells are arranged in cords and clusters with a rich vascular stroma,
which can lead to life-threatening hemorrhage with even simple bronchoscopic biopsy
maneuvers
• Regional lymph node metastases are seen in 15% of patients, but systemic spread and
death from Grade I NEC is rare
LESIONS
Grade II Neuroendocrine Carcinoma (Atypical carcinoid)
• Higher malignant potential
• Etiologically linked to cigarette smoking and more likely to be peripherally
located
• Histologic findings: areas of necrosis, nuclear pleomorphism, and higher
mitotic rates
• Lymph node metastases are found in 30% to 50% of patients
• At diagnosis, 25% of patients already have remote metastases
LESIONS
Grade III Neuroendocrine Carcinoma
• large cell–type tumors occur primarily in heavy smokers and in
the mid to peripheral lung fields
• Often large with central necrosis and a high mitotic rate, their
neuroendocrine nature is revealed by positive
immunohistochemical staining for at least one neuroendocrine
marker
LESIONS
Grade IV Neuroendocrine Carcinoma (small cell lung carcinoma
[SCLC])
• most malignant NEC and accounts for 25% of all lung cancers
• Often have early, widespread metastases
• Arise primarily in the central airways
• Symptoms: cough, hemoptysis, wheezing (due to high-grade airway
obstruction), dyspnea (due to bronchial obstruction with or without post
obstructive atelectasis), and pneumonia (caused by airway obstruction with
secretion retention and atelectasis)
LESIONS
Grade IV Neuroendocrine Carcinoma (small cell lung carcinoma
[SCLC])
• Histologically: consist of smaller cells (diameter 10 to 20 μm) with little
cytoplasm and very dark nuclei with a high mitotic rate
• Subtypes:
Pure small cell carcinoma (previously referred to as oat cell carcinoma)
small cell carcinoma with a large cell component
combined (mixed) tumors
• leading producer of paraneoplastic syndromes
LUNG CANCER EPIDEMIOLOGY
RISK FACTORS
• Cigarette smoking-leading cause

• Risk of developing lung cancer escalates
with the number of cigarettes smoked, the
number of years of smoking, and the use of
unfiltered cigarettes
• Risk of lung cancer declines with smoking
cessation, but never drops to that of never
smokers, regardless of the length of
abstinence
RISK FACTORS
• secondhand (environmental) smoke exposure confers 24% risk for lung cancer
when a nonsmoker lives with a smoker
• The amount of secondhand exposure from one large cigar is equivalent to the
exposure from 21 cigarettes
• Over 7000 chemicals have been identified in tobacco smoke
• More than 70 of the compounds are known to be carcinogens
• Main chemical carcinogens: polycyclic aromatic hydrocarbon
• polycyclic aromatic hydrocarbon compounds are activated by specific enzymes and
become mutagenic, bind to macromolecules such as deoxyribonucleic acid (DNA),
and induce genetic mutations
RISK FACTORS
• Other causes of lung cancer include exposure to a number of industrial compounds,

including asbestos, arsenic, and chromium compounds
• The combination of asbestos and cigarette smoke exposure has a multiplicative effect on
risk.
• Preexisting lung disease confers an increased risk of lung cancer— up to 13%—for
individuals who have never smoked
• Patients with secondary scar formation related to a history of tuberculosis or other lung
infections also have a higher risk of primary lung carcinoma.
• Increased risk is thought to be related to poor clearance of inhaled carcinogens and/or to
the effects of chronic inflammation.
SOLITARY PULMONARY
NODULE
• described as a single, well-circumscribed, spherical lesion that is 3 cm or
less cm in diameter and completely surrounded by normal aerated lung
parenchyma
• majority are detected incidentally on chest radiographs (CXRs) or CT scans
• The clinical significance of such a lesion depends on whether or not it
represents a malignancy
• probability of cancer in a solitary pulmonary nodule increases if the patient
has a history of smoking (50% or higher for smokers compared to 20% to
40% in never smokers)
SOLITARY PULMONARY
NODULE
• CT findings characteristic of benign lesions include small size, calcification
within the nodule, and stability over time
• Four patterns of benign calcification are common: diffuse, solid, central,
and laminated or “popcorn.”
• Granulomatous infections such as tuberculosis can demonstrate the first
three patterns, whereas the popcorn pattern is most common in
hamartomas.
• Infectious granulomas arising from a variety of organisms account for 70%
to 80% of this type of benign solitary nodules; hamartomas are the next
most common single cause, accounting for about 10%
SOLITARY PULMONARY
NODULE
CT findings characteristic of malignancy:
• include growth over time
• increasing density on CT scan (40% to 50% of
partial solid lesions are malignant compared to
only 15% of subcentimeter solid or nonsolid
nodules)
• size >3 cm; irregular, lobulated, or spiculated
edges
• corona radiata sign (consisting of fine linear
strands extending 4 to 5 mm outward and
appearing spiculated on radiographs)
• Calcification that is stippled, amorphous, or
eccentric is usually associated with cancer
METASTATIC LESIONS TO THE LUNG
• Features suggestive of metastatic disease are multiplicity; smooth, round borders on CT
scan; and temporal proximity to the original primary lesion.
• One must always entertain the possibility that a single new lesion is a primary lung
cancer.
• The probability of a new primary cancer vs. metastasis in patients presenting with
solitary lesions depends on the type of initial neoplasm.
• The highest likelihood of a new primary lung cancer is in patients with a history of
uterine (74%), bladder (89%), lung (92%), and head and neck (94%) carcinomas
METASTATIC LESIONS TO THE LUNG
• Surgical resection of pulmonary metastases
has a role in properly selected patients
• The technical aim of pulmonary
metastasectomy is complete resection of all
macroscopic tumors.
• In addition, any involved adjacent structures
should be resected en bloc (i.e., chest wall,
diaphragm, and pericardium).
• Multiple lesions and/or hilar lesions may
require lobectomy
• Pulmonary metastasectomy can be approached
through a thoracotomy or via video-assisted
thoracic surgery (VATS) techniques.
PRIMARY LUNG CANCER-ASSOCIATED SIGNS AND
SYMPTOMS
SYMPTOMS
SYMPTOMS
OTHER SPECIFIC NON-PULMONARY THORACIC SYMPTOMS INCLUDE :
1. Pancoast’s syndrome
Tumors originating in the superior sulcus (posterior apex) elicit:
2. apical chest wall and/or shoulder pain (from involvement of the first rib
and chest wall)
3. Horner’s syndrome (unilateral enophthalmos, ptosis, miosis, and facial
anhidrosis from invasion of the stellate sympathetic ganglion)
4. Radicular arm pain (from invasion of T1, and occasionally C8, brachial
plexus nerve roots).
2. Phrenic nerve palsy.

• The phrenic nerve traverses the hemithorax along the mediastinum, parallel
and posterior to the superior vena cava and anterior to the pulmonary hilum.
• Tumors at the medial lung surface or anterior hilum can directly invade the
nerve; symptoms include shoulder pain (referred), hiccups, and dyspnea
with exertion because of diaphragm paralysis.
• Radiographically: Unilateral diaphragm elevation on chest radiograph is
present
• The diagnosis is confirmed by fluoroscopic examination of the diaphragm
with paradoxical motion with breathing and sniffing (the “sniff” test)
3. Recurrent laryngeal nerve palsy.

• occurs on the left side, given the hilar location of the left RLN as it passes under the
aortic arch.
• Paralysis results from:
(a)invasion of the vagus nerve above the aortic arch by a medially based left upper lobe
tumor
(b) direct invasion of the RLN by hilar tumor and/or hilar or aortopulmonary lymph node
metastases
• Symptoms include voice change, often referred to as hoarseness, but more typically a
loss of tone associated with a breathy quality, and coughing, particularly when drinking
liquids.
4. Superior vena cava (SVC) syndrome

• Bulky enlargement of involved mediastinal lymph nodes compressing or a
medially based right upper lobe tumor invading the SVC,
• SVC syndrome symptoms include variable degrees of swelling of the head,
neck, and arms; headache; and conjunctival edema
• most commonly with NEC grade IV (small cell) lung cancer
5. Pericardial tamponade
• Pericardial effusions (benign or malignant), associated with
increasing levels of dyspnea and/or arrhythmias, and pericardial
tamponade occur with direct pericardial invasion.
• Diagnosis requires a high index of suspicion in the setting of a
medially based tumor with symptoms of dyspnea and is
confirmed by CT scan or echocardiography.
6. Back pain
• Results from direct invasion of a vertebral body and is often localized and
severe.
• If the neural foramina are involved, radicular pain may also be present.
6. Other local symptoms

Dysphagia is usually secondary to external esophageal compression by
enlarged lymph nodes involved with metastatic disease, usually with lower
lobe tumors.
Dyspnea, pleural effusion, or referred shoulder pain can result from invasion
of the diaphragm by a tumor at the base of a lower lobe.
ASSOCIATED PARANEOPLASTIC
SYNDROMES
• All lung cancer histology are capable of producing a variety of
paraneoplastic syndromes, most often from systemic release of
tumor-derived biologically active materials
• may produce symptoms even before any local symptoms are
produced by the primary tumor, thereby aiding in early diagnosis
• The majority of such syndromes are associated with grade IV
NEC (small cell carcinoma), including many endocrinopathies.
ASSOCIATED PARANEOPLASTIC SYNDROMES
1. Hypertrophic pulmonary osteoarthropathy (HPO)
• Characteristic ankle, feet, forearm, and hand tenderness and swelling

resulting from periostitis of the fibula, tibia, radius, metacarpals, and
metatarsals
• Plain radiographs show periosteal inflammation and elevation, while bone
scans demonstrate intense but symmetric uptake in the long bones.
• Aspirin or nonsteroidal anti-inflammatory agents provide temporary relief;
treatment requires successful tumor eradication
2. Hypercalcemia
• Up to 10% of patients with lung cancer will have hypercalcemia, most
often due to metastatic disease.
• Ectopic parathyroid hormone secretion by the tumor, most often
squamous cell carcinoma, is causative in up to 15%, however, and
should be suspected if metastatic bone disease is not present. \
• Symptoms: lethargy, depressed level of consciousness, nausea,
vomiting, and dehydration.
• Following complete tumor eradication, the calcium level will
normalize
3. Hyponatremia.
• Characterized by confusion, lethargy, and possible seizures, hyponatremia
• Can result from the inappropriate secretion of antidiuretic hormone from
the tumor into the systemic circulation (syndrome of inappropriate
secretion of antidiuretic hormone [SIADH]) in 10% to 45% of patients
with grade IV NEC (small cell)
• Diagnosed by the presence of hyponatremia, low serum osmolality, and
high urinary sodium and osmolality. Another cause of hyponatremia can be
the ectopic secretion of atrial natriuretic peptide (ANP)
4. Cushing’s syndrome.
• Autonomous tumor production of an adrenocorticotropic hormone
(ACTH)-like molecule leads to rapid serum elevation of ACTH and
subsequent severe hypokalemia, metabolic alkalosis, and hyperglycemia.
• Diagnosis is made by demonstrating hypokalemia (<3.0 mmol/L);
nonsuppressible elevated plasma cortisol levels that lack the normal diurnal
variation; elevated blood ACTH levels; or elevated urinary 17-
hydroxycorticosteroids, all of which are not suppressible by administration
of exogenous dexamethasone.
5. Peripheral and central neuropathies

• Immune mediated
• Cancer cells are thought to secrete antigens normally expressed only by the
nervous system, generating antibodies leading either to interference with
neurologic function or to immune neurologic destruction.
• Up to 16% of lung cancer patients have neuromuscular disability, and, of
these, half have grade IV NEC (small cell) and 25% have squamous cell
carcinomas.
ASSOCIATED PARANEOPLASTIC
SYNDROMES
6. Lambert-Eaton syndrome
• This myasthenia-like syndrome is caused by tumor secretion of
immunoglobulin G (IgG) antibodies targeting voltage-gated calcium
channels, which causes a neuromuscular conduction defect by decreasing
the amount of acetylcholine released from presynaptic sites at the motor
end plate.
• SYMPTOMS: gait abnormalities, from proximal muscle weakness and
impaired coordination
• Therapy is directed at the primary tumor with resection, radiation, and/or
chemotherapy.
SYMPTOMS ASSOCIATED WITH METASTATIC LUNG CANCER
• Lung cancer metastasizes most commonly to the CNS, vertebral bodies, bone, liver,
adrenal glands, lungs, skin, and soft tissues
• CNS metastases (10% of patients): focal symptoms include headache, nausea,
vomiting, seizures, hemiplegia, and dysarthria, are common.
• Bony metastases are identified in 25% of lung cancer patients. They are primarily lytic
and produce pain locally; thus, any new and localized skeletal symptoms must be
evaluated radiographically.
• Liver metastases and adrenal metastases are typically asymptomatic and usually
discovered by routine CT scan.
• Adrenal metastasis may lead to adrenal hypofunction.
• Skin and soft tissue metastases occur in 8% of patients dying of lung cancer and
generally present as painless subcutaneous or intramuscular masses.
LUNG CANCER
MANAGEMENT
Role of Histologic Diagnosis and Molecular
Testing
• Establishing a clear histologic diagnosis early in the
evaluation and management of lung cancer is
critical to effective treatment
• Ensure tissue samples are adequate for morphologic
diagnosis as well as providing sufficient cellular
material to enable m
• With adoption of endobronchial and endoscopic
ultrasound, electromagnetic navigational
bronchoscopy, VATS, and even transthoracic
image-guided fine-needle and core-needle biopsy,
surgeons are increasingly involved in the
acquisition of diagnostic tissue for primary,
metastatic, and recurrent intrathoracic disease,
molecular testing
LUNG CANCER MANAGEMENT
Patient Evaluation
Pretreatment evaluation encompasses three areas
1) diagnosis and assessment of the primary tumor,
2) assessment for metastatic disease
3) determination of functional status (the patient’s ability to tolerate the prescribed
treatment regimen)
ASSESSMENT OF THE PRIMARY TUMOR
• History and Physical Examination
• Chest Xray
• CT scan should be performed with intravenous contrast to enable
assessment of the primary tumor, delineation of mediastinal lymph nodes
relative to normal mediastinal structures, and the tumor’s relationship to
surrounding and contiguous structures
• MRI in lung cancer patients is reserved for those with contrast allergies or
suspected mediastinal, vascular, or vertebral body invasion.
OPTIONS FOR TISSUE ACQUISITION
Bronchoscopy has a 20% to 80% sensitivity or detecting neoplastic processes within a pulmonary lesion
depending on nodule size, bronchial tree proximity, and the population prevalence of lung cancer
Diagnostic tissue from bronchoscopy can be obtained by one of four methods:

1. Brushings and washings for cytology
2. Direct forceps biopsy of a visualized lesion
3. Endobronchial ultrasound-guided fine-needle aspiration (FNA) of an externally compressing lesion
without visualized endobronchial tumor
4. Transbronchial biopsy with fluoroscopy to guide forceps to the lesion or electromagnetic
navigational bronchoscopy
Image-guided transthoracic FNA (ultrasound or CT FNA) biopsy can accurately diagnose appropriately
selected peripheral pulmonary lesions in up to 95% of patients
Video-assisted thoracoscopic biopsy
provides valuable staging information, including sampling/dissection of mediastinal
lymph nodes and assessing whether the primary tumor has invaded a contiguous
structure (such as the chest wall or mediastinum)
most suitable for lesions located in the outer one-third of the lung
the nodules are excised with a wedge or segmental resection, if less than 3 cm, or a
core-needle biopsy can be performed under direct vision for larger lesions
Excised nodule are extracted from the chest within a bag to prevent seeding of the chest
wall
surgeon can proceed to lobectomy (either VATS or open) after frozen section diagnosis
if patient is with adequate pulmonary reserve
Thoracotomy
occasionally necessary to diagnose and stage a primary tumor
Two circumstances may require such an approach
1. a deep-seated lesion that yielded an indeterminate needle biopsy result or that could not
be biopsied for technical reasons
-tissue can be obtained via thoracotomy using FNA, core-needle biopsy, or excisional
biopsy
2. inability to determine invasion of a mediastinal structure by any method short of

palpation.
ASSESSMENT FOR METASTATIC DISEASE
TUMOR, NODE, AND METASTASIS:
LUNG CANCER STAGING
TUMOR, NODE, AND METASTASIS: LUNG
CANCER STAGING
TUMOR, NODE, AND METASTASIS: LUNG
CANCER STAGING
ASSESSMENT OF FUNCTIONAL
STATUS
• Patients with potentially resectable tumors require careful assessment of their
functional status and ability to tolerate either lobectomy or pneumonectomy
• patient’s history is the most important tool for gauging risk
patient can walk on a flat surface indefinitely, without oxygen and without having to
stop and rest secondary to dyspnea, he will be very likely to tolerate lobectomy
patient can walk up two flights of stairs (up two standard levels), without having to stop
and rest secondary to dyspnea, she will likely tolerate pneumonectomy
Nearly all patients, except those with carbon dioxide (CO2) retention on arterial blood
gas analysis, will be able to tolerate periods of single-lung ventilation and wedge
resection
STATUS
• Current smokers and patients with a greater than 60 pack-year history of smoking have
a significantly increased risk of postoperative pulmonary complications
• Heavy smokers are 2.5 times more likely to develop pulmonary complications and three
times more likely to develop pneumonia compared to patients with a ≤60 pack-year
history
• Risk reduction requires smoking cessation at least 8 weeks preoperatively; abstinence
for at least 2 weeks before surgery should be encouraged
• Patients with chronic daily sputum production will have more problems postoperatively
with retention and atelectasis; they are also at higher risk for pneumonia.
• Sputum culture, antibiotic administration, and bronchodilators may be warranted
preoperatively.
STATUS
• Pulmonary function studies are routinely performed when any resection greater than a
wedge resection will be performed.
• the two most valuable PF studies:
forced expiratory volume in 1 second (FEV1)
carbon monoxide diffusion capacity (Dlco)
• General guidelines for the use of FEV1 in assessing the patient’s ability to tolerate
pulmonary resection:
greater than 2.0 L can tolerate pneumonectomy
greater than 1.5 L can tolerate lobectomy.
LUNG CANCER TREATMENT
Grade IV NEC (Small Cell) Lung Carcinoma
• In rare circumstances where SCLC presents as an isolated lung lesion, lobectomy
followed by chemotherapy is warranted after surgical mediastinal staging has
confirmed the absence of N2 disease.
• Less than 5% are stage I, and there is no benefit from surgical resection for more
advanced-stage disease
• Treatment is chemotherapy with or without radiation therapy depending on the extent

of disease and the patient performance status.
Early-Stage Non–Small Cell Lung Cancer
- includes T1 and T2 tumors (with or without N1 nodal involvement) and T3 tumors
(without N1 nodal involvement)
- Median survival for untreated patients with stage IA NSCLC is 14 months, and 5-year
survival rate is 22%
- Depending on tumor size and location, lobectomy, sleeve lobectomy, and occasionally
pneumonectomy, with mediastinal lymph node dissection or sampling, are appropriate
for patients with clinical early-stage disease.
- Sleeve resection is performed for tumors located at airway bifurcations when an
adequate bronchial margin cannot be obtained by standard lobectomy.
- Pneumonectomy in early-stage disease include large central tumors involving the distal
main stem bronchus and inability to completely resect involved N1 lymph nodes
Management of Early-Stage Lung Cancer in the High-Risk Patient
• Lobectomy may not be an option for some patients with early-stage disease, due to poor
cardiopulmonary function or other comorbid illnesses
• The ultimate decision that a patient is inoperable regard to the patient’s ability to
tolerate surgery and the likelihood of successful resection, should be accepted only after
evaluation by an expert surgeon.
• resection, is a viable option for achieving local control in high-risk patients.
• Limited resection with wedge or segmentectomy has been considered a compromise
operation due to unacceptably high rates of local recurrence and concerns for worse
survival
Management of Early-Stage Lung Cancer in the High-Risk Patient
• For the high-risk or non-operable patient, tumor ablation techniques have
been developed for treatment of early-stage lung cancers
• The two most commonly applied ablation techniques are radiofrequency
ablation and stereotactic body radiotherapy
1. Radiofrequency ablation
INDICATION:
 Small peripheral lung tumor
 patient at risk for adverse outcomes with pulmonary resection
 patients who refuse surgery
CONTRAINDICATION:
lesions larger >5 cm
tumor abutting the hilum
 malignant pleural or pericardial effusion
greater than three lesions in one lung
presence of pulmonary hypertension
1. Radiofrequency ablation
performed using either monopolar or bipolar delivery of electrical current to electrodes
placed within the tumor tissue.
electrodes are typically inserted into the tumor mass under CT guidance
An electrical current is delivered; the current is converted by means of friction into
heat, which quickly leads to immediate and irreparable tissue destruction in the tissue
surrounding the electrode.
In tumors <3.5 cm, the rate of radiographic resolution of tumor is up to 80%, and
cancer-specific survival at 2 years was approximately 90%, indicating excellent local
control of the primary site
2. Stereotactic body radiotherapy
• Indicated for tumors greater than 2 cm from the proximal bronchial tree in
all directions
• Applies highly focused, high-intensity, three-dimensional conformal
radiation to the target lesion over a few sessions
• Excellent primary tumor control- 97.6% were deemed to have primary
tumor control at 3 years and 90.6% had local control
Chemotherapy in the Management of Early-Stage NSCLC
• Chemotherapy is considered in high risk patients with large tumors (T2a tumor >3–4
cm; T2b tumor >4–5 cm) that are node-negative
• High-risk tumor characteristics include:

 poorly differentiated tumors,
Moderately to poorly differentiated lung neuroendocrine tumors
Vascular invasion
resection limited to wedge resection only
tumors >4 cm in size
visceral pleural involvement
 when lymph node sampling at the time of resection was incomplete (Nx)
Evaluation and Management of Locally Advanced NSCLC
• Five-year relative survival in patients with locoregional disease is 28%
• Patients with clinically evident N2 disease have a 5-year survival rate of 5% to 10%
with surgery alone
• Patients with microscopic N2 disease discovered incidentally in one lymph node station
after surgical resection have a 5-year survival rate that may be as high as 30%.
• Stage III disease includes patients with small tumors that have metastasized to the
mediastinal lymph nodes as well as large tumors (>7 cm), and tumor invading
unresectable structures or the major carina with no nodal metastasis at all
• Surgical resection is appropriate for patients with a single-station metastasis with a
single lymph node smaller than 3 cm
• Histologically confirmed metastases found during preoperative staging evaluation,
patients should be referred for induction chemotherapy
Surgery in T4 and Stage IV Disease
Surgery generally does not have a role in the care of patients with any tumor
with N3 disease or T4 tumors with N2 disease
Treatment of patients with stage IV disease is chemotherapy

Surgery for Management of Pancoast’s Tumor
Pancoast Tumor
-carcinoma arising in the extreme apex of the chest with associated arm and shoulder
pain, atrophy of the muscles of the hand, and Horner’s syndrome
-designation is reserved for tumors involving the parietal pleura or deeper structures
overlying the first rib
-resection should only be performed in patients who are proven negative for mediastinal
lymph node involvement
-Survival with N2 positive nodes is poor, and the morbidity and mortality associated with
surgical resection are high
Surgery for Management of Pancoast’s Tumor
Pancoast Tumor
• Induction chemoradiotherapy followed by surgery is recommended because Pancoast’s
tumors have high rates of local recurrence and incomplete resection
• Surgical excision is performed via thoracotomy with en bloc resection of the chest wall
and vascular structures and anatomic lobectomy.
• A portion of the lower trunk of the brachial plexus and the stellate ganglion are also
typically resected.
• With chest wall involvement, en bloc chest wall resection, along with lobectomy, is
performed, with or without chest wall reconstruction
Preoperative (Induction) Chemotherapy for NSCLC
ADVANTAGES
1. The tumor’s blood supply is still intact, allowing better chemotherapy delivery and avoiding
tumor cell hypoxia (in any residual microscopic tumor remaining postoperatively), which would
increase radioresistance.
2. The primary tumor may be downstaged, enhancing resectability.
3. Patients are better able to tolerate chemotherapy before surgery and are more likely to complete
the prescribed regimen than after surgery.
4. It functions as an in vivo test of the primary tumor’s sensitivity to chemotherapy.
5. Response to chemotherapy can be monitored and used to guide decisions about additional therapy.
6. Systemic micrometastases are treated.
7. It identifies patients with progressive disease/nonresponders and spares them a pulmonary
resection
DISADVANTAGES
1. There is a possible increase in the perioperative complication rate in patients
requiring right pneumonectomy after induction chemotherapy.
2. While the patient is receiving chemotherapy, potentially curative resection is delayed;
if the patient does not respond, this delay could result in tumor spread.
• Stage IIIA N2 disease, the response rates to induction chemotherapy are high, in the
range of 70%
• cisplatin-based regimen (two to three cycles) has become standard for patients with N2
disease.
Postoperative (Adjuvant) Chemotherapy for NSCLC
• Newer, more effective agents are promising, and adjuvant therapy is better
tolerated after minimally invasive lung resection
• Any patient with nodal metastasis (N1 or N2) or with T3 tumors (defined as
tumors >5 to ≤7 cm or separate tumor in same lobe or direct invasion of
chest wall [includes parietal pleura and superior sulcus]/parietal
pericardium/phrenic nerve) should receive adjuvant chemotherapy if they
are able to tolerate the Induction chemotherapy
• the situation where the margins of resection are positive, re-resection is not
possible, concurrent chemoradiation is recommended for macroscopic
residual tumor and sequential chemoradiation for microscopic residual
tumor.
Definitive Nonsurgical Treatment for NSCLC
Sequential” chemoradiation
Involves full-dose systemic chemotherapy (i.e., cisplatin combined with a second agent) followed by
standard radiotherapy (approximately 60 Gy)
combination of chemotherapy followed by radiation has improved 5-year survival from 6% with
radiotherapy alone to 17%
Concurrent chemoradiation
• Administers chemotherapy and radiation at the same time
• Certain chemotherapeutic agents sensitize tumor cells to radiation and, thus, enhance
the radiation effect
• ADVANTAGE: Improved primary tumor and locoregional lymph node control and
elimination of the delay in administering radiotherapy that occurs with sequential
treatment.
• DISADVANTAGE:
-Reduction in chemotherapy dosage is necessary in order to diminish overlapping
toxicities
-can potentially lead to undertreatment of systemic micrometastases.
Definitive radiotherapy
• predominantly used for palliation of symptoms in patients with poor
performance status
• Cure rates with radiation as a single modality in patients with N2 or N3

disease is less than 7%.
Thoracic Surgical Approaches
1. Video-Assisted (VATS)/Robotic-Assisted Thoracoscopic Surgery (RATS)
• performed via two to four incisions measuring 0.5 to 1.2 cm in length to allow insertion
of the thoracoscope and instruments
• access incision (4th or 5th ICS) in the anterior axillary line is used for dissection of the
hilum during lung resection
• Ports are positioned high enough on the thoracic cage to have access to the hilar
structures
• Robotic approaches are similarly tailored to the side and lobe undergoing resection,
with the entire operation performed using robotic arms, except for one assistant port
through which specimens can be removed and suctioning and stapling performed
2. Open Approaches to Thoracic Surgery
Posterolateral Thoracotomy
• most frequently used to gain access to the intrathoracic space
used for most pulmonary resections, esophageal operations, and
operations in the posterior mediastinum and vertebral column
Anterolateral Thoracotomy
• traditionally used in trauma victims
• This approach allows quick entry into the chest with the patient
supine
• partial median sternotomy can also be added to an anterior
thoracotomy (“trap-door” or “hemiclamshell” thoracotomy) for
access to mediastinal structures
2. Open Approaches to Thoracic Surgery
Bilateral Anterior Thoracotomy Incision with a Transverse sternotomy

• “clamshell” thoracotomy
• standard operative approach to the heart and mediastinum in certain elective
circumstances
• preferred incision for double-lung transplantation
Thoracic Surgical
Approaches
2. Open Approaches to Thoracic
Surgery
Post-operative Care
1. Chest Tube Management
• most thoracic operations are concluded with the pleural cavity drained with a chest tube
• allows evacuation of air if an air leak is present
• blood and pleural fluid can be drained, thereby preventing accumulation within the pleural space
that would compromise the patient’s respiratory status.
• The tube is removed when the air leak is resolved and when the volume of drainage decreases
below an acceptable level over 24 hours
• remove chest tubes with 24-hour outputs of 400 mL or less after lobectomy or lesser pulmonary
resection
• In settings where normal pleural fluid dynamics have been altered, such as malignant pleural
effusion, pleural space infections or inflammation, and pleurodesis: 100 to 150 mL output over
24 hours
Post-operative Care
2. Pain Control
• permits the patient to actively clear and manage secretions and promotes ambulation and a
feeling of well-being
• most common techniques of pain management are epidural, paravertebral, and intravenous
• Epidural catheters - inserted at about the T6 level
-combinations of fentanyl at 0.3 μg/mL with either bupivacaine (0.125%) or ropivacaine
(0.1%)
• Paravertebral blocks- placed using the same epidural catheter kit 2.5 cm lateral to the spinous
process at T4 to T6
-Combinations of narcotic and topical analgesia are then infused as with the epidural catheter
• patient is typically transitioned to oral pain medication on the third or fourth postoperative day
Post-operative Care
3. Respiratory Care
• Proper pain control without over sedation is essential
• Careful assessment of the patient’s pulmonary status
• Reminders to the patient and family about the importance of coughing and deep
breathing
• Use of adjunctive respiratory equipment – incentive spirometry
• Early Mobilization of the patient- Early transition to a chair and to ambulation is the
best respiratory therapy and should be strongly encouraged
Postoperative Complications
1. Pulmonary edema
• Most devastating complication after pulmonary resection
• Occurs in 1% to 5% of patients undergoing pneumonectomy and more often
after right compared to left pneumonectomy
• Symptoms of respiratory distress manifest hours to days after surgery.
• Radiographically, diffuse interstitial infiltration or frank alveolar edema is
seen
• Pathophysiology: increased permeability and filtration pressure and decreased
lymphatic drainage from the affected lung
• Treatment consists of ventilatory support, fluid restriction, and diuretics.
2. Air Leak
• Postoperative air leaks are common after pulmonary resection, particularly
in patients with emphysematous lung, because the fibrosis and destroyed
blood supply impairs healing of surface injuries
• Prolonged air leaks management:
• diminishing or discontinuing suction (if used) in chest tube
• continuing chest drainage
• Chemical Pleurodesis- usually done with doxycycline or talcum powder
2. Bronchopleural Fistula
• High index of suspicion of air leak is moderate to large
• from the resected bronchial stump
• flexible bronchoscopy for evaluation
• Management:
-continued prolonged chest tube drainage, reoperation, and reclosure (with
stump reinforcement with intercostal or pedicled serratus muscle flap)
-very small fistula (<4 mm): bronchoscopic fibrin glue application has been
used successfully to seal the hole

Lung Neoplasm

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Lung Neoplasm

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LUNG NEOPLASM

3. Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia

• Most common lung cancer

3. Lepidic Predominant Adenocarcinomaa (LPA)

• Mucoepidermoid carcinoma consists of squamous and mucous cells and is graded as

• Cigarette smoking-leading cause

• Other causes of lung cancer include exposure to a number of industrial compounds,

2. Phrenic nerve palsy.

3. Recurrent laryngeal nerve palsy.

4. Superior vena cava (SVC) syndrome

6. Other local symptoms

1. Hypertrophic pulmonary osteoarthropathy (HPO)

• Characteristic ankle, feet, forearm, and hand tenderness and swelling

5. Peripheral and central neuropathies

Diagnostic tissue from bronchoscopy can be obtained by one of four methods:

2. inability to determine invasion of a mediastinal structure by any method short of

• Treatment is chemotherapy with or without radiation therapy depending on the extent

• High-risk tumor characteristics include:

Treatment of patients with stage IV disease is chemotherapy

• Cure rates with radiation as a single modality in patients with N2 or N3

Bilateral Anterior Thoracotomy Incision with a Transverse sternotomy

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