Lung Cancer

• First thoracic surgery of

shengjing hospital

• Hongyan Zhang
 1 Etiology and typing of lung cancer
CONTENTS
2 Clinical manifestations and manifestations of metastasis

3 Diagnosis of lung cancer

4 TNM staging of lung cancer

5 Differential diagnosis of lung cancer

6 Treatment of lung cancer

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Basic facts of lung cancer

• Lung cancer is the leading cause of cancer death in both men and
women worldwide.
• It kills more people than breast, prostate, and colon cancer
combined.
• Nowadays, more than 1.3 million people living with lung cancer
around the world.
• Lung cancer is found most frequently in persons 40-75 years of
age, with peak incidence between 55 and 65 years old.
• Most lung cancers are discovered when the disease is far
advanced and there is no currently approved screening for lung
cancer, which would detect smaller and more curable tumors.
But the high-resolution CT is used for screening early lung cancer.
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• Surgeon are interesting in the degree of fissure at the time of

resection because the complete fissure is helpful for easier
hilar dissection.
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Blood supply of lung

• The blood supply of the lung is twofold.

Unoxygenated blood is pumped to the lung
from the right ventricle by way of the
pulmonary artery. After oxygenation in the
lung, the blood is returned to the left atrium
by way of the pulmonary veins. Blood supply
to bronchi is from the systemic, circulation by
bronchi arteries arising from the superior
thoracic aorta or the aortic arch.
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Gross character

• The lung cancer occurs more frequently

in the right lung than in the left. in a
ratio of 6:4, the upper lobes are involved
more often than the lower lobes and the
middle lobe is involved the least
frequently of all in the lobes.
 01
Etiology and typing of lung cancer
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Etiology and risk factors

• Cigarette smoking
• The patient who is at high risk for lung cancer started
smoking at age 25 or before, smoked a pack a day for
20 years.
• Air pollution
• Inhaled carcinogens, asbestos dust
• Heredity, family history
• Preexisting pulmonary diseases such as tuberculosis,
pulmonary fibrosis, bronchiectasis, and COPD.
• Immune state
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Histology typing of lung cancer

Two general subtypes:

• Non-small cell lung cancer (NSCLC)
squamous cell carcinoma
Adenocarcinoma
large cell carcinoma
• Small cell lung cancer (SCLC)
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Location of lung cancer

• Central type

• Peripheral type
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squamous cell carcinoma

• 1) Male , aged > 50 , closely associated with

smoking , center type .
• 2) Growth speed is slow , long course of disease , are
more sensitive to radiation and chemotherapy
• 3) lymphatic metastasis first
hematogenous metastasis later
• 4) good prognosis
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adenocarcinoma

• 1) Predilection for younger female

• 2) Most is peripheral located in small
bronchi
• 3) no symptom, growth slowly
• 4) It metastasis early by way of vascular
system, lately of lymphatic system
• 5) It is unsensitive to radium and
chemotherapy
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large cell carcinoma

• it occurs rarely
• prognosis is very poor
• originate in large bronchi
• metastasis to the brains
• insensitive to chemotherapy
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small cell carcinoma

• Morbidity is lower than that of squamous carcinoma
• Patients age is vary younger than that of other cell type about
25%
• Predilection for male (male >female)
• Most are centrally located in larger bronchi
• The cell shape is similar to the oat so called oat cell carcinoma
• These tumors are highly malignant and spread early by way of
both the lymphatic and vascular system
• It is sensitive to radium and chemotherapy
• The prognosis is the poorest in the total
 02
Clinical manifestations and metastasis
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Clinical manifestations
• Lung cancer is the leading cause of cancer death in both men and
women worldwide.
• No symptom for early stage lung cancer, and absent of specific
symptoms.

• Intrathoracic symptoms:
• Cough with sputum (expectoration), one of the most significant
symptom, and often reported first; persistent and
stimulating cough.

• Hemoptysis or emptysis:Tumor invasion of the bronchial artery

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Clinical manifestations

• Wheezing: Tumor causing airway

stenosis

• Pneumonia:Tumor obstruction airway;

Sputum can not be ruled out
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Intrathoracic symptoms

• Dyspnea: Airway obstruction

Bronchorrhea: Tumor stimulation
Chest pain: Invading nerve
Hoarseness: Recurrent laryngeal nerve
Neck or facial swelling: Superior vena cava compression
Diaphragmatic paralysis: Compression of phrenic nerve
Pancoast’s syndrome
Horner syndrome: Sympathetic nerve
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Superior vena caval syndrome

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Pancoast tumor

• tumor in the apex of the lung or superior pulmonary sulcus. Symptoms are
pain, upper arm weakness.
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Extrathoracic symptoms

Metastatic: the commonest sites of metastases are liver, adrenal glands,

brain, skeleton, and kidney.

Nonmetastatic: secretion of endocrine or endocrine-like substances.

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Route of metastasis

• direct diffusion

• lymphatic metastasis

• hematogenous metastasis
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• Metastases from the lungs to the brain. • Skeletal metastasis.

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• Liver metastasis.
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• Lung metastasis.
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Diagnosis of lung cancer
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Diagnosis

• Early detection, early diagnosis result in better prognosis.

• Screening for high risk population is necessary.
• Chest x-rays film: eliminate in clinical
• CT: Most commonly used in clinic
• Sputum cytological study: Poor sensitivity. The detection rate was 10%
• Bronchoscopy ： Central type
• Mediastinoscopy ： Mediastinal lymph node
• Thoracentesis for pleural effusion
• Biopsy
• Thoracotomy
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• Fine-needle aspiration (FNA) ： Peripheral lung cancer

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• X-ray and CT
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Cytological examination of sputum

• Cell type as determined by cytological study

agrees with that of the final histology
diagnosis in about 85% of patients.
• Cytological studies are most often positive in-
patients which involve the main bronchi.
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• Bronchoscope
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• Biopsy of lymph nodes by mediastinoscopy

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Biopsy of lymph nodes

• Excision of lymph nodes in the supraclavicular

fossa, cervial and axillary fossa should be done
for histologic study to determined metastasis
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• Pleural effusion examination. • Open chest exploration

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PET

• Positron Emission Tomography (PET) is a

noninvasive imagine method that has
demonstrated increased glucose metabolism in
malignant cells. Recent studies have
demonstrated that it was accurate in
differentiating benign from malignant
pulmonary nodules
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Thoracoscopy

• Thoracoscopic staging of lung cancer has been

demonstrated to be safe and effective in
selected patients. The most common
application is the evaluation of indeterminate
pulmonary nodules. Thoracoscopy may help
confirm pleural invasion or dissemination
(Warn, 1993). Techniques to improve
localization and characterization of pulmonary
nodules
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TNM staging of lung cancer
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TNM staging of lung cancer

• Patients with lung cancer may have specific treatment based on their physical
character and their anticipated survival outlook.

• The staging of carcinoma of the lung by the TNM approach, devised by the
American Joint Committee on Cancer in 2017,provides a consistent ,reproducible
description of the anatomic extent of disease at the time of diagnosis
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TNM staging of non-small-cell lung cancer

• T represents the characteristics of the

primary tumor (size and involvement)
• N represents regional lymph nodes and
extrathoracic lymph node
• M shows the presence or absence of
distant metastasis
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TNM staging of non-small-cell lung cancer

• The TNM subsets are then grouped in a series of stages of

disease to identify groups of patients with similar prognosis
and therapy.
• The value of the staging system in prognosis is
demonstrated by the 5-year survival statistics.
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TNM staging of small-cell lung cancer

• For SCLC, the TNM staging system has not proved to be useful,
because widespread metastases are often present at the time of
initial diagnosis.
• Patients with SCLC are divided into two major groups :those with
limited disease and those with extensive disease.
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Differential diagnosis of lung cancer
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Differential diagnosis of lung cancer

• Tuberculosis (TB).

• Pulmonary inflammation

• Other lung tumors

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Differential diagnosis of lung cancer

• The differentiation of lung cancer from other

lung diseases mainly depends on
• Clinical symptoms
• X-ray, CT examination
• Biopsy
• Surgical resection
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Treatment of lung cancer
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Treatment of lung cancer

• Operative treatment
• Radiotherapy
• Chemotherapy
• Targeted therapy
• Chinese traditional treatment
• Immunotherapy
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Surgery

• Surgical resection offers the best chance for cure in patients

with stage Ⅰ or stage Ⅱ NSCLC, provided there are no medical
contraindications to operation. Anatomic pulmonary
resection and intrathoracic mediastinal lymph node
dissection are performed.

• Standard surgery include pneumonectomy, lobectomy,

segmentectomy, and wedge resection.
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Chemotherapy

• Combination chemotherapy has been

well tolerated and associated with a
modest improvement in survival rate.

• Patients undergoing chemotherapy has

demonstrated improvement in quality of
life.
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Radiotherapy

• Radiotherapy is an effective adjuvant

treatment in many patients

• It is to prevent the recurrence of local

tumors, especially when lymph node
sampling of the mediastinum at
operation is incomplete.
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