Pulmonary Neoplasms & Chest Disorders Ahmed Mahmoud

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1 Pulmonary Neoplasms & Chest Disorders Ahmed Mahmoud Lung Ca ;Pathological types Adenocarcinoma More common in females Peripheral location Spread mainly by blood(brain..) Incidence is increasing (the most common) Brochoalveolar is a variant of adeno with the best prognosis of all when localised Squamous cell carcinoma Central part of the lung More to obstruct bronchus with distal atelectasis,cavitation and Abscess Spread more by lymphatics Small cell (oat cell) Worse prognosis Arises from neuroendocrine cells Blood and lymph spread early Positive malignant sputum and ve CXR Other types; Large cell,adenosquamos,carcinoid, adenoid cystic and mucoepidermoid

2 Clinical presentation Nonspecific presentation;cough, haemoptysis, loss of weight, CXR ;any lesion on CXR is cancer Until proved otherwisecompare with a prior CXR done more than 2 years ago (lung tumors may have a very slow rate of growth) SPN(solitary pulm nodule)could be malignant in 60% in patients above 50 with smoking history. Pleural effusion Hoarsness of voice in left side tumors (left recurrent laryngeal nerve) Superior vena cava syndrome;face edema.. Pancoast tumor;thoracic outlet syndrome with ulnar nerve symptoms,horner syndrome Extra thoracic manifestations NON METASTATIC Clubbing, ostearthropathy Hormonal production;acth,adh(small cell) or PTH (nonsmall cell) METASTATIC Liver,adrenal,brain,bone. Bone mets (the most common cause of High Ca in lung cancer) Diagnosis CXR CT scan chest and abdomen; look for Mediastinal LNS(>1cm), pleural effusion chest wall involvement,adrenal(30%malig) Bronchscopy; sputum.bronchus,carina Percutaneous needle biopsy;peripheral lesion.

3 Mediastinoscopy,only for LNS seen on CT,upper and lower para tracheal,subcarinal Thoracoscopy for peripheral lesion PET scan, depends on glucose uptake by active cells. Very sensitive (not specific).small cell has the highest uptake. Renal cell Ca is false ve. Sarcoidosisis a cause of false+ve If all above fail, Tissue DX is obtained during thoracotomy. >20 % of thoracotomy are done on VE Tissue DX (the best chance of survival) 50% of patients are inoperable when first seen because of Anatomical (extra or Intrathoracic invasions) or Physiological Causes Detremination of Irresectability ANATOMICAL(Extra or Intra thoracic) Extrathoracic mets,(bones,liver,adrenal?,..) N.B exceptions are ; solitary brain met in adeno- Hormones prodution is not a contraindication Clubbing,osteoarthopathy ANATOMICAL (Intrathoracic); SVC Syndrome,Contralateral LN,Recurrent Layngeal N, Malignant effusion,heart,vessels.. The following are not contraindication, Chest wall,diaphragm,pericardium Ipsilateral mediastinal LN,Pancoast tumor(resect after RXT) Cell type (small cell)(resect,then Chemo)

4 Causes of inoperability Physiological Post operative FEV1 >800 CC at least for resection of lung to be successful MVV(maximum voluntary ventilation) =MBC >50 % of predicted CO diffusion capacity Coronary artery disease Stages Stage I Stage IA= T1NO; Tumor less than 3 cm surrounded by normal lung or visceral pleura and arising >2 cm distal to carina Stage IB=T2NO, Surrounded by lung >3 cm,or visceral pleura involved,>2 cm distal to carina Stage II Stage IIA= T1N1 Tumor <3cm not to adjacent organs,with positive peribrochial or hilar LNS Stage IIB=T2N1 and T3N0 T2N1, Tumor >3 cm with no adjacent organ involevement,with ipsilateral bronchial or hilar LN T3N0; tumor involving chest wall,pleura,pericardium,but not involving the carina. Nodes are negative Pancoast tumor belongs to T3NO Stage IIIA; T3N1, T1-3 N2 T3N1=Tumor invading chest wall,pleura or pericardium with ipsilateral hilar LN

5 T1-3 N2=Tumor any size invading ipsilateral mediastinal or subcarinal LNs Stage IIIB;(T4 any N- N3 anyt) Any T4 regardless of N=Tumor into adjacent organs ( heart,oesphagus,vessels..) Satellite nodule in the same lobe is T4 Satellite nodule in a different lobe is M1 N3 regardless of T= contralateral mediastinal LN. Treatment Surgery;for stages I and II and selected IIIA The minimal is lobectomy+medistinal LN dissection Wedge, only when cannot tolerate lobectomy Preop XRT for pancoast tumor, ipsilateral LNs Post op Chemo for positive lymph nodes Secondary lung tumors Criteria for resection of Lung Mets; Primary tumor is controlled No extra pulm mets (except liver in colon ca) Can resect all mets with some margin Can tolerate resection Other ttt are not better (so Germ cell tumor mets are better treated with Chemo= cisplatinum) Best prognosis is Renal cell solitary met Next is soft tissue sarcoma(25% 5ys) When the primary is Squamous cell,the lung lesion is usually a new primary With adeno it is 50 % chance of being a primary lung versus a met The longer the time between control of 1ry tumor and the appearance of the met better prognosis

6 Mediastinal tumors Neurogenic Tumors Posterior mediastinum 90 % benign Commonly asymptomatic May extend into vertebral foramina Complete surgical excision Malignancy needs post op XRT Mediastinal Compartments Anterior- prevascular compartment thymoma, lymphoma, germ cell thyroid, parathyroid Visceral- central or middle compartment foregut cysts: bronchogenic, esophageal lymphoma, pericardial cyst Paravertebral- posterior compartment neurogenic: neurilemoma, neurofibroma, ganglioneuroma, neuroblastoma Lymphoma Anterior mediastinal Large Mass ++ Dx : Surgical incisional Bx Treatment ; non surgical T cell = Chemotherapy B cell = Chemo + XRt Hodgkin has better prognosis Surgery only for residual masses Germ cell tumors Classification; benign teratoma Seminomanonseminoma Non seminoma are;teratocarcinoma-yolk sac tumorchoriocarcinoma-endodermal sinus and embroynal cell

7 Benign teratoma is entirely benign.treatment is surgical excision only Non seminoma germ cell tumor Tumor markers are elevated in most cases ;AFP 80% and HCG 20% Non surgical ttt Chemotherapy ; cisplatinum based Residual Salvage Chemo Follow up by Tumor markers Germ cell tumor ; seminoma Tumor markers,hcg increase in 10% AFP is not elevated Treatment is non surgical Radiation + Cisplatinum chemo = up to 100 % cure Residual tumor = Salvage chemo Residual tumor may be teratoma Pneumothorax Primary(spontaneuos); Tall,thin young adult less than 40 years, ruptured apical bleb seen preoperatively in15% or intraoperatively.recurrence is common Secondary to; Bullous disease,copd,asthma,cysts, cystic fibrosis,pneumonia(anerobic Staph..) Pneumothorax Indications of thoracotomy; Massive air leak preventing lung expan Persistent air leak>5 days Second episode of PNX Occuptional indications after the first episode; Airline pilots. Scuba Divers

8 Previous contralateral PNX Lung Abscess Aspiraton ;posterior segment RUL or superior segment of lower lobe Tumors,FBs,or immune deficient persons are other causes Most are treated with Antibiotics. Very minimal role of surgery Aspergilloma Fungus ball H/O TB, HIV previous scar Haemoptysis Thoracic Outlet syndrome Structures to be compressed are 1. Nerve roots. C7,8 T1. Ulnar nerve 2. Subclavian Vein 3. Subclavian Artery They are compressed by First Rib. Scalenous anterior, Medius and cervical rib Anatomy right first rib Types of TOS / treatment Neurogenic physical therapy Vascular (venous) TPA,SURGERY Vascular (arterial) surgery Approches for thoracic outlet decompression Transaxillary Supraclavicular

9 Procedure is Resection of First rib. Divide the scalene muscle and remove any cervical rib if present Congenital lobar emphysema Most common sites in order are; - Left upper lobe - Right upper - Right middle lobe - IS A SURGICAL EMERGENCY - Very rare in lower lobe 50% of cases in first week of life 30% in next 3 weeks 15% of cases have associated congenital heart diseases Surgery is an emergency With resection of the affected lobe Pulmonary sequestration 2 types Intralobar ( the more common 75%) left lower lobe Blood supply : systemic artery or arteries arising from thoracic aorta (70%) or abdominal aorta (30%) Venous drainage : pulmonary vein Extralobar Arterial suppply,descending thoracic aorta in 70% Venous darinage; systemic (azygos)or portal