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Lung Neoplasms. Sanjay Munireddy Dept of Surgery Sinai Hospital of Baltimore June17, 2008. Overview. Leading cause of cancer-related death among men and women and 2nd most common cause of overall mortality in US Estimated new cases in 2008: 215,020 Estimated deaths in 2008: 161,840.

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lung neoplasms

Lung Neoplasms

Sanjay Munireddy

Dept of Surgery

Sinai Hospital of Baltimore

June17, 2008

overview
Overview
  • Leading cause of cancer-related death among men and women and 2nd most common cause of overall mortality in US
  • Estimated new cases in 2008: 215,020
  • Estimated deaths in 2008: 161,840
epidemiology
Epidemiology
  • Recent continued decline in incidence among men (79.4 cases per 100,00)
  • Stabilization of incidence in women (52.6 cases per 100,00)
  • Greatest incidence in AA men (107.6 cases per 100,000)

NCI SEER Cancer Data

risk factors
Risk Factors
  • Smoking
  • Second hand smoke
  • Sex - men
  • Race - African American
  • Environmental gases - Asbestos, radon, tar soot, arsenic, silica etc.
  • Excessive alcohol use
  • Radiation therapy to chest
  • Family history of lung cancer
smoking
Smoking
  • Greatest risk factor; dose-response relationship between the number of pack-years smoked and lung cancer risk
  • 87% of all lung cancer deaths result from smoking
  • Death rates decrease to that of never-smokers after 10 yrs of smoking cessation
1999 who classification of lung tumors
1999 WHO Classification of Lung Tumors
  • Epithelial
    • Malignant
      • Squamous cell carcinoma
      • Small cell carcinoma
      • Adenocarcinoma
      • Large cell carcinoma
      • Adenosquamous cell carcinoma
      • Carcinomas with pleomorphic, sarcomatoid or sarcomatous elements
      • Carcinoid tumor
types
Types
  • Non-small cell lung cancer (NSCLC)
    • Comprise 80% of lung tumors
    • 50% are metastatic at diagnosis
  • Small cell lung cancer (SCLC)
    • Comprise 20%
    • 80% are metastatic at diagnosis
adenocarcinoma of lung
Adenocarcinoma of Lung
  • Most common type of lung cancer
  • Comprises 30-40% in smokers and 60-80% in non-smokers
  • Arises from terminal bronchioles
  • Usually develops in the peripheral portions of the lung
  • Slow growing than squamous cell ca.
  • Often is associated with a peripheral scar or honeycombing due to response to tumor
squamous cell carcinoma of lung
Squamous Cell Carcinoma of Lung
  • Comprise 25-40% of lung cancers; rates are declining due to reduction in smoking
  • Dose-response relationship of smoking is strongest with this type of cancer
  • Usually occurs in the lung’s central portions or in one of the main airway branches.
  • Can form cavities in the lung if they grow to a large size
  • Slow growing
large cell carcinoma of lung
Large Cell Carcinoma of Lung
  • Accounts for 10-15% of lung tumors
  • Diagnosis of exclusion; cannot diagnose on small biopsies or in lymph node metastases
  • Usually large peripheral mass with necrosis
  • Often associated with peripheral eosinophilia and leukocytosis, due to tumor production of colony stimulating factor
small cell carcinoma of lung
Small Cell Carcinoma of Lung
  • Also called undifferentiated or oat cell carcinoma
  • Accounts for 10-15% of lung tumors
  • Almost always caused by smoking
  • Fast growing compared to NSCLC
  • Usually metastatic in about 70% of cases at the time of diagnosis
  • Without treatment, has the most aggressive clinical course of any type of pulmonary tumor
  • Median survival from diagnosis of only 2 to 4 months.
clinical presentation
Clinical Presentation
  • Majority are symptomatic at presentation (>85%)
  • Symptoms are broadly classified as
    • Due to lung lesion
    • Due to intra-thoracic spread
    • Due to distant mets
    • Due to paraneoplastic syndrome
clinical presentation13
Clinical Presentation
  • Symptoms due to lung lesion/primary tumor
    • Coughing ± sputum
    • Dyspnea
    • Hemoptysis
    • Chest pain
    • Wheezing
    • Weight loss
clinical presentation14
Clinical Presentation
  • Central tumors (squamous cell carcinomas) generally produce symptoms of cough, dyspnea, atelectasis, wheezing, postobstructive pneumonia,, and hemoptysis.
  • Most peripheral tumors are adenocarcinomas or large cell carcinomas and, in addition to causing cough and dyspnea, can cause symptoms due to pleural effusion and severe pain as a result of infiltration of parietal pleura and the chest wall.
clinical presentation15
Clinical Presentation
  • Symptoms of intra-thoracic spread
    • Pleural or pericardial effusion
    • Compression of RLN (hoarseness), phrenic nerve palsy (elevated diaphragm), pressure on the sympathetic plexus (Horner syndrome)
    • Tracheal obstruction, esophageal compression, SVC syndrome
    • Superior sulcus tumors can cause compression of the brachial plexus roots as they exit the neural foramina, resulting in intense, radiating neuropathic pain in the ipsilateral upper extremity.
clinical presentation16
Clinical Presentation
  • Symptoms of distant spread
    • May occur in almost every organ system
    • Bone mets (vertebrae, ribs, pelvis are MC)
    • Hepatic mets (indicate poor prognosis)
    • Brain mets (headache, nausea, vomiting, seizures, confusion, personality changes
clinical presentation17
Clinical Presentation
  • Paraneoplastic syndromes (10%)
    • Squamous cell carcinoma: hypercalcemia due to parathyroidlike hormone production.
    • Adenocarcinomas: Clubbing, hypertrophic pulmonary osteoarthropathy and the Trousseau syndrome of hypercoagulability
    • Small cell carcinomas: SIADH, Ectopic ACTH production, Lambert-Eaton myasthenic syndrome
diagnosis
Diagnosis
  • History & physical
    • Wt. loss, respiratory distress
    • Lymphadenopathy
    • Horner syndrome
    • SVC syndrome (usually SCLC)
    • Absence of breath sounds, dullness, pleural effusions
    • Bone pain
    • Neurological deficits
diagnosis19
Diagnosis
  • CXR
  • Sputum cytologic studies: centrally located endobronchial tumors exfoliate malignant cells into sputum
  • Thoracentesis
  • FNAB
  • Bronchoscopy with BAL, brushings, biopsies
  • Staging work-up
    • Local extent
    • Distant spread
staging
Staging
  • In the United States, the standard staging workup includes at least the following:
    • Complete history and physical examination
    • CT scan of the chest and upper abdomen (including liver and adrenals)
    • Complete blood cell counts
    • Liver and kidney functions tests
    • Serum electrolytes
staging21
Staging
  • Local extent
    • Cervical mediastinoscopy
    • Left anterior mediastinotomy
  • Distant spread
    • CT or Ultrasound of the abdomen
      • liver, adrenals
    • Bone scan
    • CT head
    • MRI
    • PET scan
management
Management
  • Functional Evaluation
    • Evaluation of performance and pulmonary status should be completed before discussing treatment options
    • Pulmonary function testing, specifically forced expiratory volume in one second (FEV1) and carbon monoxide diffusion in the lung (DLCO) measurements, is a helpful predictor of morbidity and mortality in patients undergoing lung resection
management24
Management
  • Functional Evaluation
    • Patients with an FEV1 or DLCO value less than 80 percent of predicted require additional testing.
    • calculation of postresection pulmonary reserve (with ventilation and perfusion scans or by accounting for the number of segments removed); cardiopulmonary exercise testing; and arterial blood gas sampling
    • Patients with a predicted postoperative FEV1 or DLCO value less than 40 percent and a VO2max value less than 10 mL per kg per minute or an SaO2 value less than 90 percent are at high risk of perioperative death or complications
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