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Lung Neoplasms. Danielle Press,MD. Epidemiology. Decreasing incidence in men, stable incidence in women Men – 83.5 in 100,000 Women – 49.2 in 100,000 Decline likely due to public health initiatives to stop smoking Death rates decrease to that of nonsmokers 10yrs after cessation.

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lung neoplasms

Lung Neoplasms

Danielle Press,MD

epidemiology
Epidemiology

Decreasing incidence in men, stable incidence in women

Men – 83.5 in 100,000

Women – 49.2 in 100,000

Decline likely due to public health initiatives to stop smoking

Death rates decrease to that of nonsmokers 10yrs after cessation

tumor biology
Tumor Biology

Many mechanisms

Chromosomal loss of heterzygosity or allelic gain

K-ras, myc, p53 mutations

Inactivation of tumor suppressor p16INK4a (p16)

EGF receptor mutations possibly important to response to chemotherapy

non small cell lung cancer nsclc
Non-Small Cell Lung Cancer (NSCLC)
  • Evaluate for distant mets
    • Brain, contralateral lung, supraclavicular nodes, bone, liver, adrenals
    • Labs: CBC, BMP, Ca, alk phos, LDH
    • CT or PET
  • CT chest/upper abd to evaluate tumor & lymph node status
  • Mediastinoscopy – gold standard fro tissue diagnosis of mediastinal lymphadenopathy
tnm staging non small cell lung cancer
TNM Staging Non & Small Cell Lung Cancer

T1 <3cm, surround by lung or visceral pleura, no invasion of main bronchus

T2 >3cm, involves main bronchus but >2cm distal to carina; invades visercal pleura; atelectasis or obstructive pneumonitis that extends to hilar region but does not involve entire lung

T3 Any size that directly invades any of these: chest wall, diaphragm, mediastinal pleura, parietal pericardium; tumor in main bronchus <2cm from carina but no involvement of carina; atelectasis or obstructive pneumonitis of entire lung

T4 Any size that involves any of these: mediastinum, heart, great vessels, trachea, esophagus, vertebral body, carina; malignant pleural or pericardial effusion; satellite tumor nodule with ipsilateral primary tumor lobe

tnm staging
TNM Staging

N0 No regional lymph node mets

N1 Mets to ipsilateral peribronchial and/or ipsilateral hilar lyph nodes and involvement in intrapulmonary nodes by direct extension of primary tumor

N2 Mets to ipsilateral mediastinal and/or subcarinal lymph nodes

N3 Mets to contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or suprclavicular lymph nodes

M0 No distant mets

M1 Distant mets present (including metastatic tumor nodule in ipsilateral non-primary tumor lobe of the lung)

tnm staging1
TNM Staging

Grouping TNM staging

Stage 0 Tis N0 M0

Stage IA T1 N0 M0

Stage IB T2 N0 M0

Stage IIA T1 N1 M0

Stage IIB T2 N1 M0

T3 N0 M0

Stage IIIA T1 N2 M0

T2 N2 M0

T3 N1 M0

T3 N2 M0

Stage IIIB Any T N3 M0

T4 Any N M0

Stage IV Any T Any N M1

slide9

N2 nodes:

1-4

Regional nodes:

5-9

N1 nodes:

10-14

risk assessment
Risk Assessment

Comorbidities might prohibit surgical resection

Age alone is not a contraindication to surgery

Preop cardiovascular risk assessment is needed

Preop spirometry, FEV1, DLCO, ABG, quantitative perfusion scanning, formal or informal exercise testing

treatment of nsclc
Treatment of NSCLC

Stages I/II – definitive staging & pulmonary resection with negative margins

Enbloc resection is adjacent structures are involved

Peripheral tumors can be taken with non-anatomic wedge resection – higher risk for locoregional recurrence (25-50%)

Central tumors should be treated with sleeve lobectomy rather than pneumonectomy when possible

Nodal status should be confirmed – systematic sampling vs nodal dissection

survival rates of nsclc
Survival Rates of NSCLC

5-Yr Survival

Stage I – 60-70%

Stage II – 40-50%

Stage IIIA – 15-30%

  • Staging
  • Histology – needs to be further defined
    • Squamous has better survival than non-squamous cancer
    • Does not seem to influence survival in late stage tumors
patterns of recurrence
Patterns of Recurrence
  • Predominant sites of relapse for all stages after resection are distant mets
  • For all stages, brain is single most common site of relapse
  • Other common metastatic sites
    • Bone
    • Ipsilateral or contralateral lung
    • Liver
    • Adrenal glands
  • 60% recurrences in 1st 2yrs after resection
  • Virtually of recurrences related to primary tumor occur within 5yrs of resection
  • Risk of new second cancer – 2-3% per year
  • New, non-pulmonary cancer – breast, colon, prostate
treatment of stage iii disease
Treatment of Stage III Disease
  • Is locoregionally advanced disease
  • Stage IIIB considered unresectable
    • T4 or N3 disease has no role for resection
    • Small series have shown resection with invasion of SVC, left atrium, or aorta after induction chemo to downsize has survival benefit
  • Stage IIIA treatment is controversial & complex
treatment of stage iiia
Treatment of Stage IIIA
  • 5yr survival for N2 disease is 0-40%, usually 20-30%
    • Varies with mediastinal nodal involvement, size of primary tumor, & ability to achieve complete resection
  • Evidence suggests survival benefit for pts receiving preop chemo

Stage IIIA

T1 N2 M0

T2 N2 M0

T3 N1 M0

T3 N2 M0

stage iiia neoadjuvant therapy
Stage IIIA Neoadjuvant Therapy

Optimal treatment not yet fully defined

Improved resectability & survival with induction chemo vs resection or radiation alone

Higher doses of radiation (>5500 cGy) are associated with postoperative ARDS and bronchial stump leak

superior sulcus tumors
Superior Sulcus Tumors

Pancoast tumors

Previously thought to be uniformly fatal

Frequently involve: brachial plexus, subclavian vessels, spine

Usually T3 or T4 (Stage IIIA or IIIIB)

Patients without N2 disease should have induction chemoradiation followed by resection

neuroendocrine tumors
Neuroendocrine Tumors

Carcinoid

Atypical carcinoid

Small cell

Large cell

typical atypical carcinoid tumors
Typical & Atypical Carcinoid Tumors
  • Low-grade malignant potential
  • About 2% of lung cancers
  • From neuroendocrine stem cells of bronchial epithelium
  • Atypical carcinoids
    • Increased mitotic activity
    • Increased nuclear pleomorphism
    • Areas of disorganization of architecture & tumor necrosis
carcinoid tumors
Carcinoid Tumors
  • Presentation
    • Hemoptysis
    • Dyspnea
    • Recurrent/persistent pneumonitis
  • Diagnosis
    • Bronchoscopy
    • CXR
  • Carcinoid syndrome – only about 2%, usually in pts with liver mets
  • Common sites of mets: lung, bone, liver, adrenals, brain
carcinoid tumors1
Carcinoid Tumors
  • Treatment is surgical resection
    • Even in presence of nodal involvement
    • Should include mediastinal lymph node sampling or dissection
  • Lobectomy needed in 50%
  • Endoscopic resection is associated with local recurrence – should only be palliative
  • Long term surival >90% after resection in typical carcinoid, 5yr survival after resection in atypical carcinoid 60%
  • Recurrence more frequent in tumors >3cm with lymph node mets
large cell neuroendocrine carcinoma
Large Cell Neuroendocrine Carcinoma

Microscopoicly similar to neuroendocrine tumors

Tumors are large, have high mitotic rate, frequently have necrosis

High-grade tumors

Related to smoking

Survival w/resection: 5yr 267%, 10yr 9%

Management similar to NSCLC

small cell lung cancer
Small Cell Lung Cancer

Most aggressive clinical course

Often widely disseminated at diagnosis

Responsive to chemotherapy

Limited disease = confined to one hemithorax and regional lymph nodes, ipsilateral pleural effusion (positive or negative cytology)

Distant mets: bone, liver, bone marrow, CNS

<10% SCLC is referred for surgical evaluation

small cell lung cancer1
Small Cell Lung Cancer
  • Response to chemoradiation
    • Limited disease – 85-90%
    • Extensive disease – 75-85%
    • Chemo = cisplatin, etoposide
  • 2yr survival remains poor
  • Role for resection in T1-2, N0-1 disease
    • Adjuvant chemo usually given
    • Relapse at primary site uncommon after resection
bronchial gland carcinomas
Bronchial Gland Carcinomas

About 1% of all lung neoplasms

Also called primary salivary gland-type tumors or bronchial adenomas

Centrally located tumors present with irritation, cough, SOB, hemoptysis, recurrent infection, wheezing, stridor

Smoking not a risk factor

Most don’t metastasize

Treatment is complete excision, preservin as much pulmonary tissue as possible

adenoid cystic carcinoma
Adenoid Cystic Carcinoma

Slow growing malignant tumor arising from submucosal glands of the trachea & main bronchi

Tend to spread in the submucosal plane along the lymphatics

Treat of choice is total resection

Postoperative radiation is given

Palliative treatment is endoscopic laser removal & radiation

mucoepidermoid carcinoma
Mucoepidermoid Carcinoma

Low or high-grade malignancy

Have same microscopic appearance as the salivary gland tumor

Present as submucosal lesions

Treatment is similar to carcinoid

High-grade tumors have the same prognosis as bronchogenic carcinoma

Complete surgical resection is the mainstay of treatment

mucous gland adenoma
Mucous Gland Adenoma

Rare, submucosal tumors arising from mucous glands

Also known as bronchial cysts or papillary cystadenomas

Benign tumor behavior

Treated with endoscopic excision

Surgical resection if endoscopic excision is contraindicated or incomplete or if distal lung is damaged by chronic infection

surgical resection of pulmonary metastases
Surgical Resection of Pulmonary Metastases

First reported in 1926

Historically done in pts w/complete resection of primary tumor, no evidence of recurrence or other metastatic disease, & general good health

Indications for resection of metastases have become more liberal

clinical presentation diagnosis
Clinical Presentation & Diagnosis
  • Asymptomatic in 85%
  • CXR – well-circumscribed spherical, solid mass with well-defined borders
  • Usually arise from parenchyma
    • Endobronchial mets from renal cell, colon, breast
  • Hilar or mediastinal nodal involvement with pulmonary mets – poor prognostic indicator
  • Solitary lesion: metastatic or new primary?
    • More likely to be metastatic if primary lesion is sarcoma or melanoma
    • More likely new primary if original tumor was head & neck or breast
criteria for surgical resection
Criteria for Surgical Resection

Disease-free interval – time from resection of primary tumor to diagnosis of mestastases

Tumor doubling time – measure of aggressiveness of tumor growth

Number of metastatic nodules – considered predictive of survival

Resection should only be undertaken if complete resection is considered feasible

Not every metastatic lesion should be resected – some nodules indicate disseminated disease even if pulmonary nodule is solitary (breast)

metastatectomy primary disease recurrence
Metastatectomy & Primary Disease/Recurrence
  • Metastatic lesion & recurrence at primary site
    • Resect recurrent primary first
  • Primary tumor & metastatic disease diagnosed simultaneously
    • Resect metastatic disease first if primary tumor might not be completely resectable
preoperative evaluation
Preoperative Evaluation
  • Similar to that for pulmonary resection for primary cancer
  • Pulmonary function post-chemotherapy may be substantially reduced
    • Bleomycin & mitomycin diminish DLCO & cause ARDS-like picture postop (prevent by using <35% FiO2 intraop)
  • Preop cardiac evaluation necessary, especially in pts receiving doxorubicin
  • Avoid surgery while pt is neutropenic or thrombocytopenic
surgical technique
Surgical Technique
  • Two priniciples:
    • Complete resection of disease
    • Maximal sparing of functioning lung tissue
  • Anterolateral or posterolateral thoracotomy for unilateral disease
  • Bilateral disease should be resected simultaneously if possible
    • Median sternotomy or clamshell incision
  • VATS doesn’t allow palpation of lung – its role is questioned in resection of metastatic disease
  • Repeat metastatectomy for recurrent disease is beneficial
hamartoma
Hamartoma
  • Most frequent benign tumor
    • 75% of benign lesions
  • Most frequent component is cartilage
  • Extremely slow growth
  • Do not require excision unless centrally located & cause symptoms of obstruction, etc or carcinoma can’t be ruled out
other benign tumors
Other Benign Tumors

May present as endobronchial lesions

May be removed endoscopically

Surgical excision when diagnosis is in doubt or when endoscopic excision has been incomplete

Peripheral tumors are often removed for diagnosis