Lung Lesions

1. 2. 3. 4. Solitary Pulmonary Nodule. Benign lung tumors. Carcinoid tumor Carcinoma of the Lung

Solitary Pulmonary Nodule

Definition. Less than 2 cm. Within the lung parenchyma Etiology !nflammatory granulomas !nfection e.g. "B# histoplamosis# coccidomycosis... !mmune mediated e.g. sarcoidosis# rheumatoid nodules or Wegner granuloma $although usually multiple% Neoplastic Benign &alignant Presentation 'symptomatic $incidental finding on chest ( ray or C" scan% Diagnosis Benign )s &alignant *istory 'ge# smo+ing# occupation# other primary tumors#,% !maging C(- and C" 1. "ime if the nodule did not change from a pre)ious radiograph# then it is most li+ely a .enign lesion. 2. 'ttenuation 1. Calcification /iffuse# central# lamellar or chondroid 0popcorn0 are patterns of .enign lesions.

&alignant tumors usually ha)e eccentric calcification. 2. 1at content indicate .enign lesion especially hamartoma. 3. &argin 1. Speculated margin 2 345 malignant. 2. Smooth margin not specific $may .e .enign or malignant% 4. 6asuclarity $C" 7ith contrast% malignant tumors are highly )ascular. P8" scan &ore than 345 sensiti)e and specific . &alignant tumors ha)e increased meta.olism 2 increase upta+e..

1. 2. 3. 4. 9.

*istopathology. Culture. Biopsy "rans.ronchial $7ith fluoroscopy guidance% Percutaneous core $near%# 1N' $central% 8:cisional B: $open thoractotomy or 6'"S%.

Complications pneumothora: $more than 145%# haemothora:. Treatment /epends on the ris+ for malignancy. 1. Surgical remo)al $either open or through 6'"S% in patients 7ith high ris+ for malignancy. 2. ;.ser)e and follo7<up 7ith C" e)ery 3 months for 1=2 years if "here is lo7 ris+ of cancer. "he nodule sho7s .enign appearance. "here is no radiological change in the si>e of the nodule for 2 years. ;r if there is a poor operati)e ris+

Benign Lung Tumors

1. -are. Classification 8pithelial Polyps Papillomas 2 Bronchial mucous gland adenoma &esodermal Chondroma# Lipoma# 1i.roma $125%# Leiomyoma. Sclerosing haemangioma &iddle<aged 7omen. Solitary nodule partially calcified. *aemangiopericytoma highly )ascular 7ith malignant potential. ?n+no7n @ Clear cell tumor $sugar tumor% *amartoma the most common .enign lung tumor. ;ccur in all ages 7ith slight male predominance. Well circumscri.ed slo7<gro7ing single nodules up to 2 cm in si>e C" ApopcornB calcification and fat. ;thers e.g. plasma cell granuloma# germ cell tumor $teratoma%# (anthoma and inflammatory pseudotumors,

2.

3.

4.

Bronchial Carcinoid

?sed to .e called A.ronchial adenomaB 95 of all lung cancers. Neuroendocrine $'P?/% tumor that arise from Culchits+y cells.

Typical Carcinoid: 345 of .ronchial carcinoids. Well differentiated# locally in)asi)e tumor 7ith lo7 malignant potential. -arely cause carcinoid syndrome. *ighly )ascular. "reated .y surgical resection 7ith intraoperati)e fro>en section. Prognosis after resection is e:cellent. Atypical Carcinoid: !ncreased cellularity# pleomorphism and mitotic acti)ity. &ore aggressi)e 7ith high tendency to metastasi>e to regional lymph nodes. Surgical e:cision is the treatment of choice.

Lung Cancer
Epidemiology

!n the past 3 decades# "he incidence of lung cancer has increased significantly in de)eloped countries. !t is second most common cancer in .oth se:. 295 of all cancer death in ?S# "he num.er one cause of cancer death in .oth se:.

Etiology 1. Smo+ing $responsi.le of D95 of all lung cancers % i. type ii. duration iii. amount i). passi)e $35 of patients 7ith lung cancer% 2. 8n)ironmental radon gas #as.estos #chromium #silica #arsenic ,.etc 3. /ietary fat and cholesterol )s. fruit # )egeta.le and )itamin ' EE 4. Pree:isting lung disease C;P/ # diffuse pulmonary fi.rosis and scaring from "B or infarction. 9. !nheritance positi)e family history has .een descri.ed as a rare autosomal co<dominant resulting in earlier age of onset lung cancer. F. &olecular genetic alteration ;ncogenes $-'S% or tumor suppresor gene $p93 and -B % on cell gro7th. Classification Based on histological differentiation 1. 'denocarcinoma $495% "he most common type. "end to .e in peripheral lung parenchyma and in al)eolar septa Lymph node metastasis is common 2. SGuamous cell $epidermoid% carcinoma $345% "end to .e centrally $maHor .ronchi%. !n)ade locally. 3. Large cell $undifferentiated% carcinoma $9<145% "end to .e in peripheral lung ;ften ca)itate 8arly metastasis 4. Small cell carcinoma$245% discussed later 9. Carcinoid and uncommon lung cancers. Presentation
Local in)asion of primary tumor I45 of the patients are symptomatic. Centrally Cough dyspnoea# unresol)ed pneumonia# 7hee>e and hemoptysis. Peripherally chest 7all pain# pleural effusion# tumor capitation and dyspneoa. -egional spread 7ithin thora: and to mediastinum Pleura $pain# effusion%# chest 7all$pain%# pericardium$effusion%# superior )ena ca)a$o.struction%# Pancoast tumor$superior sulcus tumor% # cer)ical sympathetic ner)es$*orner syndrome%# recurrent laryngeal ner)e$hoarseness%# phrenic ner)e $ hemediaphram% or esophagus$dysphasia%.

/istant &etastasis Li)er# .one# .rain or adrenals

Paraneoplastic Syndrome Jeneral anore:ia# cache:ia and lo7 grade pyre:ia SCLC 'C"* # S!'/* and 8ton<lam.ert syndrome SGuamous cell carcinoma P"*.

Diagnosis *: K P8. Sputum cytology ha)e little role in routine 7or+<up of patient 7ith suspected lung cancer. Chest :<ray initial diagnostic procedure of choice in suspected patient. !ts help in locali>e the tumor# presence of mediastinal or hilar lymph node# pleural effusion and lung consolidation. 'denocarcinoma Well defined peripheral nodule and &ay ha)e chest 7all in)ol)ement. SGuamous Lung Cancer central located # associated atelectasis and hilar adenopathy Large cell carcinoma peripheral mass may ca)itate and association 7ith hilar or mediastinal adenopathy . C" scan useful for assessing the si>e of primary cancer # pro:imity to adHacent organ and for planning surgical approaches. &-! no ad)antage o)er C" # it more accurate in assessing spinal cord in)asion. Bronchoscopy play an essential role in diagnosis # staging and treatment. Precutaneous needle .iopsy fluoroscopic or C"<guided &ediastinoscopyL&ediastinostomy its improtant for staging. "horacoscopy most useful for e:amining pleural space for seeding of tumor .

Surgical Treatment of Lung Cancer (NSCLC) Principles 1. Complete resection of the primary tumor 7ith its intrapulmonary lymphaticMs. 2. !ntraoperati)e fro>en sections to asses the safety margin.. 3. !ntraoperati)e lymph node staging. Contraindications to Surgical esection 1. /istant metastasis $&1%. 2. !n)asion of central mediastinal structures $heart# great )essels# trachea and oesophagus%$"4%. 3. &alignant pleural effusion $"4%. Surgery for NSCLC 1. Stage !<!! 1. Surgery is the most effecti)e treatment 2. -adiotherapy may .e used if patient is inopera.le. 2. Stage !!!<!6 1. Local $N4% selected patients $alone or 7ith induction therapy%. 2. N2 Contro)ersial. Com.ined modality $Surgery N radiation% 3. N3 $contralateral LN% surgery is a.solutely contraindicated. 4. &1 $/istant &etastasis% palliati)e surgery Surgical !ptions for Lung Cancer 1. WedgeLSegmental resection peripheral tumor O 3 cm in patients 7ith poor pulmonary reser)e. 2. Lo.ectomyL.iloectomy 1. Preser)e lung function N adeGuate tumor margin. 2. &ortality O 35. 3. Pneumonectomy 1. if the tumor in)ades other pulmonary structures e.g. mainstem .ronchus or main pulmonary artery. 2. &ortality I5 4. 6ideo 'ssisted "horacosopic Surgery $6'"S% 1. Not recommended for definiti)e treatment# .ut may .e used for 7edge resections in high ris+ patients. 9. Palliati)e resections 1. Non curati)e. 2. ?sed to impro)e the Guality of life if there is sepsis due to .ronchial o.struction or there is massi)e hemoptysis $asphy:ia%. "ollo#$up % outcome * # 8 K C(- e)ery 3ms for 2ys and e)ery Fms for su.seGuent 3ys Tumor recurrence: 7ithin first 2<3 ys 1. local recurrence same lung or surgical margin 2. regional recurrence 7ithin mediastinal lymph node. 3. systemic recurrence other lung or outside thora:. Second primary cancers: increased ris+ of de)eloping second primary tumor of upper areodigesti)e tract $ i.e. oropharyn: # esophagus # lung % the prognoses or estimated 9<year sur)i)al rates# in the ?nited States are as follo7s o)erall is 135 .ecause most of the patient diagnosed in stage !6. Stage !' < I95 Stage !B < 995

Stage !!' < 945 Stage !!B < 445 Stage !!!' < 14<395 Stage !!!B < 95 $Stage !!!B lesions are non resecta.le.% Stage !6 < Less than 95 C&emot&erapy

?sed in the management of NSCLC $Stage !!!<!6%. Com.ination $multi<agent% chemotherapy is more effecti)e than single<agent chemotherapy . &ay .e used as induction agents .efore operation to impro)e the resecta.ility 2 2 mortality K mor.idity. or as postoperati)e adHu)ant $Not pro)en% or as radiosensiti>ers in concurrent chemo<radiotherapy.

Small Cell Lung Cancer (SCLS) ;at cancer =245 8pithelial tumor capa.le of e:pressing neuroendeocrine amine precursor upta+e and decar.o:ylase $'P?/% mar+er# 7hich can act as neurotransmitters and hormones. !t is aggressi)e tumor 7ith high rates of cell proliferation molecular genetic alteration than NSCLC. 8arly metastasis . Strong associated 7ith smo+ing . "end to .e centrally in C"( 7ith .ilateral mediastinal lymph node in)ol)ement . Staging of SCLC: Limited disease confined to one side of lung 8:tensi)e disease contralateral lung or e:tra thoracic . 6ery limited disease confined to the lung 'anagement of SCLC: Primarily treated 7ith chemotherapy 8:tensi)e disease maHority of patient com.ination therapy 9ys sur)i)al O 95 Limited disease 34 5 of patient 945 ha)e compleate response to therapy 9ys sur)i)al 245 6ery limited disease rare surgery is preferred 9ys sur)i)al F4<I4<5