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Lung Neoplasms

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.

anthony-maynard
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Lung Neoplasms

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  1. Lung Neoplasms Danielle Press,MD

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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)

  7. 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

  8. N2 nodes: 1-4 Regional nodes: 5-9 N1 nodes: 10-14

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. Neuroendocrine Tumors Carcinoid Atypical carcinoid Small cell Large cell

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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)

  31. 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

  32. 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

  33. 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

  34. Results

  35. Benign Tumors of the Lung

  36. 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

  37. 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

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