Download TNM * Staging of lung cancer

Dr.Waseem HAJJAR MD, FRCS,
Assistant Professor &
Consultant thoracic surgeon
KKUH, King Saud University
 Solitary Pulmonary Nodule.
 Benign lung tumors.
 Carcinoid tumor
 Carcinoma of the Lung
Solitary Pulmonary Nodule
 Definition. Less than 3 cm. Within the lung
parenchyma
 Presentation: Asymptomatic (incidental finding on
chest X ray or CT scan)
 Significance: To distinguish benign lesion ( tumor –
inflammatory ) from early stage highly curable cancer
 Etiology:
 Inflammatory granulomas
 Infection e.g. TB, histoplamosis, coccidiodomycosis
 Round pneumonia
 Immune mediated e.g. sarcoidosis, rheumatoid nodules
or Wegner granuloma (although usually multiple)
 Neoplastic
 Benign
 Malignant
Diagnosis
 Benign vs Malignant
 History: Age, smoking, occupation, other primary
tumors,…)
 Imaging:
 CXR and CT:
CXR and CT- Time:
 if the nodule did not change from a previous
radiograph, then it is most likely a benign lesion.
CXR and CT- Attenuation:
1.
Calcification:
Diffuse, central, lamellar or chondroid "popcorn" are
patterns of benign lesions.
Malignant tumors usually have eccentric calcification.
2.
Fat content: indicate benign lesion especially
hamartoma.
CXR and CT- Margin
1.
2.
Speculated margin 90% malignant.
Smooth margin: not specific (may be benign or
malignant)
Vasuclarity (CT with contrast):
 malignant tumors are highly vascular.
PET scan:


More than 90% sensitive and specific.
Malignant tumors have increased metabolism increase
uptake..
Histopathology.

Culture.
Biopsy:




Transbronchial (with fluoroscopy guidance)
Percutaneous: core (near), FNA (central)
Excisional Bx (open thoractotomy or VATS).
Histopathology.
 Complications: pneumothorax (more than 10%),
haemothorax.
Treatment
1.
2.
Depends on the risk for malignancy.
Surgical removal (either open or through VATS) in patients
with high risk for malignancy.
Observe and follow-up with CT every 3 months for 1–2 years if:
There is no radiological change in the size of the nodule for 2
years.
There is low risk of cancer.
The nodule shows benign appearance.
Or if there is a poor operative risk
Benign Lung Tumors
 Rare.
 Incidental findings as solitary lung nodules. Clinically asymptomatic.
 Classification:
 Epithelial:



Polyps
Papillomas
Bronchial mucous gland adenoma
 Mesodermal:
 Chondroma, Lipoma, Fibroma (12%), Leiomyoma.
 Lipoma:
Arising from submucosal fat between the cartilaginous rings of the
bronchus
Presents mostly by endobronchial symptoms
Treated by brochoscopic excision
 Sclerosing haemangioma:
Middle-aged women.
Solitary nodule partially calcified.
 Haemangiopericytoma: highly vascular with malignant potential.
Benign Lung Tumors


Unknown ;
 Clear cell tumor (sugar tumor)
 Hamartoma: the most common benign lung tumor.
Occur in all ages with slight male predominance.
Well circumscribed slow-growing single nodules up to 2 cm in
size
CT: “popcorn” calcification and fat.
Others e.g. plasma cell granuloma, germ cell tumor
(teratoma), Xanthoma and inflammatory pseudotumors
Definitive diagnosis is made by excisonal biopsy
Rigid bronchoscopy diagnostic and therapeutic in case of symptomatic
lesions
Hamartomas
(chondroadenomas)
Most common type of benign lung tumor, slow growing lesion
Mainly occur in adults.
Hamartomas are peripherally located.
Grossly, they have a firm marblelike consistency.
Histologically, hamartomas generally consist of epithelial tissue
and other tissues such as fat and cartilage.
 Radiologically appears as well-circumscribed single nodules, up to
2cm , it can be localized in the lung





 CT scanning shows calcification and fat in up to half of the
lesions.
Parenchymal hamartoma of the
lung. The surrounding lung falls
away from the well-circumscribed
mass, a typical feature of these
lesions. The hamartoma shows a
variegated yellow and white
appearance, which corresponds
respectively to fat and cartilage
Benign lung tumors can be classified by their
origin into:
Mesodermal (fibroma, lipoma,
leiomyoma, chondroma, granular cell
tumor, sclerosing hemangioma)
Other (myofibroblastic tumor,
xanthoma, amyloid, mucosaassociated lymphoid tumor).
Benign Lung Lesion
Unknown (hamartoma, clear cell,
teratoma), epithelial (papilloma,
polyps),
NOTE:Adenoma and hamartomas
constitute the largest group
ofbenign lung lesion
Bronchial Carcinoid
 Used to be called “bronchial adenoma”
 5% of all lung cancers.
 Neuroendocrine (APUD) tumor that arise from
Kulchitsky cells.
Types of Carcinoid tumor
Typical lung carcinoid
carcinoid
Atypical lung
Bronchial Carcinoid
 Typical Carcinoid:
 90% of bronchial carcinoids.
 Well differentiated, locally invasive tumor with low malignant







potential.
Rarely cause carcinoid syndrome.
Highly vascular.
Treated by surgical resection with intraoperative frozen section.
Prognosis after resection is excellent.
Atypical Carcinoid:
Increased cellularity, pleomorphism and mitotic activity.
More aggressive with high tendency to metastasize to regional lymph
nodes.
 Surgical excision is the treatment of choice.
Carciniod Tumor
Carcinoid tumors are a slow-growing cancer that can
arise in several places throughout your body.
Carcinoid tumors, which are one subset of tumors
called neuroendocrine tumors,known as the
usually appear in the gastrointestinal tract
(appendix, stomach, small intestine, colon,
rectum) and in the lungs.
Lung Cancer
 Epidemiology




In the past 3 decades, The incidence of lung cancer has
increased significantly in developed countries.
It is the most common cancer in males and second most
common cancer in females.
25% of all cancer death in US,
The number one cause of cancer death in both sex.
Lung Cancer
 Etiology
 Smoking (responsible of 85% of all lung cancers ):




type
duration
amount
passive (3% of patients with lung cancer)
 Environmental: radon gas, asbestos, chromium, silica,
arsenic, ionizing radiation, and viral infection
Lung Cancer
 Etiology
 Dietary: fat and cholesterol vs. fruit , vegetable and
vitamin A
 Preexisting lung disease: COPD , diffuse pulmonary
fibrosis and scaring from TB or infarction.
Lung Cancer
 Etiology
 Inheritance: positive family history has been described
as a rare autosomal co-dominant resulting in earlier
age of onset lung cancer.
 Molecular genetics alteration: oncogenes (RAS) or
tumor suppressor gene (p53 and RB ) on cell growth.
Lung Cancer
 Classification
 Based on histological differentiation:
1.
•
•
•
2.
•

•
3.
•
•
•
Adenocarcinoma (45%):
The most common type.
Tend to be in peripheral lung parenchyma and in alveolar septa
Lymph node metastasis is common
Squamous cell (epidermoid) carcinoma (30%):
Tend to be centrally (major bronchi).
Keratinization. Sputum cytology.
Invade locally.
Large cell (undifferentiated) carcinoma (5-10%)
Tend to be in peripheral lung
Often cavitate
Early metastasis
4. Small cell carcinoma(20%):
5. Carcinoid and uncommon lung cancers.
Types of Lung Cancer:
 The main types of lung cancer are small cell lung
carcinoma (SCLC ) and non-small cell lung carcinoma
(NSCLC ).
Lung Cancer
 Presentation
Local invasion of primary tumor:
 70% of the patients are symptomatic.
 Centrally: Cough dyspnoea, unresolved pneumonia,
wheeze and hemoptysis.
 Peripherally: chest wall pain, pleural effusion, tumor
cavitation and dyspnea.

Presentation
 Regional spread within thorax and to
mediastinum:
 Pleura (pain, effusion), chest wall(pain),
pericardium(effusion), superior vena cava(obstruction),
Pancoast tumor(superior sulcus tumor), cervical
sympathetic nerves(Horner syndrome), recurrent laryngeal
nerve(hoarseness), phrenic nerve (hemediaphram) or
esophagus (dysphasia).
Lung Cancer
 Presentation
Distant Metastasis
Liver, bone, brain or adrenals
 Paraneoplastic Syndrome
these are the distant effects of the tumor (endocrine, neurological,
skeletal, hematological, cutanous) unrelated to the metastasis .
There is production of one or more active substances (ACTH, ADH,
calcitonin, growth hormone, parathyroid hormone)
General: anorexia, cachexia and low grade pyrexia
SCLC: ACTH , SIADH and Eton-lambert syndrome
Squamous cell carcinoma: PTH.
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Lung Cancer
 Diagnosis
 Hx & PE.
 Sputum cytology: have little role in routine work-up of
patient with suspected lung cancer.
Tumor
Tumor
Bronchoscope
Tumor
lung-cancer-upper-lobe
Lung Cancer
 Diagnosis
 Chest x-ray: initial diagnostic procedure of choice in
suspected patient.
 It helps in localizing the tumor, presence of mediastinal
or hilar lymph node, pleural effusion and lung
consolidation.
Adenocarcinoma : Well
defined peripheral
nodule and May have
chest wall
involvement.
 Squamous Lung
Cancer: central
located, associated
atelectasis and hilar
adenopathy
 Large cell carcinoma :
peripheral mass may
cavitate and
association with hilar
or mediastinal
adenopathy .
Small cell tumor:
bulky mediastinal
lymphadenopathy,
large central tumors
or rarely a small
peripheral tumor
 Pancost tumor :
Tumor at the apex of the lung or superior sulcus that
may involve :
 the brachial plexus
 sympathetic ganglia
 Vertebral bodies
Leading to pain, upper extremity weakness, and Horner’s
Syndrome.
 Horner’s syndrome :
Injury to the cervical sympathetic chain:
1.
2.
3.
4.
Ptosis
Miosis
Anhydrosis of ipsilateral face .
Endophthalmosis.
Lung Cancer
 Diagnosis
 CT scan : useful for assessing the size of primary
cancer , proximity to adjacent organ and for planning
surgical approaches.
 F.O. Bronchoscopy.
 MRI: no advantage over CT , it more accurate in
assessing spinal cord invasion.
Lung Cancer
 Diagnosis
 Bronchoscopy : play an essential role in diagnosis , staging
and treatment.
 Percutaneous needle biopsy: fluoroscopic or CT-guided
 Mediastinoscopy/Mediastinostomy: its improtant for
staging.
 Thoracoscopy : most useful for examining pleural space for
seeding of tumor .
Staging of
NSCLC
(Non Small Cell Lung Carcinoma)
Why do we need staging ?
What TNM stands for ?
Staging of NSCLC: T descriptor
# T1
<3cm
# T2
1.>3cm invading the visceral pleura
2.within a major bronchus >2cm
distal to the carina.
3.Associated with partial atelectasis or
obstructive pneumonitis .
Cont.
# T3
1.tumor of any size+direct invasion
of non-vital structure
2.within a major bronchus <2cm
distal to the carina.
3.Associated with complete atelectasis or
obstructive pneumnitis
Cont.
#T4 1.tumor of any size+direct invasion of
vital organs
2.malignant pleural effusion
3.precardial effusion
# Tx primary tumor can not be assessed
# T0
no evidence of tumor
# Tis carcinoma in situ
Staging of NSCLS: N descriptor
# N0 -- no nodal met.
# N1 -- nodes within the ipsilateral lung
# N2 -- subcrinal nodes & paratracheal LN
ipsilateral to the tumor.
# N3 -- nodes in mediastinum contraleteral to
lung tumor or in the supraclavicular region
# Nx -- regional nodes can not be assessed
Staging of NSCLS: M descriptor
M0:*NO DISTANT METASTASIS
M1:*DISTANT METASTASIS PRESENT
NEW INTERNATIONAL REVISED STAGE GROUPING
Stage 0
Stage IA
Stage IB
Stage IIA
Stage IIB
Stage IIIA
Stage IIIB
Stage IV
TIS
T1, NO, MO
T2, NO, MO
T1, N1, MO
T2, N1, MO
T3, NO, MO
T1-3, N2, MO
T3, N1, MO
T4, Any N, MO
Any T, N3, MO
Any T, Any N, M1
Mountain CF. Chest 1997; 111
Surgical Treatment of Lung Cancer
(NSCLC)
Principles
1.Complete resection of the primary
tumor with its intrapulmonary
lymphatic's.
2.Intraoperative frozen sections.
3.Intraoperative lymph node staging.
Contraindications to Surgical
Resection
1.Distant metastasis (M1).
2.Invasion of central mediastinal
structures(T4).
3.Malignant pleural effusion (T4).
Surgery for NSCLC by stage
Stage I-II
Surgery is the most effective treatment lobectomy
Radiotherapy may be used if patient is inoperable.
Stage III-IV:
Local (N0): selected patients (alone or with
induction therapy).
N2: Controversial. Combined modality (Surgery +
radiation)
N3 (contralateral LN) surgery is absolutely
contraindicated.
M1 (Distant Metastasis): palliative surgery
Surgical options for lung cancer:1.Wedge/Segmental resection
2.Lobectomy/biloectomy
3.Pneumonectomy
4. Video Assisted Thoracosopic Surgery
(VATS)
5.Palliative resections (noncurative).
Follow up and outcome:H , E & CXR every 3ms for 2years and every 6ms
for subsequent 3years
Tumor recurrence: first 2-3 years
local recurrence: in the same lung or surgical
margin
regional recurrence: within mediastinal lymph
node.
systemic recurrence: contralateral lung or
outside thorax.
There is increased risk of
developing second
primary tumor of upper
areodigestive tract ( i.e.
oropharynx , esophagus ,
lung ) after having the
initial lung cancer tumor.
prognosis
5-year survival rates, in the United States are as
follows:
Stage IA - 75%
Stage IB - 55%
Stage IIA - 50%
Stage IIB - 40%
Stage IIIA - 10-35%
Stage IIIB - 5% (Stage IIIB lesions are non
resectable.)
Stage IV - Less than 5%
overall is 13% because most of the patient diagnosed
in stage IV.
Chemotherapy
Used in the management of NSCLC (Stage III-IV).
Combination (multi-agent) chemotherapy is more
effective than single-agent chemotherapy.
May be used as:
1.before operation to improve the respectability.
2.postoperative adjuvant (Not proven but
considered).
3.radiosensitizers in concurrent chemoradiotherapy.
4.inoperable patient.
Other treatment
choices are :
•Chemotherapy,
•Radiation therapy
(radiotherapy),
including
radiosurgery (SRS),
or targeted therapy.
This means less radiation affects nearby healthy
tissues.
Small cell lung cancer
(SCLC):-
Small cell lung cancer (SCLC):Oat cancer –20%
Epithelial tumor capable of expressing
neuroendeocrine amine precursor uptake and
decarboxylase (APUD) marker, which can act as
neurotransmitters and hormones. (ACTH, ADH)
Presentation:
1.aggressive tumor with Early metastasis.
2.Strongly associated with smoking .
3.Symptoms may be related to:
# Local tumor growth
# Regional lymph node metastases
# Distant metastases
# Associated with Paraneoplastic Syndrome
# Anorexia, Cachexia & low grade pyrexia
# ACTH , SIADH
Work up:1. Hx & Ex
2. Routine investgations
CBC, LFT, …etc.
3. Imaging
a.CXR (Tend to be centrally
with bilateral mediastinal lymph node
involvement)
b.CT of chest
c.CT of abdomen
d.Bone scan
e.CT or MRI of brain
4.Bone marrow aspiration
Staging of SCLC:Limited disease: confined to
ipsilateral lung, hilar, mediastinal, &
supraclavicular LN.
Extensive disease: contralateral lung
or extra thoracic .
Very limited disease: confined to
the lung
Management of SCLC:Primarily treated with chemotherapy
Extensive disease: majority of patient
combination chemotherapy
5ys survival < 5%
Radiotherapy is used for palliation
As in brain metastasis
Limited disease : 30 % of patient
50% have complete response to therapy
5ys survival 20%
Very limited disease : vey rare
chemotherapy
5 years survival 60-70-%