surg medias tin um spn lungca

8/3/2019 Surg Medias Tin Um Spn Lungca

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The Mediastinum

- Anatomic space that lies between two pleural cavities and extends from the diaphragm to the

thoracic inlet.

Subdivisions of the Mediastinumas seen in cross section

•anterior mediastinum (1)•middle mediastinum (2)

•posterior mediastinum (3)

A lot of lymph nodes can be found in the mediastinal compartments = a common neoplasm:LYMPHOMA because of lymphatic spread.

I. Anatomya. Borders

Thoracic Inlet – Superior Diaphragm – InferiorlySternum – AnteriorlyVertebral Column – Posteriorly

b. 3 Compartments and Contents:

Compartment Contents

Anterosuperior Thymus gland, lymph nodes, fat, aortic arch, superior vena cava, parathyroid gland, ectopic thyroid tissue

Middle Pericardium, heart, great vessels, trachea, and trachealbifurcation, main bronchi, phrenic nerves, hilar lymph node

Posterior Esophagus, vagus nerves, sympathetic chain, thoracicduct, descending thoracic aorta, azygous vein,

hemiazygous vein, paravertebral lymph node

sometimes the thyroid grows too big due to anomalies, so big that it goes into the neck or into themediastinum.

Topic: Mediastinum, Solitary Pulmonary Nodule, Lung CA

Lecturer: Dr. Gervasio



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II. Diagnostica. Chest X-rays – mediastinal masses commonly found incidentallyb. CT Scan – second most common modality used, next to x-ray

c. Magnetic Resonance Imaging – useful for better visualization of certain vascular structures

d. CT Guided Needle Biopsy (FNAB vs Core)e. Mediastinoscopy with biopsy – cytopathologists needed to read FNAB better

• Mediastinoscopy is a surgical procedure to examine the inside of theupper chest between and in front of the lungs (mediastinum).

f. VATS (Video-Assisted Thorascopic Surgery) • is a minimally invasive surgical technique used to diagnose and treat problems in the

chest. During this surgery, one or more small incisions are made in the chest. A tiny

fiber-optic camera (called a thorascope) is inserted through one incision, and surgical instruments are inserted through this or other small incisions. The thoracoscopetransmits images inside the chest on a video monitor, guiding the surgeon inmaneuvering instruments to complete the procedure (sounds a lot like laparascopic surgery right?)

g. Radionuclide Scanning – a way of imaging bones, organs and other parts of the body by

using a small dose of a radioactive chemical.h. Angiography

i. Immunologic Staining – this is done since it may be difficult to distinguish one mediastinaltumor from the other

It is important to know the normal first, before you can understand the abnormal.Below is a normal CXR shown with labels.

absent clavicle on the left side note gas bubble of left side; dextrocardia



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III. Mediastinal Tumors and CystsIn Adults

o 25-35% malignant;o Neurogenic tumors most common @ 20%o Thymomas (most common anterior mediastinal tumor in adults), congenital cysts,

lymphomas (most common in both adults and children but more common in children?Which one is it doc? =/ )

o Usually asymptomaticIn Childreno 25-45% malignanto Lymphomas (most common), neurogenic tumor

Symptomatology:

1/3 to half of the cases are asymptomatic Non-specifc symptoms include chest pain, cough, dyspnea (Compression Syndrome) Endocrine Symptoms:

o Hypertension – Pheochromocytomao Hypercalcemia – Parathyroid tumor o Thyrotoxicosis – Intrathoracic goiter o Gynecomastia – Choriocarcinoma

I. Thymoma

Most common anterior mediastinal mass in adult• Rare in children

1/3 are asymptomatic at diagnosis Symptoms include: mass effects (compression symptoms) and systemic

effects due to paraneoplastic syndromes (Myasthenia gravis)• Myasthenia gravis is seen in 10-50% of patients with thymomas• Thymomas is seen in only 8-15% of patients with Myasthenia gravis

Histopathology: proportion of lymphocytes to epithelial cells Malignancy = Invasiveness (capsular or vascular) Treatment: Surgery + radio and chemotherapy

II. Germ Cell Tumor Primary extra-gonadal germ cell tumors are RARE!

• Only 1% of all mediastinal tumors. Most common in the anterior mediastinum

M>F predilection (4:1) Commonly affects young adults Types:

• Seminoma• Embryonal cell carcinoma• Choriocarcinoma• Malignant Teratoma• Endodermal yolk sac tumor

Diagnosis: CT Scan and Tumor Markers (B-HCG, A-fetoprotein,

Carcinoembryonic antigen or CEA) Treatment: Complete Resection and Adjuvant Therapy

• Seminomas – radiosensitive = better prognosis• Other tumors – chemotherapy

III. Lymphomas Mediastinal involvement seen in 50% of both Hodgkin’s and non-Hodgkin’s

lymphoma

Most common mediastinal malignancy Most commonly seen in the anterior mediastinum Symptoms include: cough, chest pain, fever and weight loss Diagnosis:

• Chest X-ray and CT Scan• Mediastinotomy/mediastinoscopy with biopsy

Sometimes immunohistopathology is done if pathologists can’t figure it out!

Treatment:• Radiotherapy and Chemotherapy• Surgery – done mainly for diagnosis

Resection is NOT done for lymphomas

IV. Teratomas Mostly in adolescents 80-85% of cases are benign Contains all 3 germ layers: endoderm, mesoderm, and ectoderm Many are asymptomatic; others have symptoms related to compression

(cough, pleuritic chest pains, dyspnea) Diagnosis: X-ray and CT Scan (smooth walled cystic or solid lesions) Treatment: Total Surgical Excision



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Middle Mediastinal Lesionso usually cystic o 2 most common lesions:

Pericardial Cyst• Usually asymptomatic

• Found on chest x-ray at cardiophrenic angle• Surgery is both diagnostic and therapeutic

Bronchogenic Cyst• Arise posterior to the carina• May be asymptomatic or may cause compression symptoms• Treated by excision

Patients often complain of compression symptoms

(+) lining of the cyst on CXR – differentiates it frompneumothorax

Posterior Mediastinal Lesionso mostly neurogenic lesions along the paravertebral gutter o 25% are malignanto 75% of cases occur in children (<4 years old)

Higher probability of malignancy

Surgery may not be an option in most malignant cases

Dumbbell tumors – tumors that grow inside the spinal canal with another extension outside; surgically a cause for concern; may cause rapid bleeding death

More diagnostic tools are implicated to study the spinal canal

o Common histologic types:Neurilemomas Neurofibromas Neurosarcomas Ganglioneuromas Neuroblastomas Pheochromocytoma

– from Schwanncells; slowgrowing; well

circumscribedand have adefined capsule

– has malignantpotential; poorlyencapsulated

and consists of randomlyarranged

spindle-shapedcells

– originate bymalignantdegeneration of

either neurilemomas or neurofibromas, in

addition todeveloping denovo; usually

occurs in adults

– from sympatheticganglia; wellencapsulated

– also fromsympathetic chain;highly invasive

(have alreadymetastasize beforediagnosis)

Rarely occurs;behave similarly toadrenal lesions

o Symptoms: Chest pain Spinal cord compression Endocrine symptoms Fever, vomiting, diarrhea and cough in Neuroblastoma

o Treatment: Surgery and Radiotherapy (for malignant lesions) In the recording doc said chemo and radiotherapy??

Superior Vena Cava Syndromeo 85% of cases are due to Bronchogenic CA (most commonly small cell type – 40%)

o Causes:• Mediastinal tumors• Fibrosing mediastinitis• Thoracic aortic aneurysm• SVC thrombosis due to catherization/instrumentation

o Presents as venous distention, facial edema, plethora, headache, and respiratorysymptoms

o Diagnosis: CT Scan

o Treatment:• Radiation and Chemotherapy (palliative)• Steroids and Diuretics – still questionable• Bypass or Vein Reconstruction (for benign lesions)• Stenting: Endovascular Procedure

IV. Mediastinal InfectionsAcute Mediastinitis

fulminant infection with high morbidity and mortality Rapid spread through areolar planes, within 24 hours, to involve neck andlungs Both gram (+) and (-) bacteria Symptoms: chest pain, dysphagia, respiratory distress, subcutaneous

crepitation Diagnosis: Chest X-ray, Water soluble contrast study Treatment: hydration, drainage, control of primary problem (must be early and

aggressive) **antibiotics are also given Etiology: Esophageal or tracheal perforations

• Open heart surgery – more indolent course; usually due toStaphylococcus (MRSA)

Esophageal perforation – a very real complication; rare in trauma; more commonly injured in endoscopicprocedures or intentional intake of corrosive substances (acid ingestion is common in the phils)

Chronic Mediastinitis Chronic fibrosis and inflammation Usually due to granulomatous infections (TB, Histoplasmosis)



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SOLITARY PULMONARY NODULE

—SPN: 3 cm or less in diameter About 40% malignant—Lung mass: greater than 3 cm Vast majority are malignant

size = risk of it being malignant it is important to rule out malignancy!

Differential Diagnosis of SPN—Neoplasm—Infection (commonly TB)—Inflammation—Vascular —Trauma—Congenital—Rheumatoid nodule—Lymph node—Sarcoidosis

by examining the CXR, one can have an idea if it is malignant or being consider px risk factors, medical Hx

Factors Influencing Probability of Malignancy

—Size—Growth rate 25% in diameter = doubling of the volume

more malignant = shorter doubling time don’t rely on just one radiologic examination, usually a series of radiographs must be reviewed to compare the

size of the tumor seen in older films

—Number —Density—Circumstances of CT—Patient age—Gender —Smoking history—Spirometry—Occupational history—Endemic granulomatous disease

Size of SPN—Most SPN are less than 2 cm in diameter —Malignant nodules

—40% less than 2 cm—15% less than 1 cm

—1% less than 7 mm—0% less than 5 mm

Growth Rate: Doubling Time—Volume = 4/3 Π r

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—25% increase in diameter results in doubling of volume

—Non-malignant disease: less than 20 days or greater than 400 days—Malignant lesions: 30 to 180 days

note: germ cell tumors, melanomas, sarcoma can grow in 2 weeks classically; thyroid can take months

Radiographic Characteristics

Malignant disease Benign disease

—Spiculated (primary) 90% malignant—Round, smooth, and peripheral(metastatic) 20% malignant—Thick walled cavity—Eccentric calcification

—Characteristic calcifications—Smaller than 5 mm—Non-solid lesion 5-9 mm—Thin walled cavity—Satellite nodules**no growth in the last 2 yrs? Probably benign

Note: Eccentric calcifications can occur in malignancies, especially at scar sites, so called scar carcinomas



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SPN: RUL

SPN: RUL: Spiculated lesion Malignancy, Right upper lobe, posterior segmentTB almost never affects

anterior segment

SPN: Lesion behind rib One of the reasons theydo the Apico-lordoticview

SPN: Posterior lesion Primary lung cancer, RUL,posterior segment

Popcorn calcification

Central calcification



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WORK-UP OF SPNMultidisciplinary Approach—PCP—Radiology

—Pulmonary—Thoracic surgery

—Oncology—Review prior films!

Others:Advanced directivesStratification of careInformation regarding possible outcomesPt advocate and shepard

Imaging and Procedures—CXR

—CT Scan—CT Scan with contrast to evaluate mediastinum

—Serial scans at 3, 6, 12, and 24 months

—Can consider trial of antibiotics prior to repeat scan in 6 weeks —Newer CT techniques

—Volumetric analysis—Multi-slice scanner

—PET Scan—Positron Emission Tomography—18-FDG (fluorodeoxyglucose)

—increased uptake by metabolically active cells (like tumor cells, but not exclusively…socorrelate clinically)—does not enter glycolysis—Allows more accurate identification of tumors, lymph nodes, and metastatic disease

Benign disease Malignant disease 96% sensitivity 96% sensitivity88% specificity 77% specificity

Note: Can more clearly determine if a lesion is malignant; Can detect LN mets and

unsuspected metastatic disease

Limitations of PET Scans—Spatial resolution 7-8 mm thus unreliable for lesions less than 1 cm—False positives in infection or inflammation—False negatives in tumors with low uptake such as bronchoalveolar cell carcinoma—High post test likelihood of malignancy (14%) in high risk patients with negative PET

Utilization of PET Scans

—Negative PET in high risk patients still need tissue diagnosis…so why get it?—PET not usually indicated unless it will change management—PET not indicated if surgery is planned—PET not indicated with known malignancy

—Bronchoscopy—Limited role—Transbronchial needle aspiration of mediastinal lymph node—Useful for large central lesions and endobronchial lesions—Can detect infection—No use in peripheral nodules

—Biopsy—CT guided—Transthoracic needle aspiration (TTNA)

—Increasing utilization of TTNA—Not indicated for patients committed to surgery—Accuracy for detecting malignancy 64-100%—Yield increased when cytopathologist present

—Three results:—Malignant

—Specific benign, e.g. TB—Non-specific benign, e.g. bronchoalveolar hyperplasia—Complications:

—Pneumothorax 25%, chest tube <5%, Hemoptysis <10%—Relative contraindications:

—Pulmonary HTN, severe COPD, AVM’s, coagulopathy—Absolute contraindication:

—One lung or bilateral lung transplant—Fine needle aspiration (FNA)

—Surgical —Video Assisted Thoracic Surgery (VATS)

—peripheral nodules within 2 cm of pleura

—for solid lesions; superficial lesions (lung surface)—for lesions not diagnosed by other means

—Open Thoracotomy—commitment to resection with curative intent; if lesion is not locatedsuperficially

—No change in two years - no further

evaluation—Characteristic calcifications of benign

disease

—Lateral films for “hidden” lesions

—Initial CXR then serial CT Scans



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Pulmonary Specific Preoperative Evaluation Prior to Lung Resection—PFT’s are predictive of post-op complications and mortality—DLCO correlates with risk of post-op mortality better than FEV1—PaCO2 > 45 not an independent risk factor

—Three stages:—PFT’s

—Quantitative Lung Scan—Exercise Testing

Stage I Assessment: PFT’sPredictors of Low

Complication Rates

Stage II Assessment:Quantitative V/Q Scan

Stage III Assessment:Exercise Testing

—No further work-up and nolimitations:—FEV1 > 2 L andDLCO > 60% predicted

—Pneumonectomy:—FEV1 > 2L and DLCO > 60% predicted

—Lobectomy:—FEV1 > 1L and

DLCO > 50% predicted

—Wedge / Segmentectomy:—FEV1 > 0.6 L and DLCO > 50%predicted

—Patients who do not meetStage I criteria

—Ventilation:133

Xe—Perfusion:

99Tc labeled

macroaggregates

—Radioactive uptake correlates

with lung function

—Post-op FEV1 = (pre-opFEV1) x (% of radioactiveuptake of non-operated lung)

—Pneumonectomy:—ppo FEV1 > 40% of

predicted

—ppo DLCO > 40% of predicted

—Cardio-pulmonary exercisetesting (CPET)

—VO2 > 20 ml/kg/min…acceptable risk

—VO2 < 15ml/kg/min…increased risk

—VO2 > 20 ml/kg/mincorrelates with 5 flights

—Stair Climbing—3 flights: FEV1 > 1.7 L

—5 flights: FEV1 > 2 L

Exceptions to the RulesCHEST 2005; 127:1984-1990

Foundation of Algorithms—No change in 24 months on CXR or CT requires no further evaluation—Serial CT Scans at 3, 6, 12, and 24 months

—TTNA for those not committed to surgery—Surgical biopsy with curative intent—Pre-op evaluation prior to surgery



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Sample Pre-biopsy AlgorithmCHEST 2004; 125:1522-1529

Sample Post-biopsy AlgorithmCHEST 2004; 125:1522-1529



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Sample Preoperative Evaluation AlgorithmCHEST 2003; 123:2096-2103

Cases

—Case I: 20 yo female, family history of TB, non-smoker, with calcified 1 cm nodule in posterior segmentof RUL – also seen in x-ray 6 months ago —Work-up: Observation and serial imaging if indicated (because risk for lung CA is)

—Case II: 60 yo male history of O2 dependent COPD, remote colon cancer, 40+ pk yr smoker , with 2.5cm irregular nodule in anterior segment of RUL

—Work-up: Tissue diagnosisBiopsy with curative intentPreoperative evaluation with PFT’s, DLCO, andquantitative lung scan if indicatedTTNA if surgery not an option (because risk of malignancy is )

Summary—SPN by definition is 3 cm or less

—40% are malignant—NSCLC 5-year survival

—Stage I 60%—Stage IV 1%

—Doubling times of cancer can be 30 days—REVIEW PRIOR FILMS!!!—No change in 2 years…no further work-up—Serial CT Scans at 3, 6, 12, and 24 months—TTNA for those not committed to surgery—Surgical biopsy with curative intent—Pre-op evaluation prior to surgery—PFT’s, Quantitative Lung Scan, CPET

LUNG CANCER

BRONCHOGENIC CARCINOMA Leading cause of cancer death 40 years old and above (>95%) Etiology:

Smoking – implicated in 75% or moreat least 20 pack-yearsimpact of second-hand smoke

AsbestosPetroleum productsRadioactive materials

(Role of Genetics ) - oncogenes

- there is a 20 year lag between smoking & lung

CA

- cessation of smoking = risk of developinglung CA compared to those who continue

smoking, however, risk is still compared to

never-smokers



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PRIMARY LUNG CANCER: CLASSIFICATION

Non-small cell CA Small cell / oat cell

Squamous / EpidermoidAdenocarcinoma

Scar carcinoma

Bronchoalveolar cell CA (variant)AdenosquamousLarge cell anaplastic / undifferentiated

overall 5 yr survival < 15%

50% mets at diagnosis surgery an option up to 70% 5 yr survival for Stage IA

overall <10% 5 yr survival

70% mets at diagnosis surgery not an option usually more aggressive

more proximal near tracheobronchial tree

more common associated with smoking

develops more in the periphery incidence number of female cases can also be attributed to previous injury to

the lung PTB is a possible risk factor (fibrosis) Metastasis is not uncommon

Undifferentiated CA

Tend to rapidly evolve and spread Tx: surgery Can grow anywhere, but usually centrally

located

Aggressive type of tumor Very poor prognosis Tx: non-surgical

Usually diagnosed late Generally responsive to chemotherapy,

but because patients are diagnosed late =advanced disease = poor prognosis

BRONCHOGENIC CA: DIAGNOSIS Chest x-ray

- Since the chest is a 3D structure, it is useful to get CXR

- Request for upright PA (postero-anterior) view

- Also request for the lateral upright CXR- Can detect ≥1cm nodules Sputum cytologyMay still be of some use in certain cancersBut most useful for infectious diseases

Bronchoscopy- helps assess the resectability of the tumor

CT + percutaneous needle biopsy = most useful- to obtain cytologic specimens (washing / brushing / biopsy)

- to assess bronchial/carinal involvement (assess resectability)



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Percutaneous needle biopsy CT Scan

- to assess tumor location, size, extension (useful for staging, but biopsy is still needed to come up withactual Dx of CA- to assess mediastinal lymph node status (problem: inflammatory vs neoplastic)

- with biopsy, to get histologic diagnosis Mediastinoscopy / mediastinotomy

Thoracotomy- frozen section – rapid histopathology

- not routinely done

CLINICAL MANIFESTATIONS May be asymptomatic; seen only on chest x-ray Often in advanced stages when symptomatic, and on diagnosis

Pulmonary symptoms: Extrapulmonary symptoms

cough fever dyspnea chest pain sputum production

- related to site of metastasis- may be secondary to hormone-like

substance produced by the tumor (e.g. Small cell CA Cushing’sSyndrome)

PANCOAST TUMOR Superior pulmonary sulcus tumor Different from apical lung carcinoma Symptoms may be due to:

Brachial plexus involvementSympathetic ganglia involvement

Vertebral body involvement / collapseHorner’s syndrome

ptosis miosis anhydrosis enophthalmos

BROCHOGENIC CA: STAGING

Based on the TNM ClassificationT – tumor size, location, extentN – regional lymph node involvementM – distant metastasis

Considers Host Performance StatusHo (normal activity) H4 (bedridden)

Categories: c - clinicals - surgicalp – postsurgical / pathologicr – retreatmenta - autopsy

**paralysis of the hemodiaphragm – consider possible involvement of the phrenic nerve

**hourseness – consider involvement of the laryngeal nerve**each lung lobe has its own arterial supply, drainage, etc – each can function independently**lobectomy is usually done (lobectomy)

**a px can even tolerate removal of one whole lung (Pneumonectomy)

BRONCHOGENIC CA: TREATMENT- Surgery – for early lesions ( up to IIIA )

Lobectomy usually minimum resectionPneumonectomy or variant at times

- Radiotherapy - as adjuvant / palliative tx; usually given after surgery of if surgery is not possible- Chemotherapy – as neoadjuvant / adjuvant / palliative tx- Immunotherapy – still being developed

**after surgical resection body compensates lungs tend to hyperinflate**if a whole lung is removed replaced with fluid solidification fibrosis

BRONCHOGENIC CA: CONTRAINDICATIONS TO SURGERY Malignant pleural effusion Recurrent laryngeal nerve involvement (manifests with hoarseness, but also rule out laryngitis

before considering matastasis) Distant metastasis Contralateral mediastinal LN involvement Carinal / high paratracheal LN involvement Scalene or supraclavicular LN involvement

Tumor invasion of the heart, great vessels, esophagus, trachea, vertebral body Superior vena cava syndrome (secondary to compression by the tumor) Phrenic nerve paralysis Poor pulmonary function (relative contraindication; in line with this…some surgeons would still do a

segmentectomy (less than a lobectomy) just to reduce the tumor load in order to improve thepulmonary function)



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**sometimes a tumor might obstruct the airway, usually the primary and secondary bronchi. So if possible,laser ablation is done to re-establish the airway. A stent is sometimes inserted just to open up the airway

PALLIATIVE TREATMENT Surgery – USUALLY NOT ADVOCATED Radiotherapy / Chemotherapy

Bronchoscopic obliteration of tumor by laser – for bronchial obstruction

PROGNOSISDepends on: Cell type and differentiation

Stage at the time of diagosisVarious host factors

NSCLC Survival Rates›Stage I 60%›Stage II 23%

›Stage IIIA 11% surgery›Stage IIIB 5% no surgery›Stage IV 1%

**Distinction between IIIA and IIIB is key due to surgical intervention**Malignant effusion is IIIB, surgery not indicated, therefore tap the effusion

Small Cell Lung Cancer **Surgery rare and limited to very small localized early disease**Brain mets occur in 10% at diagnosis**Paraneoplastic syndromes….SIADH, Eaton Lambert,

›Limited (30-40%) ›Extensive (60-70%)

›confined to one hemithorax›one RT portal›chemo and RT›median survival: 18 mo›5 yr survival: < 18%

›not limited›cannot fit in one RT portal›chemo, palliative RT›median survival: 7 mo›5 yr survival: < 2%



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METASTATIC LUNG CANCER Fairly common May be the only site of metastasis from a nonpulmonary tumor Spread to lungs is by direct infiltration, lymphatics, blood (more important route)

SURGICAL TREATMENT: PRINCIPLESSingle or multiple metastatic tumors, even when in both lungs, CAN be removed as part of treatment

(usually the sarcomas) as long as you can:- preserve as much normal lung- have adequate margins of resection

Exclusion of other metastatic sites is important

The primary site must be controlled

Other modalities of treatment not effective

END OF TRANSCRIPTION

Hi homer leelee baggie rencie markie jemelee =)

surg medias tin um spn lungca

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