Carcinoma Lung

1. CARCINOMA LUNG
DR DHANESH KUMAR

2. Epidemiology
• Most common diagnosed Cancer worldwide
• 1.8 million new cases yearly diagnosed globally
out of which 1.5million deaths
• 13% of global cancer burden
• Highest incidence in Hungary(51/100000/yr)
• Incidence increasing in India and China
• 6.9% of all new cancers
• 9.3% of all cancer related death in india
• Incidence in India 28/100000

3. Presentation- Incidence
• Till 40 yrs; M=F
• 50-70 years; M>F because of smoking habits
• Women –Younger, localized, Adenocarcinoma
• SCLC-Most cases 60-80 Yrs
• Smokers

4. Etiopathogenesis
• Smoking (78% in men and 90% in women)
• Asbestos exposure(upper lobe)
• Radon exposure
• Chronic interstitial pneumonitis
• Inorganic arsenic exposure
• Radioisotope, ionizing radiation(SCC)
• Atmospheric pollution
• Chromium, Ether, nickel exposure(Sq.C.C)
• Vinyl chloride exposure

5. Symptoms and signs
• Cough-Dry/Productive
• Chest pain
• Shortness of breath
• Coughing up blood
• Wheezing
• Hoarseness
• Recurring infections such as bronchitis and
pneumonia
• Weight loss and loss of appetite
• Fatigue

6. Presentation

7. NCCN Guidelines of evaluation
• Nodule on x-ray
• Multidiscipllinary evaluation
• Risk assessment
• Radiologic factors
• Findings:</=8mm :R. Survey
– >8mm:PET/CT
– </=10mm:R.Survey
– >10mm:LDCT in 3-6 month

8. CLASSIFICATION OF CA LUNG
• Small cell lung carcinoma(oat cell
carcinoma):15%
• Non-small cell lung carcinoma:80-85%: 3 types
-Adenocarcinoma
-Squamous cell carcinoma
-Large cell carcinoma

11. Staging system
• History and physical
examination
• Chest radiography
• Sputum cytology
• CT
• PET
• Bone scan
• MRI
• Bronchoscopy
• Endobronchial USG
• Percutaneous
transthoracic needle
biopsy
• Cervical Mediastinoscopy
• Left ant. Mediastinotomy
and Extended cervical
Mediastinoscopy
• Scalene node biopsy
• VATS
• Thoracotomy

12. Staging
• AJCC and UICC 7th edition:2007
• IASLC(International association for the study
of lung cancer)
• cTNM /pTNM

14. AJCC and UICC• TX-Primary can not be assessed
• T0-no evidence of primary tumor
• T is-carcinoma in situ
• T1a-tumor</=2cm
• T1b->2cm but </=3cm
• T2a->3cm but</=5cm
• T2b->5cm but </=7cm
• T3->7cm or invading chest wall
• T4-any size invading heart, RLN,
esophagus
• NX-regional lymph nodes cannot be
assessed
• N0-no regional lymph node metastasis
• N1-metastasis to I/L peribronchial, hilar,
intra pulmonary nodes.
• N2-Metastasis in I/L mediastinal or
subcarinal lymph nodes
• N3-metastasis in C/L medistinal hilar , I/L
or C/L scalene or supraclavicular lymph
nodes.
• MX-metastasis cannot be assessed
• M0-no distant metastasis
• M1a-sep. tumor nodule in C/L lobe tumor
with Pleural nodules or malignent pleural
effusion.
• M1b-distant metastasis

16. Metastatic workup
• Metastatic sign and
symptoms:
• Bone pain
• Spinal cord impingement
• Neurological sign and
symptoms may include
the following:
Headache
Weakness or numbness of
limbs
Dizziness and
Seizures
• Bone scan
• MRI
• CT scan
• Tumor markers-NSCLC-
TPS,CYFRA-21-1,CEA
• SCLC-NSE

17. Surgical Treatment
• Lobectomy –In resectable NSCLC
• Sublobar Resection
• Pneumonectomy
• Mediastinal lymph node dissection

18. Lobectomy
• Lobectomy with complete en bloc tumor removal
remains the std. in pt. with resectable NSCLC.
• Position: Lateral decubitus
• Incision: Posterolateral
• Mobilization- hilar dissection
• Management of vessels(Auto suture GIA stapler /
electrocautry /ligatures).Order of division: PA, Vein,
bronchus
• Management of bronchus: Hand suturing tecnique,
stapler
• Placement of chest tubes: Apical, Basal

19. Sublobar resection
• NSCLC pt. who cannot tolerate anatomical lobectomy.
• Anatomical segmentectomy: Early stage NSCLC at low risk,
poor CP reserve.(Procedure of choice)
• Landmark is diseased bronchus, identification is key step
• Segmental vein divided last after identification of
intersegmental plane
• 4-0 PDS ,absorbable interrupted suturing for bronchial
closure. (Inflation-Deflation tecnique)
• Stapling may be performed if sufficient length of diseased
segmental bronchus is available.
• Wedge resection :for small ,peripheral ,early stage NSCLC.
often accomplished by VATS

20. Pneumonectomy
• Reserved for central lesions, Good CP reserve
• Incision: Posterolateral thoracotomy via 5th ICS
• Hilar dissection(Double ligation/Stapling)
• Management of bronchus(Avoid BPF)
• Management of postpneumonectomy space:
chest tube/Pleur-Evac(drainage system)
– Avoid negative pressure

21. Mediastinal lymph node dissection
• Gold std. for staging
• Integral part of the surgical treatment of lung
cancer to determine accurate nodal status.
• Intra-operative frozen section
• Lymph node sampling (Hilar/Mediastinal L.N)
 Systemic sampling
 Complete lymph node dissection
 Extended lymph node dissection

22. Surgical treatment of NSCLC
• Mainly for Stage I or stage II NSCLC
• Stage IIIA and IIIB :Chemo-radiotherapy
– Heterogenous group, selected patients
 Decision depends upon:
 Extent of disease
 Age
 CP reserve
 Performance status
 Comorbid risk factors

23. Surgical treatment of NSCLC (T1&T2)
• Lobectomy>Sublobar resection>SBRT
• Three fold increase in incidence of local recurrence in
patients treated by resection smaller than lobectomy.
• Sublobar resection can be performed on patients with
small, peripheral ,early-stage NSCLC without
jeopardizing the clinical outcome.
• Key factors to obtain optimal result with
segmentectomy are:
– Surgical margins
– Tumor size
– lymph node assessment

24. T3
• NSCLC involving the chest wall but without
mediastinal node disease are good candidates for
surgical treatment
• Superior sulcus tumors: Combined modality
,induction chemoradiotherapy followed by
surgery
• Tumor in proximity of carina: Sleeve lobectomy
• Tumors invading mediastinum or diaphragm:
Prognostic factors are-nodal disease
,completeness of resection, and depth of
diaphragmatic invasion .

25. T4
• Heart and Great vessels: Rarely surgical
candidates
• Carina and Trachea: Carinal resection
• Ipsilateral pulmonary metastasis: Stage of
mediastinal node is key prognostic factor
• Vertebral body: Hemi/Total vertebral body
resection
• Esophagus:Unresectable

26. N0&N1
• In patients with N0-1 disease type of pulmonary
resection depend upon T category
• Intraoprative interlobar or hilar nodal assessment
is critical in decision making for sublobar
resection. VATS has role in it.
• N0NSCLC with local tumor invasion (T3):Extended
en bloc resection such as pneumonectomy
/sleeve resection/chest wall resection
• Cisplatin based adjuvant chemotherapy shows
improved survival in N1/NO and >T1b tumor

27. N2
• Chemoradiation + surgery
• N2 found on pretreatment staging:
– Bulky, multistation ,cytologically proven
:Chemoradiotherapy: Monoclonal antibodies
– Nonbulky, single station: Curative surgical resection
Neoadjuvant chemo. has role .
• N2 found at thoracotomy: Aborting Lung resection
followed by Induction therapy possibly followed by
lung resection or lung resection followed by adjuvant
therapy.

28. N3
• C/L mediastinal LN metastases are considered
a C/I for surgery because long term outcome
with surgery has been dismal.
• 0% 3 year survival rate for patient with NSCLC
who underwent induction chemoradiotherapy
followed by surgery.
• Should be treated nonsugically

29. M1a and M1b
• M1a:Additional nodule in
C/L lung: Median survival 10
month
• 5yr survival rate 3%
• FDG PET sensitive for
malignent metastatic
disease
• When double primaries
without mediastinal
disease, the optional
treatment is two stage
lobectomy for C/L lung
• Malignent pleural effusion:
C/I for surgery
• M1b:Adrenal gland:
Complete surgical resection
of both can improve survival
• Brain:30-50% patients
• Resection of solitary brain
metastases in a patient with
completely resected NSCLC
carry a potential cure rate
• Use of WBR (Whole brain
radiation)alone or with
surgery also have a role
• Stereotactic radiosurgery
another alternative along
with chemoradiotherapy

30. Treatment of SCLC
• Stages I-III disease :Chemoradiation
• Stage IV disease : chemotherapy only
cisplatin
carboplatin
cyclophosphamide
Surgery:1. For small peripheral tumor without nodal
involvement
2.Local control compaired with
chemoradiotherapy
3.Mixed histology tumor
4.Salvage surgery

31. Minimally invasive approaches
• INDICATIONS
• Similar to lobectomy using
open approach
• Clinical stage-I
• Age>70 yrs
• CONTRAINDICATIONS
• Inability to achieve
complete resection
• T3 or T4 tumor
• Active N2 or N3 disease
• Inability to achieve single-
lung ventilation.
• Tumor in lobar orifice at
bronchoscopy
• Complex ,calcified benign
hilar lymphadenopathy
• Prior thoracic irradiation
• Prior thoracic surgery

32. Strategy for Thoracoscopic lobectomy
• Single lung anesthesia using double lumen ET tube or
bronchial blocker
• Position: Full lateral decubitus with slight flexion at the
level of hip
• 1st incision :7th or 8th ICS in MAL for thoracoscope (10mm
port access).For Ant.-Sup. hilum visualization
• 2nd incision:5h or 6th ICS just inf. to breast(4,5-6mm ant.
access incision)
• 30*/45* angled scope /flexile scope can be used
• Thorcoscopic staplers for control of vessel, bronchus,
fissure
• Wedge resection performed using an automatic stapling
device

33. Specific technical considerations
• L.U Lobectomy
• Left sup. Pulmonary vein
identified
• Pulmonary artery mobilized
• Left upper lobe bronchus is
visualized which may be
stapled and divided.
• Branches of pos. and
lingular arteries are stapled.
• R.U Lobectomy
• Slightly more difficult
• SPV identified and
mobilized
• UL branches are encircled
• PA mobilized, truncus
anterior may then be
stapled and divided
• Rt . Bronchus exposed and
upper lobe bronchus may
be stapled and divided
• Post. Ascending arterial
branch is stapled

34. • R.M Lobectomy
• SPV identified and
mobilized
• Middle lobe vein is
encircled and stapled
• Expose middle lobe
bronchus and atrery
• Artery is stapled and
divided
• Lower Lobectomy(R orL)
• Lung is retracted
anteriorly
• Incise the pleura over
the IPV, which then be
encircled and stapled
• Lower lobe bronchus,
arterial trunk encircled
and stapled
• Fissure is completed

35. • Segmentectomy
• In patients with poor lung
function or synchronous
primary tumors
• Small ,peripheral tumor
• Through thoracosope
• Wedge resection
• In pt. with small
peripheral tumor who will
not tolerate anatomic
resection
• ND:YAG laser and
monopolar floating ball
device
• VATS wedge resection of
small peripheral nodule
carried out using
endoscopic stapling
device

36. Multimodal Therapy
• Adjuvant therapy
Chemo/radiotherapy
• Induction therapy
• Guidelines
• Staging must include a through
search for distant metastatic
disease.
• Endoscopic and endobronchial
staging modalities more
refined
• Chemotherapy should revolve
around a platinum based
regimen
• More benefit with intended
dose of chemotherapy
• Adjuvant chemotherapy for
larger IB /II/III NSCLC

37. Surgical strategies for tumors invading the chest wall
• Demographics and
symptoms
• 7TH Decade
• Incidence and mortality
High in men
• Chest pain-40-60%
• Recurrent LRTI-10-25%
• Weight loss-10-18%
• Hemoptysis-12%
• Dyspnea-11%
• Cough-11%
• Asymptomatic-25%
• Diagnosis
• Chest roentgenography
• Rib destruction
• Transthoracic needle
aspiration
• CT, MRI, Bone scan, PET

38. • Staging
• Combind CT-PET scan
• MRI brain
• Surgical pathologic
staging (T,N,M)
• Role of EBUS –guided FNA
• Navigational
bronchoscopy
• Treatment
• N2- Induction
chemotherapy
• Surgery when objective
response to
chemotherapy and whose
disease can be completely
resected
• Progression even on
chemotherapy –no
surgery

39. • Preoperative assessment
• Physiologic testing for
cardio-pulmonary reserve
• Management of DM and
nutritional support
• Phrenic nerve and
diaphragmatic involvemet
• Operative techniques
• Epidural catheter
• Double lumen tube
• PL thoracotomy
• Anterior neck approach
• For large tumor: use
stapler
• When adhesions: Extra
pleural dissection

40. • Reconstruction
• Controversial
• All full thickness skeletal
defect that have the
potential for paradox
• Size ,location of resection
guide the decision
• Midthoracic pot. defect
• Fascia lata graft ,muscle
transposition, LD ,PM, RA,
SA, Trapezius, deltoid,TRAM
flap, PTFE,PPMM
• Postoperative care
• Tailored to individual
patient
• Decision on extubation
• Epidural anesthesia
• Chest tube removed on 7th
day
• Antibiotics only for 24 hours

41. • Complications
• Seroma
• Wound infection
• Respiratory mechanical
changes
• Pathology and Results
• R0,R1,R2 Resection
• Depth of chest wall
invasion
• Opretive mortality is
with in 30 days of
surgery
• Results varies from
centre to centre

42. Anterior Approach to Superior sulcus lesions
• Presentation
• <5% of NSCLC
• Upper lobe ,invades
parietal pleura, Fascia,
brachial plexus,1st
rib,platysema
• Pulmonary symptoms
uncommon
• Abnormal sensation,pain
in axilla and medial
aspect of upper arm
• Overt pancoast syndrome
• Preoperative studies
• Assess for operability
• Diagnosis by :clinical
examination, X-ray,
bronchoscopy, sputum
cytology, FNA biopsy
• Tissue diagnosis: video
assisted thoracoscopy

43. Anterior transcervical technique
• One lung anesthesia with
urine output
mesurement, body temp.
mesurement
• Position: supine with neck
hyperextended and head
turned away from
involved site
• Incision: L-shaped
cervicotomy including
vertical pre-
sternoceidomastoid
incision
• Inferior belly of omohyoid
divided scalene fat pad is
dissected and sent for
pathology examination
• Division of sternothyroid
and sternohyoid
• Subclavian artery is
dissected
• Chest wall resection is
completed before the
upper lobectomy
• Three level laminectomy

44. Surgical Morbidity and Mortality
• 5 year survival= 11%-
17%
• Stage1A-75%
• Stage1B-55%
• StageIIB-40%
• StageIIIA-10-35%
• Stage IIIB-<5%
• Stage IV-<5%

45. Prognosis
• Prognostic factors for lung cancer
NSCLC:
Stage at presentation
Performance score
Weight loss
SCLC:
Stage at presentation
Performance score
Weight loss
Elevated LDH
Male sex
Hyponatremia
Elevated ALP

46. Screening
• Chest radiograph
• C.T scan
• LDCT: low density C.T
• NLST: National lung
screening trial
• ACS: American cancer
society
• ACCP: American college
of chest physician
• NCCN: National
comprehensive cancer
network
• USPSTF:U.S. Preventive
services task force

47. Other Lung Malignancy
• Bronchopulmonary carcinoids
• Carcinoids tumorlets
• Primary pulmonary salivary gland type neoplasms
• Primary pulmonary sarcomas
• Primary solitary pulmonary plasmacytoma
• Primary pulmonary lymphoma
• Primary pulmonary melanoma
• Primary pulmonary carcinosarcoma
• Secondary lung tumors

48. Secondary lung tumors
 Evaluation of patient
• Symptoms and
presentation
• Radiological evaluation
• Tissue diagnosis
• Indications for surgery
• Surgical approach
• Lymph node dissection
• Results of pulmonary
metastasectomy
• Alternative treatment
options
• Palliative therapy

49. References
• Sabiston and spancer surgery of chest 8TH
Edition
• Winston W Tan :NSCLC;SCLC
• e-Medicine lung cancer updates