PNEUMOTHORAX.

BRONCHOPULMONARY TUMORS
MEDICAL & SURGICAL PATHOLOGY 1
PNEUMOTHORAX
PNEUMOTHORAX
 Presence of air/gas in the pleural cavity resulting in partial or total collapse of
the lung
 Sources :
o Endogenous : lung, lower airways, digestive tube (oesophagus
rupture/perforation)
o Exogenous : traumatic or procedure-related entry of air/gas through the
chest wall
 Classification :
1. Spontaneous
a. Primary – no pre-existent lung pathology
b. Secondary – presence of previous pathology (e.g. emphysema)
2. Traumatic
3. Iatrogenic (related with medical/surgical procedures)
PRIMARY SPONTANEOUS PNEUMOTHORAX

 Usually caused by rupture of subpleural blebs in patients without subjacent lung disease
 Blebs : small subpleural thin-walled cavities (1-2 cm) usually located at the apex of the lungs
 Negative pleural pressure gradient that increases towards the apices of the lungs generating higher distending
forces inside the alveoli, predisposing to blebs formation
 90% of patients have visible blebs on chest CT scan or at surgery
 Taller individuals and smokers are more prone to develop PSP
BLEBS
SECONDARY SPONTANEOUS PNEUMOTHORAX

 Develop in patients with underlying lung diseases, which have less respiratory reserve and tolerate poorly even a
small pneumothorax
 Causes :
1. Primary lung disease (emphysema/COPD – chronic obstructive pulmonary disease, cystic fibrosis, interstitial lung
disease) : most frequent cause
2. Pulmonary infections
3. Malignant lung tumours
4. Catamoenial pneumothorax – in women with pleural endometriosis; occurs within the first days after the onset of
menstruation
5. Connective tissue disorders
TRAUMATIC PNEUMOTHORAX

 Air entering pleural cavity can be exogenous or endogenous

 Exogenous :
o Penetrating thoracic trauma - high risk of generating a tension
pneumothorax through a valve-like mechanism
 Endogenous :
o Blunt chest trauma with rib fracture and lung laceration
o Blunt chest trauma with sudden increase of pressure in the airways and the
digestive tract with secondary perforation and air leakage
 Symptoms :

Chest pain

Cough

Dyspnoea (breathlessness)

PNEUMOTHORAX
Signs :
CLINICAL PRESENTATION
Tachypnoea

Thoracic asymmetry

Hyper-sonority at percussion of the thoracic wall over the pneumothorax area

Muffled/absent respiratory sounds at auscultation

Jugular ingurgitation (in case of tension pneumothorax)

TENSION PNEUMOTHORAX

 Life-threatening condition generated by a complete pneumothorax that generates a very high positive pressure in
the pleural cavity inducing mediastinal shift and subsequent compression of the heart and the superior and inferior
vena cava with compromise of the venous return and cardiocirculatory collapse
 Most common causes :
o Severe thoracic trauma
o Barotrauma due to positive pressure ventilation (during resuscitation and in patients requiring mechanical ventilation)
 Treatment : emergent chest decompression by insertion of a large-bore needle in the 2 nd intercostal space, followed
by chest drain placement
PNEUMOTHORAX
IMAGE DIAGNOSIS

A. PT on CT B. partial right PT C. partial right PT D. left tension PT

PNEUMOTHORAX
MANAGEMENT

Acute setting :
 Monitor the patient’s vital signs
* In a shocked patient with suspicion of tension PT, thoracic decompression as soon as possible, based on clinical evaluation
 Place the patient in a semi-recumbent position to facilitate breathing (thorax at 30-45º)
 Administer O2 to correct hypoxemia and facilitate pleural air resorption
 Administer iv analgesics
 Obtain chest X-ray to confirm diagnosis as soon as possible
 Chest drain insertion (majority of cases)
PNEUMOTHORAX
MANAGEMENT

Definitive treatment : In chronic (usually defined as PT lasting > 5 days) and

recurrent pneumothorax
Consists in inducing adhesion formation between the pleural membranes :
o Chemical pleurodesis
o Abrasion pleurodesis
o Pleurectomy
Specific treatable causes of pneumothorax :
o Wedge resection of ruptured bullae
o Lung volume reduction in chronic obstructive pulmonary disease
o Different types of lung resection in tumoral pathology
Wedge lung resection
BRONCHOPULMONARY TUMORS
CAUSES OF PULMONARY NODULES

 Malignant :
o Bronchogenic carcinoma
o
 Non-neoplastic :
Metastases
o Pulmonary carcinoid o Infectious granulomas (TB, histoplasmosis)
o Lymphoma o Other infections (Aspergillus, Echinococcus,
 Benign :
Pneumocystis)
o Vascular (pulmonary infarct, arteriovenous
o Hamartoma
malformations)
o Lipoma
o Inflammatory (sarcoidosis, Wegener disease,
o Fibroma/ Neurofibroma
rheumatoid nodules)
o Leiomyoma
o angioma
LUNG METASTASES

 Cancers that most frequently metastasize to the lung :

o Breast
o Head and neck
o Melanoma
o Colorectal
o Kidney
o Germ cell
o Sarcoma
PULMONARY NODULES
 A pulmonary nodule is defined on imaging as a small (≤3 cm), well defined lesion completely surrounded by
pulmonary parenchyma

 Management according to :
Biopsy (surgical/non-surgical)
o Malignancy risk (see previous slide)
o Biopsy risk OR
o Surgical risk
Follow-up with CT scan surveillance
o Patient’s preference
o Adherence to follow-up visits
LUNG CANCER
LUNG CANCER
EPIDEMIOLOGY

INCIDENCE
PREVALENCE
LUNG CANCER
RISK FACTORS

 Cigarette smoking = No.1 risk

factor (responsible for some
90% of the cases)
o Likelihood of lung cancer is
15-30 higher in smokers
o Smoke contains some 70
carcinogens
 Radon = naturally occurring
colourless and odourless gas
from the soil, that enters
buildings through construction
materials and small gaps and
creaks
LUNG CANCER
CLINICAL PRESENTATION

 Cough - especially persistent, new onset cough in a current or former smoker

 Haemoptysis – blood-tinged sputum
 Dyspnoea
 Chest pain – usually form invasion on the thoracic wall
 Hoarseness – in lung cancers that infiltrate the recurrent laryngeal nerve
 Recurring pneumonia in the same location
 Pleural effusion
 Weight loss, anorexia, fatigue
 Symptoms generated by distant metastases and paraneoplastic syndromes
LUNG CANCER
DIAGNOSIS

Steps :
 Identify lung nodule/mass compatible with cancer
 Evaluate locoregional spread (lymph nodes, nearby structures – mediastinum, heart, great vessels, thoracic wall)
 Evaluate distant spread

Modalities :
• Imaging techniques : chest X-ray, CT scan (chest, abdomen, head)
• Nuclear medicine : PET-scan – evaluates the presence of metastases
• Invasive modalities :
o Bronchoscopy and endobronchial ultrasound and biopsy of masses/lymph nodes
o Thoracentesis with sampling of malignant pleural effusion for cytologic study
o Percutaneous, image-guided biopsy of peripheral lung masses
o Surgery : thoracoscopy, mediastinoscopy
 Chest X-ray Chest CT scan PET/CT scan
Lower left lobe cancer Relation with surrounding structures Metastases
BRONCHOSCOPY - ENDOBRONCHIAL ULTRASOUND
MEDIASTINOSCOPY FOR LYMPH NODES BIOPSY
LUNG CANCER
TYPES OF CANCER
LUNG CANCER
SMALL CELL LUNG CANCER (SCLC) VERSUS NON-SMALL CELL LUNG CANCER (NSCLC)

 SCLS accounts for 15-20% of all lung cancers

 Staging systems differ :
o For NSCLC : classic T(umor) – N(odes) – M(etastases) staging system with 4 stages
o For SCLC : 2-stage system
1. Limited : disease on one side of the chest, within a single radiation field
2. Extensive : beyond one side of the chest

 Prognosis : SCLC metastasizes much faster than NSCLC and can be fatal in a matter of weeks if not treated
 Same treatment modalities (chemo and radiotherapy, surgery) but with different chemosensitivities between the 2
types
STAGING
LUNG CANCER
TREATMENT

SURGERY

CHEMOTHERAPY

RADIOTHERAPY
IMMUNOTHERAP
Y
LUNG CANCER
SURGERY

 Preferred treatment modality for curable disease (stages I-II) in fit patients
 Decision to perform depends on tumour size and location, pulmonary reserve and age
 Anatomic resection is preferred in the majority of patients with NSCLC (lobectomy, pneumonectomy)
 Non-anatomic resection (sublobar resection / wedge resection) – in patients with poor pulmonary reserve and
small peripheral cancers with favourable histology
 Video or robotic-assisted approaches whenever possible, based in the anatomy and the surgical experience of the
team
 Complete curative surgery implies :
1. Resection margins free of tumour (“en bloc” resection of involved structures whenever feasible – chest wall, diaphragm)
2. Adequate, systematic lymph node dissection according to preoperative staging
OPEN LOBECTOMY VATS LOBECTOMY
LUNG CANCER
CHEMOTHERAPY

 Alone or in combination with radiotherapy

 Modalities :
o Adjuvant treatment – after radical surgery (improves survival)
o Neoadjuvant treatment – before surgery, to induce tumour shrinkage in initially non-resectable tumours
o Palliative treatment – in metastatic disease
 Based on platinum-derived agents (oxaliplatin, carboplatin)
 Gene mutations detection suitable to targeted therapies have allowed the development of a wide array of
monoclonal antibodies that can be used in metastatic disease to improve survival
LUNG CANCER
RADIOTHERAPY

Goals : maximize tumour control and minimize

toxicity
 preoperative or postoperative therapy for selected
patients treated with surgery
 definitive therapy for early-stage cancers in patients
with contraindications for surgery
 definitive therapy for locally advanced cancers,
generally combined with chemotherapy
 therapy for limited recurrences and metastases
 palliative therapy for patients with incurable
Stereotactic radiotherapy cancers