LUNG TUMOURS

Causes and Risk factors of Lung Cancer

 Solitary Pulmonary Nodule (SPN)
• Single lung opacity of size less than 3 cm
• Discrete and does not attach to the lung border or pleura
• Associated lymphadenopathy is characteristically absent
• Incidentally discovered during routine scans of the chest in relatively
asymptomatic patients
• Found incidentally on 0.1% to 0.2% of chest x-rays and 13% on CT
scans
What is a Nodule?
• a spectrum of abnormalities

Nodules
( )
Focal Abnormalities

Spiculated Calcified
Scar Nodule
Nodule
 Benign SPN
• Infectious: Granulomatous Infections, Fungal Infections, Parasites
• Inflammatory: Rheumatoid Arthritis, Granulomatosis With
Polyangiitis
• Congenital Nodules
• Scars as a Sequela of Previous Infections
• Bronchogenic Cysts
• Arteriovenous Malformation
• Mucus Plugging, Rounded Atelectasis, Pulmonary Infarction
• Fibromas, Hamartomas
 Malignant SPN
• Bronchogenic Carcinoma (Both Small Cell And Non-small Cell
Carcinomas)

• Metastatic Cancers

• Carcinoids

• Lymphomas

• Sarcomas
INVESTIGATIONS
• SPN (>8 mm)or high risk patient Positron emission tomography scan
• Tumor markers CEA, FR positive circulating tumor cells, LG3BP, and
C163A
• Biopsies – FNAC, liquid biopsy, or excisional biopsy
• CT-guided transthoracic needle aspiration
• Bronchoscopy
• Radial probe endobronchial ultrasound (RP-EBUS)
• Thin/ultrathin bronchoscopes
• Virtual navigation bronchoscopy (VBN)
• Robotic bronchoscopy
• Electromagnetic navigation bronchoscopy (ENB)
Lung imaging reporting and data system (Lung-RADS)
Classification tool to evaluate findings on a low dose CT scan when
screening for lung cancer
• Category 0 (incomplete)
• Category 1 (negative) less than 1% chance of malignancy
• Category 2 (benign appearance) <1% chance of malignancy
• Category 3 (probably benign) 1% to 2% chance of malignancy
• Category 4A (probably suspicious) 5 to 15% chance of malignancy
4B (suspicious) >15% chance of malignancy.
4X (suspicious) is either category 3 or 4 with other features
suspicious for malignancy
Mayo Clinic Calculator (1997)
• Increased age
• Upper lobe location of the nodule
• Nodule diameter in mm
• Spiculation
• Smoking
• Extra-thoracic cancer >5 years
Brock University calculator (2013)
Also adds
• Emphysema
• Ground-glass opacity
• Subsolid nodule
• Female sex
• Number of nodules
• Family history of lung cancer

Notably, it does not take into account smoking status

Treatment
• 2017 Fleischner Society Guidelines
• American College of Chest Physicians (ACCP) guidelines
• Follow up
• Chemotherapy
• Radiotherapy
• Open thoracotomy
• VATS (video-assisted thoracic surgery)
• RATS (robotic-assisted thoracoscopic surgery)
 Lung Cancer or Bronchogenic Carcinoma
• Tumors originating in the lung parenchyma or within the bronchi
• Most commonly diagnosed cancer, accounting for approximately 12.4% of all
cancers diagnosed worldwide

• It is hypothesized that repeated exposure to carcinogens, such as cigarette

smoke leads to dysplasia of lung epithelium  Exposure continues  Genetic
mutations and affects protein synthesis  Disrupts the cell cycle and promotes
carcinogenesis.
• The most common genetic mutations responsible for lung cancer development
are MYC, BCL2, and P53 for small cell lung cancer (SCLC)
and EGFR, KRAS, and P16 for non-small cell lung cancer (NSCLC).
Etiology
• Smoking is the most common cause

• Exposure to other carcinogens, such as asbestos, radon

• Risk of lung cancer secondary to passive smoking increases by 20 to 30%

• Radiation for non-lung cancer treatment

• Exposure to metals such as chromium, nickel, arsenic, and polycyclic

aromatic hydrocarbons
 • Squamous cell CA

Central tumors • Small cell CA

• Adenocarcinoma
• - bronchial derived
• - bronchioloalveolar ca
Peripheral
tumors • Large cell carcinoma
 2021 WHO Classification system
• Precursor glandular lesions • Salivary gland-type tumors
• Adenocarcinomas • Neuroendocrine tumors
• Adenosquamous carcinomas • Neuroendocrine carcinomas
• Squamous precursor lesions • And other epithelial tumors
• Squamous cell carcinomas
• Large cell carcinomas
• Sarcomatoid carcinomas
• Lung neuroendocrine neoplasms
 Classification of bronchogenic
carcinoma

Malignant epithelial tumors/ Malignant Miscellaneous

bronchogenic carcinoma mesothelial malignant
tumor tumor

1- Non-Small Cell 2- Small cell lung 3-Combined 4- Carcinoid Malignant

Lung Carcinoma carcinoma (SCC) patterns tumor 5- Others mesothelioma 1-
(NSCC) : Carcinosarcoma

1. Squamous Epithelial
cell 2- Pulmonary
carcinoma blastoma

Fibrous
2. (spindle cell)
3- Melanoma
Adenocarcinoma

3. Large cell Biphasic

carcinoma 4- Lymphoma

5- Others
-Adenocarcinomas is now the most frequent histologic subtype of bronchogenic
carcinoma
-More common in patients under the age of 40, women and non-smokers
-Peripheral adenocarcinomas are sometimes associated with pulmonary scars and
therefore are also referred to as scar carcinomas.
-Tend to metastasize widely at early stage
-They are classically peripheral tumors arising from the peripheral airways and alveoli.
-The hallmark of adenocarcinomas is the tendency to form glands that may or may not
produce mucin.
-Rarely cavitate
-Associated with hypertrophic pulmonary osteoarthropathy “Clubbing of the fingers”
-20% of adenocarcinoma of the lung are associated with mutations of epidermal
growth factor receptor (EGFR) and respond to its anti therapy
Large Cell Carcinoma
• Frequency: 10 %
• strongly associated with smoking
• usually located peripherally.
• This group of carcinomas is undifferentiated.
• They are made up of large and anaplastic cells.
• They may exhibit neuroendocrine or glandular differentiation markers when
studied by immunohistochemistry or electron microscopy.
• Poor prognosis.
Small cell carcinomas
SCLC are a type neuroendocrine tumors arising from neuroendocrine cells + more common in men.

Highly malignant and aggressive tumor, poor prognosis, rarely resectable.

Strongly associated with cigarette smoking. 95% of patients are smokers

Centrally located perihilar mass with early metastases (Early involvement of the hilar and
mediastinal nodes)

- Chemotherapy responsive
- least likely form to be cured by surgery; usually already metastatic at diagnosis

Able to secrete a host of polypeptide hormones like ACTH, antidiuretic hormone (ADH), calcitonin,
gastrin-releasing peptide and chromogranin.

It may be associated with paraneoplastic syndrome, Cushing’s, and Eaton-Lambert syndrome

Clinical features of bronchogenic carcinoma:

• Local effects of the tumor

• Due to distant metastasis

• Paraneoplastic syndrome

• Kidney stones due to persistent hypercalcemia

• Can be silent - early stage, no symptoms or insidious lesions.
• Cough- when the tumor gets larger -Most common symptom (75% of
cases)
• Weight loss (40% of cases)
• Chest pain (30% of cases)
• Hemoptysis (25%–30% of cases) - especially when cavitation starts.
• Dyspnea -when it’s enlarged and obstructing the lung.
• Hoarseness -because of invasion of hilum –recurrent laryngeal nerve
paralysis
• chest pain- especially when it reaches pleura, pericardial or pleural
effusion.
• Symptoms due to invasion and metastatic spread.
Lung cancer evaluation can be divided as:
• Radiological staging
• Invasive staging
Goals of Initial Evaluation
• Clinical extent and stage of the disease
• Optimal target site and modality of 1st tissue biopsy
• Specific histologic subtypes
• Presence of co-morbidities, para-neoplastic syndromes
• Patient values and preferences regarding therapy
• Contrast-enhanced CT chest with extension to upper abdomen up to the
level of adrenal glands
• Imaging with PET or PET-CT directed at sites of potential metastasis
when symptoms or focal findings are present or when chest CT shows
evidence of advanced disease
• Mediastinoscopy
• Thoracoscopy
Treatment of Non-Small Cell Lung Cancer
(NSCLC)
Stage I
• Surgery is the mainstay
• Lobectomy or pneumonectomy with mediastinal lymph node sampling
Stage II
• Surgery followed by adjuvant chemotherapy
• Pancoast tumor is neoadjuvant chemotherapy and concurrent
radiotherapy followed by resection
Stage III
• Stage IIIA disease with N1 lymph nodes, surgery with curative intent
is the treatment of choice
• no agreement on treatment for patients with stage IIIA tumors with
N2/N3 lymph nodes
• T4 tumors are usually treated exclusively with chemoradiation.
• Stage IIIB tumors are treated the same way unresectable IIIA cancers
are treated, with concurrent chemo-radiotherapy
Stage IV

• Incurable and therapy is aimed at improving survival and alleviating

symptoms

• Single or double drug-based chemotherapy is offered

Targeted Therapy for NSCLC

• EGFR (epidermal growth factor receptor) is a mutation inhibited by

tyrosine kinase inhibitors erlotinib, gefitinib, and afatinib.

• ALK (Anaplastic lymphoma kinase) includes the specific inhibitors

crizotinib, ceritinib, and alectinib. A structurally similar mutation is
ROS-1. The FDA recently approved crizotinib for treating cancers
expressing ROS-1 mutation.
Immunotherapy for NSCLC
• Nivolumab
• Pembrolizumab
• Atezolizumab
• Bevacizumab
Small Cell Lung Cancer Treatment
Treatment of Limited-stage Small Cell Lung Cancer
• Stage I limited-stage small cell lung cancer (LS-SCLC) is lobectomy
followed by adjuvant chemotherapy
• LS-SCLC with mediastinal or hilar lymph node involvement is 4 to 6
cycles of chemotherapy followed by radiation therapy
Treatment of Extensive-stage Small Cell Lung Cancer (ES-SCLC)
• Platinum-based chemotherapy
• Median survival from the time of diagnosis of ES-SCLC is only 8 to
13 months
Lobectomy
LUNG METASTASIS
• Lung is the second most frequent site of metastatic focus.
• It is estimated that 20 to 54% of malignant tumors developing
elsewhere in our body would have pulmonary metastasis
The patient can be asymptomatic
• Systemic symptoms:
• fatigue
• nausea
• anorexia
• weight loss
Localized symptoms:
• Pleurisy/pleural effusion
• Cough (productive and non-productive)
• Dyspnea
• Hemoptysis
• Scalp metastasis
• Electrolyte disturbances
• Pancoast tumor
• Superior vena cava syndrome
Tumors spread to the lungs either by hematogenous or lymphatic route or by
direct invasion.
1. Hematogenous spread: tumors with venous drainage into lungs, e.g., head
and neck, thyroid, adrenals, kidneys, testes, melanoma, and osteosarcoma.
2. Lymphatic spread: occurred in two ways: either antegrade lymphatic
invasion through the diaphragm and/or pleural surfaces or by retrograde
lymphatic spread from hilar nodal metastases. Examples include lung,
stomach, breast, pancreas, uterus, rectum, and prostate cancer.
3. Direct spread to pleura: hematogenous dissemination with extension to
the pleura, with lymphatic spread, or from established hepatic metastases.
Examples include cancers of the lung, breast, pancreas, and stomach.
TREATMENT

• Chemotherapy

• Immunotherapy

• Radiation

• Primary Management

• Surgery Option on Case to Case Basis