LUNG &

MEDIASTINUM
TNM Staging of the Lung
TNM Staging of the Lung
Histology of the Lung Cancer
• Smal Cell Lung Cancer
• Non-Small Cell Lung Cancer
1. Squamous Cell Carcinoma
2. Adenocarcinoma
3. Large Cell Carcinoma
62 yo M smoker w/ lung nodule
• Biopsy shows moderately differentiated adenocarcinoma.
• CT Chest: 3.2 x 2.8 cm lesion in right lower lobe, no lymph nodes.

• Stage?
• T2aN0  Stage IB
62 yo M smoker w/ Stage IB NSCLC

What are the treatment options?

• Surgery
• Definitive Radiation
• Stereotactic Body Radiation Therapy (SBRT): If < 5cm
•
62 yo M smoker w/ Stage IB NSCLC
WHAT SURGERY WOULD YOU RECOMMEND?
• Lobectomy & Mediastinal LND

• What about a Pneumonectomy?

• Mortality ~6% (institution dependent)
• For comparison, lobectomy mortality ~3%
• May be necessary for tumors near proximal bronchus

• What about a Wedge Resection?

• Only if physiologically compromised (PFTs) – not an
oncologic operation
Stage IV NSCLC
• Patient presents with metastatic disease

• Treatment?
• ECOG PS 0-2: Chemo ± palliative RT
• First-line chemo uses 2 agents for 3-4 cycles.
• ECOG PS 3-4: Best supportive care

• MS?
• 6-18 mo, usually ~8-10
 48 yo F smoker p/w RUE pain/weakness
• MRI chest is done to look
for what?
• Gets CT scan, which shows:

• What else might you see on exam?

Superior Sulcus Tumor
Horner’s Syndrome Horner’s Syndrome
• Which is affected side? • Miosis – Constricted Pupil
• Ptosis
• Anhidrosis
• Can also be facial
flushing
Malignant Pleural Mesothelioma
• Arises from mesothelial
surfaces of pleural and
peritoneal cavities,
tunica vaginalis,
pericardium

• Pathology:
• ~40% non-epithelial
• 20-35% biphasic
• 10-15% sarcomatoid
• ~60% epithelial
48 yo F smoker w/ sup sulcus tumor
• Pancoast tumor:
• Superior sulcus tumor with:
• Shoulder/arm pain
• Atrophy of arm muscles
• Horner’s syndrome.
• However, don’t need to have symptoms.
• Radiographic invasion of apical structures:
• ribs/periosteum
• lower nerve roots of brachial plexus
• sympathetic chain
• subclavian vessels are classified as Pancoast.
• Infiltration of chest wall at level of 2nd rib or lower or of visceral
pleura only does NOT meet criteria for Pancoast tumor, these
are simply superior sulcus tumors or an upper lobe cancer.
Mesothelioma – Epidemiology
• More common in the US than anywhere else
• MALE predominance (M:F = 5:1)
• Median age 65-72 years
• 60-70% are RIGHT sided (<5% bilateral)
• Most common primary cancer of the pericardium
• Incidence increasing
• 2,500 cases per year in the US (expected to peak in 2020)
• 1 in 150 men born in the 1940’s are projected to die from malignant pleural
mesothelioma
• Untreated – median survival: 4 – 8 months
Favorable Factors:
• Epithelial histology (versus sarcomatoid) • Lack of weight loss
• Young age (<55 years, <75 years) • Normal platelet count & hemoglobin
• Good performance status • Lack of chest pain at diagnosis
• Early-stage disease (stage I) • Pleural fluid pH >7.3 and high pleural/serum
Female gender glucose ratio
•
Mesothelioma – Etiology
• The vast majority of mesothelioma cases are attributed to ASBESTOS
exposure
• Associated with >50-70% of cases
• 1940s-1970s: used for insulation, textiles, construction materials
• Latency period of 3-4 decades following exposure
• High risk workers may predispose family members to developing
mesothelioma
• Rod-like amphiboles (crocidolite) more likely to cause cancer than the
Serpentine (chrysolite) variety (95% of the asbestos found in US buildings)

• Less common etiologies:

• Radiation therapy (Breast, lymphoma, testicular)
• Erionite fibers (mineral in gravel roads)
• Collapsotherapy (the induction of artificial pneumothorax or
pneumoperitoneum for treatment of tuberculosis)
• DNA tumor simian virus SV40 (acts as co-carcinogen with asbestos)
Mesothelioma – Presentation
• Often locally advanced at presentation
• 90% with dyspnea, non-pleuritic chest wall pain, or both
• 10-20% present with spontaneous pneumothorax
• Advanced disease:
• Clotting abnormalities
• Respiratory failure/pneumonia
• Small bowel obstruction (direct extension through diaphragm in ~1/3)
• Myocardial involvement (cause of death in ~10%)
• Exam: Dullness at the lung base
• Imaging
• Pleural plaques & interstitial fibrosis seen on CXR (20%) or CT chest
(50%)
• CXR: Large, freely movable effusion
• CT chest: Discrete nodules & plaques  form rind which causes constriction
Mesothelioma - Treatment
• Resectable
• Treatment?
• EPP (mortality 5-30%)
• Post-op RT 54 Gy
• Sequential pemetrexed (Alimta; antifolate) & cisplatin
• Outcome?
• Trimodality: MS 19 mo, otherwise <1 yr
• LF 25-50% depending on series, even with trimodality
Mesothelioma – Surgery (EPP)
Extrapleural pneumonectomy
• En bloc resection: pleura, lung, diaphragm, ± pericardium
• Sample mediastinal LN.
• Reconstruct diaphragm with Gore-Tex graft.
• Perioperative mortality 6-30%

PFTs/Cardiac Eval:
• Patient selection  predicted post-op FEV1 > 1.0L
 PaO2 > 65 mmHg (on RA)
• limited, early stage dz (NOT T4, N2-3 or M1)  PaCO2 < 45 mmHg (on RA)
• PS 0-1  EF > 40%
 mean PA pressure < 30
• Epithelial or Mixed Histology mmHg
• Able to tolerate tri-modality therapy

www.ctsnet.org
 Mesothelioma – Surgery (PD)
Pleurectomy and decortication
• Removes pleura
• Historically for palliation (leaves tumor behind).
• Some places now doing Radical Pleurectomy
• Complete removal of the pleura & all gross disease w/
mediastinal sampling
• perioperative mortality 2-5%
• less cytoreductive than EPP

www.acssurgery.com