Post on 03-Jun-2018
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Lung Tumors
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Bronchogenic Carcinoma
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Introduction
Brochogenic carcinoma is also called Lung cancer.
It is a frequent and important neoplasm in both
developed country and developing country. In recent years, it has been reported that lung
cancer is the leading fatal neoplasm of men and
women. It is strongly associated with the use of tobacco
products, particularly with cigarettes.
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Incidence and prevalence
Lung cancer is the leading cause of cancer-related death of men in 28 developed countries of
the world
Squamous cell carcinoma is thought to be themost frequent form of the tumor (30-50 percent of
all cases),followed by adenocarcinoma, large cell
carcinoma, and small cell carcinoma.
Nowadays an increase has occurred in the
incidence of adenocarcinoma, which is the most
common histologic subtype.
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Endobronchial leiomyoma
Tracheal lipoma
Endobronchial schwannoma
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Etiology and pathogenesis
Cigarette smoking
Occupational associations: asbestos,
uranium (in miners), arsenical fumes,
nickel,radon gas ects.
Other factors include air pollutions ,
ionizing radiation .
Nowadays It is reported that tuberculosis is
associated with the incidence of lung
cancer.
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Pathogenesis
Many factors influence the formation oflung cancer. The development of lungcancer is a multistepp process. Thetransformation process of normalbronchial epithelial cells to malignantcells is unknown.
Perhaps It is related to: damage of
cellular DNA; alteration in cellularoncogen expression; tumor-derivedfactors that stimulate cellular division.
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Etiology and pathogenesis
Chronic inflammation of the lung, such
as from interstitial fibrosis and areas of
scarring is associated with the occurrenceof adenocarcinoma.
Genetic factors are also involved in the
formation of lung cancer.
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Major categories of genes that potentially
determine susceptibility to lung cancer, includeproto-oncogenes, tumor suppressor genes, ects.
Oncogene abnormalitiesOncogene SCLC NSCLC
Ki-ras 0 30-50% of adenocarcinomasH-ras 0 Rare mutation, over expression
N-ras 0 Rare mutation, over expression
Myc Majority Gene amplification and
overexpression
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ClassificationsAccording to anatomy:
(1)Central lung cancer,mostly is squamous cellcarcinoma and small cell carcinoma.
(2) Peripheral lung cancer, mostly is adenocarcinoma.
According to histologic classification:
Small cell lung cancer(SCLC)
Non-small cell lung cancer(NSCLC).
Squamous cell carcinoma
Large cell carcinoma
Adenocarcinoma
Adenosquamous carcinoma.
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Small Cell Carcinoma
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Small Cell Carcinoma
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Adenocarcinoma
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Adenocarcinoma
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B. Non-Small Cell Carcinoma Squamous cell carcinoma: It is the most common
subtype.It arises from altered bronchial epitheliumand growth in situ.It is related to cigarettesmoking.Cavitation can occure distal to theobstructing mass.
Adenocarcinoma: It arises from the submucosalglands,located in peripheral airways andalveoli.Peripheral adenocarcinomas are usually well-circumscribed, grey-white masses that rarely cavitate.
Adenocarcinoma is usually a slow-growing cancer,but can be difficult to detect because the diseasetypically involves the periphery of the lung, resultingin fewer early symptoms than cancers that develop
centrally, near the airways
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Classification
Large-cell carcinoma, can be quite large and
not infrequently cavitate. The tumor cells have
large nuclei,prominent nucleoli and abundant
cytoplsma.
There are two types Giant-cell carcinoma
Clear-cell carcinoma.
Adenosquamouscc: There are definite featuresof adenocarcinoma and squamous ce carcinoma.
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Clinical Manifestations
Due to primary lesions:
cough, dyspnea, hemoptysis, sputum, wheezing,
weight loss, fever, pneumonia
Due to local extension:chest pain,hoarseness,superior vena cava
syndrome, horners syndrome, dysphagia,
pericardial effusion,pleural effusion,diaphragm paralysis
Only 5-15 percent of patients are asymptomaticwhen discovered to have bronchogenic carcinoma.
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Clinical manifestations
Regionnal spread to hilar and mediastinal
nodes may cause dysphagia due to esophageal
compression, horsenessdue to recurrent laryngealnerve compression, horners syndrome due to
sympathetic nerve involvement, and elevation of
the hemidiaphragm from phrenic nervecompression.
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Pancoasts Tumor
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Clinical manifestations
Extrapulmonary manifestations. Including
metastasis to other organs, such as brain,
central nervous system, skeleton system,
liver,adrenal glands and lymph nodes ects.
Paraneoplastic syndromes are remote effects
of the tumor. They lead to metabolic and
neuromuscular disturbances unrelated to theprimary tumor, metastases, or treatment. They
may be the first sign of the tumor.They do not
indicate that a tumor has spread.
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Clinical manifestations
Paraneoplastic syndromesinclude:
hypertrophic pulmonary osteoarthropathy hypercalcemia
inappropriate antidiuretic hormonesecretion syndrome
polymyositis
subacute cerebellar degeneration peripheral neuropathies cushingssyndrome ects.
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Physical examinations
Endobronchial obstruction may result in
a localized wheeze
Lobar collapse may result in an area of
decreased breath sounds and dullness to
percussion.
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Diagnosis of lung cancer requires:
A:detecting the tumor
B:establish the cell type
C:define the stage of the tumor among
these, determing cell type is the most
important because it influences the
treatment.
Diagnosis of Bronchogeniccarcinoma
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Available methods to detect the tumor: Chest X-ray
Computer Tomography(CT)
Magnetic Resonance imaging (MRI)
Positron Emission Tomography (PET)
Hystologic examination (mainly sputum
examination, bronchoscopy biopsy,bronchial
brushing , bronchial washings, transbronchialneedle aspiration and transthoracic needle).
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Chest X-ray
Is the most important examination method. Itcan detect the presence of lung cancer. Themost frequent finding is a tumoral mass in thelung field.
Secondary manifestations seen on the chestradiograph include lober collapse,pneumonitisbecause of endobronchial obstruction,elevationof the hemidiaphragm, pleural effusion, hilar
and mediastinal adenopathy and erosion of ribsor vertebrae due to metastases.
Alveolar cell cancer can manifest as a localizedinfiltrate mimicking pneumonia.
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Chest X-ray
If a patient presents with chronic cough,
sputum with blood stipes, and dyspnea, lowfever we must perform a chest X-ray. The
most frequent finding is a mass in the lung
field.
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On chest X-ray, secondary manifestations
include lobar collapse, pleural effusion,
pneumonitis, elevation of the hemidiaphragm,hilar and mediastinal adenopathy, and
erosion of ribs or vertebrae due to metastases.
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Obstructive atelectasis
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Central bronchogenic carcinoma
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Central lung cancer manifestations
on chest radiography
Secondary manifestations we mentioned
above may be exist if metastases happen,including lobar collaps, obstuctive
pneumonitis, pleural effusion.
Mainly shows a mass locate in the one side
of hilar,some times it makes the mediastinum
widen.
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Peripheral lung cancer on chest
radiography
The most frequent finding is a mass in the
lung field. Sometimes the mass is not smooth,and with a cavity. Secondary manifestations
can be also seen on the chest X-ray, such as
pleural effusion.
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Alveolar cancer on chestradiography
The chest X-ray usually shows dissiminatedsmall nodules in the lung field.
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Lung cancer on CT
CT is the most useful in evaluating patientswith pulmonary and mediastinal masses.It is also useful for detecting multiple
metastases.CT can show the exact location and size ofthe tumoral a mass in the ( important fromthe surgical point of wiew) It also shows the
nodules in the mediastinum.Sometimes,when a mass locates behind theheart, chest X-ray can`t detect it .CT candetect some hidden sites of lung cancer.
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Peripheral carcinoma
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BronchoscopyIt is important both for determining if a
tumor is present and for obtaining tissue for
histologic diagnosis.
Usually, the combination of bronchial
brushing and forceps biopsy is positive 90 to
93 percent of the tumors located in proximalairway.
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Bronchoscopic appearances of small
cell carcinoma
Thickened membranous portion of
posterior membrane with
prominent mucosal folds
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Transbronchial lung biopsy It may be utilized when the tumor is located
in peripheral airways.
Transthoracic needle biopsy with CT guidance
can be used to detect lesions located near the
chest wall
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Thoracotomy
If the methods mentioned above are not
useful for detecting the cell type of lung
cancer, thoracotomy may be used.We should analyse some other factors
before we adopt the method, for example the
age of the patient,the pulmonary function,and complicating illness.
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In some circumstances,a histologic diagnosis
can be made by biopsy of metastatic sites,such
as lymphy nodes, liver, bone or bone marrow.
Histologic examination
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Small Cell Carcinoma
Adenocarcinoma
Squamosus cell carcinoma
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Other laboratory examinations
tumor markers
CEA
CA199
CA211
NSEGene examination (p53gene, ras gene)
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Medical history
Clinical manifestations
Physical examination
Laboratory and Imaging examinations
(chest X-ray, CT scanning, histologic
examination of sputum, biopsy tissueobtained by bronchoscopy, bronchial
brushing.)
Positive Diagnosis based on:
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TNM classification of lung cancer
Primary Tumor(T)
TX:primary tumor can not be assessed. tumor present asdetermined by presence of malignant cells in
bronchopulmonary secretions, but not radiographicallyvisible; no evidence of primary tumor
T0:No evidence of primary tumor
Tis:carcinoma in situ
T1:Tumor 3 cm or less surrounded by lung or visceral pleura,but without evidence of invasion proximal to lobar bronchusat bronchoscopy
T2:Tumor more than 3 cm or tumor invading visceral pleuraor associated with obstructive pneumonitis or atelectasis;involving less than entire lung; at bronchoscopy, proximalextent of visible tumor must be within a lobar bronchus or atleast 2 cm distal to carina
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T3:Tumor of any size with direct extension into chestwall, diaphragm, or mediastinal pleuraor pericardium
without involving heart, great vessels, trachea,
esophagus, or vertebral body; also includes superior
sulcus tumors and
T4:Tumor of any size invading mediastinum or
involving heart ,great vessels, trachea,esophagus,
vertebral body,or carina or presence of malignantpleural effusion
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Nodal Involvement(N)
Nx: can not assess regional lymph node N0:No demonstrable metastasis to regional lymph
nodes
N1:metastasis to peribronchial or the ipsilateral, orboth,hilar lymph nodes,including direct extension
N2:metastasis to ipsilateral mediastinal lymphnodes and subcarinal lymph nodes
N3:metastasis to contralteral mediastinal lymphnodes,contralateral hilar lymph nodes,ipsilateral orcontralateral scalene or supraclavicular lymphnodes
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Distant metastasis(M) Mx: distant metastasis can not be assessed
M0:No distant metastasis
M1:Distant metastasis present
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Small cell lung cancer has often metastasized
at the time of diagnosis.TNM staging is not suited to small cell lung
cancer.
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TreatmentIncluding:
A:Surgery
B:ChemotherapyC:Radiation therapy
D:Some other therapy
immunologic therapy
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We must measure pulmonary function before
surgical therapy.
Forced vital capacity greater than 2 liters and a
forced expiratory volume in the first second
(FEV1)of greater than 50 percent of the forced
vital capacity predict that a patient can tolerate
the consequences of pneumonectomy.
Surgery
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Surgery
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Surgery
S
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Surgery
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Chemotherapy
Non-small cell lung cancer
MVP:MMC 6-8mg/m2 (1), VDS 3mg/m2
NP:VP-16 (d1,d8). DDP 100mg/m2 (d1)GP
Small-cell lung cancer it is highly responsive to
chemotherapy.EP regimen VP-16 100mg/m2 d1~d3.
DDP 100mg/m2 d1. GP
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Chemotherapy drawbacksAggressive chemotherapy produces
complications and symptoms in all patients.
All experience anemia,leukopenia andopportunistic infections.
Other complications include nausea,vomiting
possible cadiotoxicity, hemorrhagic cystitis and
peripheral neuropathy.
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Radiation therapy
It is of proven benefit in controlling bone
pain,spinal cord compression, superior vena
cava syndrome and bronchial obstruction.
1 Epithelial Tumours
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1 Epithelial Tumours1.1.Benign
1.1.1. Papillomas
1.1.1.1. Squamous cell papillomaExophytic
Inverted
1.1.1.2. Glandular papilloma
1.1.1.3. Mixed squamous cell and glandular apilloma
1.1.2. Adenomas
1.1.2.1. Alveolar adenoma
1.1.2.2. Papillary adenoma
1.1.2.3. Adenomas of salivary-gland type
Mucous gland adenomaPleomorphic adenoma
Others
1.1.2.4. Mucinous cystadenoma
1.1.2.5. Other
1. Epithelial Tumours
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1.2. Preinvasive lesions
1.2.1. Squamous dysplasia/Carcinoma in situ
1.2.2. Atypical adenomatous hyperplasia1.2.3. Diffuse idiopathic pulmonary neuroendocrine cell
hyperplasia
1.3. Malignant
1.3.1. Small Cell Carcinoma1.3.2. Non-Small Cell Carcinoma
1.3.2.1. Squamous Cell Carcinoma
1.3.2.2. Adenocarcinoma
Acinar
Papillary
Bronchioloalveolar carcinoma
Solid adenocarcinoma with mucin
1. Epithelial Tumours
1 3 4 ll i
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1.3.4. Large cell carcinoma
Variants
1.3.4.1. Large cell neuroendocrine carcinoma
1.3.4.1.1. Combined large cell neuroendocrinecarcinoma
1.3.4.2. Basaloid carcinoma
1.3.4.3. Lymphoepithelioma-like carcinoma
1.3.4.4. Clear cell carcinoma1.3.4.5. Large cell carcinoma with rhabdoid
phenotype
1.3.5. Adenosquamous carcinoma
1.3.6. Carcinomas with pleomorphic,
sarcomatoid or
sarcomatous elements
1 3 2 3 L C ll C i
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1.3.2.3. Large Cell Carcinoma
1.3.2.4. Adenosquamous carcinoma
1.3.2.5. Carcinoid tumor
Typical carcinoidAtipical carcinoid
2.Soft Tissue Tumours
2.1 Localized fibrous tumour2.2 Epithelioid hemangioendothelioma
2.3 Pleuropulmonary blastoma
2.4 Chondroma
2.5 Calcifying fibrous pseudotumour of the pleura
2.6 Congenital peribronchial myofibroblastic tumour
2.7 Diffuse pulmonary lymphangiomatosis
2.8 Desmoplastic small round cell tumour
2.9 Other
3 Mesothelial Tumours
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3 Mesothelial Tumours3.1 Benign
3.1.1 Adenomatoid tumour
3.2 Malignant
3.2.1 Epithelioid mesothelioma
3.2.2 Sarcomatoid mesothelioma
3.2.3 Biphasic mesothelioma
4 Miscellaneous Tumours4.1 Hamartoma
4.2 Sclerosing hemangioma
4.3 Clear cell tumour
4.4 Germ cell neoplasmsTeratoma, mature or immature
Malignant germ cell tumour
4.5 Thymona
4.6 Melanoma
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Combined Small Cell CC and Adenocarcinoma
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Combined Small Cell CC and Squamous Cell CC
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Large Cell Carcinoma
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Small Cell Carcinoma
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Small Cell Carcinoma
Lung Cancer: Overview
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Lung Cancer: Overview
Lungcancer is the leading cause of cancer death in both men and
women, and accounted for approximately 27% of all cancer deaths
Alarmingly, 87% of lung cancer deaths could be prevented by
eliminating tobacco abuse.(American Cancer Society Illinois Cancer Facts & Figures, 2006)
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Lung Cancer: Women
Account for 12% of all new cases
More deaths from lung cancer than breast,ovarian,
and
uterine cancers combined.
Women are more susceptible to tobacco effects. 1.5times more likely to develop lung cancer than men with
similar smoking patterns.
Jemal A, Thomas A, Murray T, Thun M. (2002).American Cancer SocietyFacts & Figures (2004
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Metastatic nodes
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Sputum Sample of Bronchogenic Carcinoma
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Sputum Sample of Bronchogenic Carcinoma
Hamartoma
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Hamartoma
Tracheal papillomatosis
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Tracheal papillomatosis
Endobronchial amyloidoma
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Endobronchial amyloidoma