Lung mediastinal tumors
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Lung and Mediastinal Tumours
Dr. Manu Mohan. K
Asst. Professor
Pulmonary Medicine
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Epidemiology
Most common form of malignant diseases 40,000 new patients per year 8% male deaths and 4% of all female
deaths Men > women, middle age
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Etiological factors
Tobacco smoking
Cigarette smokers are 8-20 times more likely to develop lung cancer than life long non smokers.
Squamous and small cell carcinoma have clear association with smoking.
Adenocarcinoma is commonest histological type in a non smoker
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Atmospheric pollution
Controversial
Radon - radiation
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Occupational factors
Asbestos – mining, processing, usage. Radioactivity – metal ore mining, uranium
mining. Nickel – refining. Chromium salt – extraction, production,
usage. Arsenic – metal refining, chemical
industry, insecticides.
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Pulmonary scarring
Localised areas of pulmonary scarring Diffuse pulmonary fibrosis Cryptogenic fibrosing alveolitis is
associated with adenocarcinoma Tuberculosis – scar carcinoma,
adenocarcinoma Bronchioloalveolar carcinoma also
occur in areas of scarring
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Histological classification
1. Squamous cell carcinoma (epidermoid carcinoma)
2. Small cell carcinomaa. oat cell carcinomab. intermediate cell typec. combined oat cell
carcinoma
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3. Adenocarcinoma a. acinar b. papillary adenocarcinomac. bronchioloalveolar d. solid carcinoma with mucous
4. Large cell carcinoma5. Adenosquamous carcinoma
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6. Carcinoid tumours7. Bronchial gland carcinoma
a. adenoid cystic carcinomab. mucoepidermoid carcinomac. others
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Growth factors
Polypeptides that take part in the control of cell differentiation and proliferation
Bombesin/gastrin releasing peptide – growth factor for small cell carcinoma
Non small cell carcinoma – few growth factors are recognized, EGF, TGF
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Genetic abnormalities
Loss of short arm of chromosome in small cell carcinoma (p14, p23)
CDKN2 gene on chromosome 9 – Non small cell lung carcinoma
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Oncogenes
myc genes – small cell lung carcinoma
Kras – adenocarcinoma
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Tumour markers
Substances produced by tumour cells that are released in to blood stream.
Neuron specific enolase, creatinine phophokinase BB, CEA
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Modes of presentation
Worsening of preexisting respiratory state.
No symptoms, detected by the chance of finding an opacity.
Nonspecific symptoms of malignancy like malaise, anorexia, and weight loss
Metastatic disease
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Central tumours Cough – most common symptom New cough that persists longer than 2
weeks in a patient of 40 years who is a smoker.
Hemoptysis – usually streaky Breathlessness – due to central airway
narrowing, partial or total collapse of a distal segment
Chest pain – deep chest discomfort, due to peribronchial and perivascular nerve involvement.
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Peripheral tumours
Cough and hemoptyis Bronchorrhoea Dyspnoea Chest pain
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Distant spread
Skeletal metastasis – bone pain, pathological fractures
Cerebral metastasis – progressive neurological symptoms
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Clinical features
Frequently no abnormal findings Hoarseness Bovine cough Clubbing HPOA
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Lymphatic involvement – scalene and supraclavicular
Axillary lymph nodes due to chest invasion
Stridor, wheezes
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Atelectasis Pleural effusion SVC obstruction Diaphragm palsy Enlarged liver Raised intracranial pressure Dysphagia
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Investigations
Chest radiography Nearly always abnormal
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Collapse Pleural effusion Elevated hemi diaphragm Widening of mediastinum Lymphangitis carcinomatosa Pneumonic shadow – bronchioloalveolar
carcinoma Pancoast tumour
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Solitary pulmonary nodule (SPN)
Opacity of less than 3 cm without surrounding atelectasis and or adenopathy.
Doubling time Calcification
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Solitary pulmonary nodule
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Sputum cytology – more yield in central tumours
60-70% positive yield in experienced hands
Single sample – 40% 4 samples – 80%
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Bronchoscopy – most useful for central tumours
Tumours beyond bronchoscopic view – Transbronchial needle biopsy, blind brushing and washing
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Other investigations
Percutaneous needle biopsy Aspiration of subcutaneous swelling Pleural fluid study Thoracoscopic lung biopsy Mediastinoscopy Thoracotomy
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StagingNon small cell carcinoma
TNM staging Primary tumour (T) Tx, T0, T1s, T1, T2, T3, T4 Nodal involvement (N) N0, N1, N2, N3. Distant metastasis (M) M0, M1
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Staging
Small cell lung carcinoma Limited Extensive
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Treatment
Non small cell lung carcinoma Surgery – best result, but only a
small minority Types of surgery Pneumonectomy Lobectomy VATS – segmentectomy 5 year survival rate overall 35%
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Radiotherapy Stage I&II – inoperable due to medical
contraindicationsIndications Hemoptysis, pain, cough, dyspnoea due
to large bronchus obstruction, mediastinal compression, symptoms due to intracranial metastasis, symptoms due to spinal cord compression.
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Endobronchial treatment
Laser therapy Endobronchial radiotherapy Photodynamic therapy
Chemotherapy
Poor response to chemotherapeutic agents
Combined modalities
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Small cell carcinoma
At presentation 70% have extensive disease
Chemotherapy More sensitive to chemotherapy Combined therapy preferred than
monotherapy
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Radiotherapy Primary tumour control Prophylatic cranial irradiation Surgery
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Paraneoplastic syndrome
Non metastatic metabolic/neuromuscular manifestations
Hypercalcemia SIADH Ectopic ACTH HPOA
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Gynaecomastia – large cell and adeno carcinoma
Eaton-Lambert syndrome, polymyositis/dermatomyositis
Peripheral neuropathy Cerebellar ataxia
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Superior venacava obstruction
Small cell carcinoma Diagnosis – swelling of face and upper
torso and distension of veins across the chest, upper arms and neck.
Treatment – chemotherapy, radiotherapy and stenting
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Superior sulcus tumour Pancoast Pain in lower part of shoulder and
inner aspect of the arm (C8, T1 and T2)
Sympathetic ganglion involvement – stellate
Diagnosis Treatment - radiotherapy and
surgery
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Prevention
Primary prevention
Stop smoking
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Mediastinum lies centrally within the chest and spans the region vertically from the thoracic inlet to the diaphragmatic hiatus, transversally between the parietal pleura, and coronally between the sternum and vertebral column.
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Mediastinal Compartments
3 compartmentsAnterior compartment Middle compartment Posterior compartment
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Anterosuperior compartment
Structures
Common lesions
Rare lesions
Ascending aorta
Thymomas Vascular lesions
Superior vena cava
Lymphomas Mesenchymal tumors
Azygos vein
Germ cell tumours
Endocrine tumours
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Thymus glandLymph nodes
Transverse and great vesselsConnective tissue
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Middle compartment
Structures
Common lesions
Rare lesions
Heart and Pericardium
Foregut cysts
Pleural and pericardial cysts
Trachea and bronchi
Lymphatic tumours
Neuroenteric and gastroenteric cysts
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Posterior compartment
Structures Common lesions
Rare lesions
Sympathetic chain
Tumours of Neurogenic origin
Vascular tumour
Vagus nerves
Mesenchymal tumours
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Thoracic duct
Lymphatic lesions
Lymph nodesDescending aorta
oesophagus
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Symptoms and Mechanisms
Symptoms Mechanisms
cough Airway narrowing, compression
Chest pain Chest wall invasion, neural invasion
Dyspnoea Airway compromise, pericardial tamponade, pleural effusions, pulmonary stenosis, heart failure.
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Hemoptysis Bronchogenic carcinoma, airway invasion, pulmonary stenosis, heart failure
Dysphagia Oesophageal narrowing/obstruction, oesophageal motor dysfunction
Hoarseness Vocal cord paralysis
Facial swelling Superior vena cava syndrome
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Incidence
Adults65% in Anterosuperior, 10% in the middle and 25% in the posterior compartments
Children28% Anterosuperior, 10% in middle, 62% in the posterior compartment
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Investigations
• Noninvasive diagnostic procedures• Computed tomography• Magnetic resonance imaging• Ultrasonography• Radio nuclides
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Biochemical MarkersAFB, HCG – nonseminomatous germ cell tumour, Teratoma, Carcinoma
CEA Catecholamines,vanillylmandelic acid,
homovanillic acid – Pheochromocytoma Nor epinephrine, epinephrine –
paraganglioma,ganglioneuroma, neuroblatoma
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Invasive biopsy proceduresFNABSurgical procedures
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Lesions masquerading as mediastinal tumours
• Substernal Goiter• Cystic Hygroma• Lesions originating from thoracic
skeleton• Vascular lesions• Oesophageal lesions• Pulmonary lesions• Sub diaphragmatic Lesions
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Paraneoplastic syndromes associated with Thymoma
Well established Myasthenia gravis Pure red cell aplasia Acquired hypogammaglobulinemia Non Thymic cancers
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Less well established Pancytopenia Lambert-Eaton Peripheral neuropathies CNS changes Multiple endocrine defects Multiple rheumatologic disorders Nephrotic syndrome
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Thymoma is the most common primary neoplasm of the mediastinum
15% of Thymic lesions Equal frequency in male and female 40-60 years 75% in anterior mediastinum More than 90% are visible on chest
radiograph
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Surgical resection Radiotherapy Unresectable, recurrent or
metastatic Thymoma- chemotherapy
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Tumours of lymph nodes
Lymphomas › 10-14% of mediastinal tumours› rare in posterior mediastinum› Hodgkin’s and Non Hodgkin’s› 20-30% asymptomatic› 60-70% symptoms of local
invasion› 30-35% systemic symptoms
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Non-Hodgkin’s lymphoma› 5% with mediastinal involvement› Large irregular anterior and superior
mediastinal involvement› Radiation therapy effective in low grade
lymphoma› chemotherapy
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Germ cell tumours
Benign and malignant
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Benign germ cell tumours (Teratoma)
Constitute 70% of the lesions in children and 60% in adults.
Contain multiple tissues that are foreign to the part of the body in which they develop.
Symptomatic only when infected
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Malignant germ cell tumours
Malignant mediastinal teratoma Mediastinal seminoma Nonseminomatous tumours-
embryonal carcinoma, choriocarcinoma, endodermal sinus tumours, teratocarcinoma
Chemotherapy and radiotherapy, surgery
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Middle mediastinal tumours Bronchogenic cysts
Mediastinal cysts form 20% of mediastinal tumours
60% of mediastinal cysts are bronchogenic cyst
Oesophageal cysts Neuroenteric cysts Mesothelial cysts
Pericardial or pleuropericardial cysts
Thoracic duct cyst
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• Neurogenic tumours• Most common malignancy in children• In children 50% malignant, adults 10%• Dumbbell tumours – intraspinal
extension• CT, MRI, myelography
Tumours of nerve sheath origin› Benign – neurilemoma or neurofibroma› Malignant tumours-incidence of
malignancy more in von Recklinghausen’s disease
› Poor prognosis
Posterior mediastinal tumours
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Tumours of autonomic nervous system› Neuroblatoma, ganglioneuroblastoma
rare in adults
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Endocrine tumours
Mediastinal pheochromocytoma
Parathyroid adenoma
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