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Lung Lesions

Done by: Abdulaziz Alhujairy .. Supervised: Dr.Waseem Hajjar

AbdulAziz Alhujairy

on 23 November 2011

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Transcript of Lung Lesions

Lung Lesions Objectives Done By : Abdulaziz Alhujairy To identify lung lesion and how to manage.
To differentiate between Benign lung lesions.
Understand Solitary lung lesion and how to approach.
Identify and treat Pulmonary carcinoid tumor.
To have a clear picture about lung cancer.
The surgical role in treating lung lesion.
Supervised by :
Dr.Waseem Hajjar A lung lesion is abnormal tissue found on or in a person’s lung. It appear as lump of mass of tissues and other matter such as hardened blood, or pus in the lungs. They may appear in the bronchi or in the air sacs.
Wherever they are found, they can cause pronounced difficulty in the respiratory system especially if they are malignant.

Carcinoid tumors are a slow-growing cancer that can arise in several places throughout your body.
Carcinoid tumors, which are one subset of tumors called neuroendocrine tumors APUD {amine-precursor uptake and decarboxylation}, known as the usually appear in the gastrointestinal tract (appendix, stomach, small intestine, colon, rectum) and in the lungs.
Metastasis to the Liver with GI symptoms. In some cases, lung lesions may be numerous and may form on a specific area which is known as solitary lung lesion.
In general, lung lesions may be classified as benign or malignant. Lung Lesion (cc) image by nuonsolarteam on Flickr Benign granulomateous lesion (TB)
benign tumors (hamartoma,
bronchial adenoma
mucous gland adenoma)
Tuberculosis creates cavities visible in x-rays like this one in the patient's right upper lobe.
Malignant carciniod lung tumor
Lung cancer(SCLC,NSCLC) A CXR in a patient with central cancer of the right lung. Notice the white mass in the middle portion of the right lung
Lung Lesion Benign lung tumors are a heterogenous group of neoplastic lesions originating from pulmonary structures. These tumors include bronchial adenomas, hamartomas, and a group of uncommon neoplasms (eg, chondromas, fibromas, lipomas, leiomyomas, hemangiomas, teratomas)
Although benign lung tumors do not pose a significant health problem, complications can result from an obstructive lesion that could predispose the patient to pneumonia, atelectasis, and hemoptysis.
Age range is 17-77 years.
The exact cause is unknown, because it is usually asymptomatic and discovered incidentally. According to origin they are classified Mesodermal
fibroma, lipoma, leiomyoma, chondroma,
granular cell tumor, sclerosing hemangioma
myofibroblastic tumor, xanthoma, amyloid,
mucosa-associated lymphoid tumor
hamartoma, clear cell, teratoma
papilloma, polyps
Adenoma and hamartomas constitute the largest group of benign lung lesion
It is clinically asymptomatic .
It may present with atelectesis ,airway obstruction <<suggesting an endobronchial origin.
Majority identified incidentally finding on CXR.
CT scanning and FNA occasionally suggest a benign diagnosis
Definitive diagnosis is made by excisonal biopsy
Rigid bronchoscopy diagnostic and therapeutic in case of symptomatic lesions
Most common type of benign lung tumor, slow growing lesion
Mainly occur in adults.
Hamartomas are peripherally located.
Grossly, they have a firm marblelike consistency.
Histologically, hamartomas generally consist of epithelial tissue and other tissues such as fat and cartilage.
Radiologically appears as well-circumscribed single nodules, up to 2cm , it can be localized in the lung
CT scanning shows calcification and fat in up to half of the lesions.
Mucous Gland Adenomas
Is a peripheral circumscribed mass in the lung less than 3 centimeters in diameter.
It can be an incidental finding found in up to 0.2% of chest X-rays and around 1% of CT scans
The nodule most commonly represents a benign tumor such as a granuloma or hamartoma,
but in around 10-20% of cases it represents a malignant cancer, (But smoker patients older than 50 years have >50% risk for lung cancer).
Usually asymptomatic but it may include {coughing,hemoptysis,chest pain, and weight loss}
Make up 50% of all benign pulmonary tumors. The use of the term bronchial adenoma should be discouraged because it encompasses several benign and malignant tumors. Hamartomas (chondroadenomas) Parenchymal hamartoma of the lung. The surrounding lung falls away from the well-circumscribed mass, a typical feature of these lesions. The hamartoma shows a variegated yellow and white appearance, which corresponds respectively to fat and cartilage
Bronchial Adenomas Solitary lung lesion
(Coin lesion) Definition:
Chest X-ray showing a solitary pulmonary nodule (indicated by a black box) in the left upper lobe.
A solitary pulmonary nodule is defined as a single, discrete pulmonary opacity that is less than 3 cm in diameter, surrounded by normal lung tissue, and not associated with adenopathy or atelectasis.
Lesions larger than 3 cm are considered masses and are treated as malignancies until proven otherwise.
Generally, a pulmonary nodule must reach 1 cm in diameter before it can be identified on a chest radiograph.
Pathophysiology So how to approve that it is a benign lesion: Persons younger than 35 years without other risk factors.
Stability of the SPN over a period of 2 years on chest x-ray film.
Benign appearance on chest x-ray film.
When it is significant:In the presence of risk factors for malignancy: Size:
>1cm (have a chance for malignancy)
>4cm (very likely to be malignant) Indistinct margin (Corona radiata sign)
Old age
Documented growth on follow up x ray
(If no change in two years, most likely benign)
We start by order the following investigation:
chest x ray
TB skin test
Sputum cultures
sputum cytology(diagnostic in 5%-20%)
chest CT

In case of early bleeding we do bronchoscopy.
A CXR or chest CT scan can differentiate between malignant and benign lesion:

popcorn calcification ==> Hamartoma
Concentric calcification ==> calcified granuloma.
Spiculated lesions, with scattered calcification ==> Are highly suspicious of malignancy.
Approach Managment Based on the results of exams and tests, persons with SPN can be divided into the following 3 groups:
Persons with benign SPN: undergo chest x-ray films or CT scans every 3-4 months in the first year, every 6 months in the second year, and once every year for up to 5 years.
Persons who have been diagnosed with a malignant SPN should have the nodule surgically removed.
Persons with SPN that cannot be classified as either benign or malignant
{Most persons fall into this category}.
However, as many as 75% of these patients have malignant nodules on further evaluation. Therefore, such persons are also advised surgical removal.
Surgical excision is the mainstay of management. Types of surgery :
for central
placed lesions
Lobectomy with nodes
dissection for primary
(if resectable by
preop evaluation)
Carciniod Tumor Most well differentiated and least biologically aggressive type of cardconoid tumor.

Grow slowly and tend to metastasize infrequently

Consist of polygonal cells arranged in clusters.
Typical Carcionoid Tumor Types of Carcinoid tumor
Typical lung carcinoid Atypical lung carcinoid More aggressive histologic and clinical picture.

Metastasize at a considerably higher rate than do typical carcinoid tumors(predominantly lymph node) reported in 50-70% and, therefore, carry a worse prognosis.

Variable nuclear configuration and moderate mitotic activity Atypical Carcinoid Tumor Carcinoid syndrome has been reported in association with very large bronchopulmonary carcinoid tumors or in the presence of metastatic disease. It is noted much less frequently in association with carcinoids of pulmonary origin than those originating within the gastrointestinal tract.
Carciniod Tumor Frequency The gastrointestinal tract is the most common area in which carcinoid tumors arise.
Bronchopulmonary carcinoid tumors are reported to represent about 10% of all carcinoid tumors.
One to 6% of all lung tumors are carcinoid tumors.(10% are atypical)
Carcinoid tumors occur in equal numbers of males and females.
The average age is 40-50 years,.
Atypical carcinoid tumors appear in older people than typical carcinoids do.
90% of tumors develop within a bronchus.(10% of tumors arise in a mainstem bronchus; rarely appear in the trachea. )
10% of tumors are located in the pulmonary periphery.. About 25% are asymptomatic.
In symptomatic patients,
Symptoms of bronchial obstruction:
persistent cough, hemoptysis, recurrent or obstructive pneumonitis,Wheezing, chest pain, and dyspnea.

Symptoms of malignancy:
Weight loss, fatigability, and generalized illness.

Clinical presenatation Chest xray:An abnormal finding on chest X-ray is present in about 75% of patients with a carcinoid lung tumor

Bronchoscopy: It reveals round red-yellow-purpule mass covered by epithelium that protrudes into bronchial lumen.
Carcinoid tumor is Red shiny and it’s very easy to bleed Investigation Bronchoscopic image shows a red nodule that obstructs the entrance to the lower lobe bronchus
CT scan: Some carcinoid lung tumors that are small or covered by other organs in the chest may not be seen on a chest X-ray
MRI: Same as CT but it help in differentiating small tumors from adjacent blood vessels
Radionuclide :
1)Octreotide scintigraphy
2) Iodine-131 meta-iodo-benzyl guanidine (MIBG) scintigraphy

Biopsy:Even if a chest X-ray and/or CT scan shows a tumor, these exams cannot confirm whether the mass is a carcinoid lung tumor, a lung carcinoma, or a localized infection.

Chest radiograph (CXR) demonstrates complete collapse of the left lower lobe. The cause of collapse is not identified on the image,so we asked for a ct scan.
CT scan shows a hyper attenuating nodule within the left main bronchus. This is a bronchial carcinoid tumor.And then we need to ask for biopsy to confirm the diagnosis.
Stage Type of the tumor
Staging (cc) image by anemoneprojectors on Flickr Stage 2
bronchopulmonary lymph node involvement Stage3
mediastinal lymph node involvement Stag 1 Typical carcinoid tumor Atypical carcinoid tumor Atypical carcinoid tumor All pulmonary carcinoid tumors should be treated as malignancies by doing total surgical resection as long as no surgery contraindication exist.

No medical therapy exists for the primary treatment of carcinoid tumor of the lung.
Chemotherapeutic agents and radiation therapy have been used in the treatment of metastatic disease (Carcinoid Syndrome)
Managment Medical Therapy Surgical resection is the primary mode of therapy .

We have different types of surgical treatment,but anatomic lobectomy is the most commonly performed procedure at present for resection of pulmonary carcinoid tumors.
Surgical Therapy Most tumors follow a benign course and are amenable to surgery.
Surgical options range from radical resection (the tumor with a good margin of normal tissue is removed) to minimally invasive surgery.
Different surgical options include the following:

1-Sleeve resection: Section of the airway containing the tumor is removed. In this procedure, we have to remove one part of the main bronchus containing the tumor and anastmose the bifurcation with bronchus intermmedius, instead of pneumonectomy to preserve the other tumor free lobes)

2-Segmental resection: Segment of the lung containing the tumor is removed.

3-Wedge resection: Small wedge of the lung containing the tumor is removed.
Types of surgery 4-Lobectomy: Lobe of the lung containing the tumor is removed.

5-Pneumonectomy: Entire lung containing the tumor is removed. (Rarely)

6-Endoscopic tumor ablation using laser: This technique involves removal of the tumor through the bronchoscope, using laser. It is reserved for treating bronchial obstruction caused by the tumor or reduction of the tumor mass prior to surgical resection. This procedure is rarely curative on its own.
Endoscopoic tumor ablation using laser, is not curative we use only in palliative treatment

After discharging from the hospital, we need to follow up the pt for 2-3 months in the first year (clinically and chest x ray), then every 6 months for the following years.

Follow Up Carcinoid lung tumors generally have a better prognosis(mainly typical) than other forms of lung cancer.

Typical carcinoid lung tumors:
5-year survival rate of 78%-95%
10-year survival rate of 77%-90%.

Atypical carcinoid lung tumors :
5-year survival rate of 40%-60%
10-year survival rate of 31%-60%. Prognosis Unlike most lung tumors, carcinoid lung tumors have not been associated with smoking, air pollution, or other chemical exposures. Therefore, there are no known ways to prevent carcinoid lung tumors.

Prevention Lung cancer is a disease which consists of uncontrolled cell growth in tissues of the lung.
The vast majority of primary lung cancers are carcinomas, derived from epithelial cells.
The incidence of lung cancer has increased significantly over the last three decades.
The most common cancer in male and the second in female ( after a breast cancer)
It is the 1st most common cause of cancer-related death in both men and women.

Cancer Definition Smoking:
responsible for 85% of all lung cancers .
Passive smoking account for 3 %
( nitrosamines and polycyclic aromatic hydrocarbons)

Asbestos , silica ,chromium, cadmium
Causes Dietary:
cholesterol and high fat diet increases the risk.
Fruit and vegetables decreases the risk

Pre- existing lung lesion :
COPD, IPF , TB or infarct, Viruses ( HPV , CMV)

Inheritence: Autosomal Dominant
Molecular genetics.

Causes For a primary tumor: respiratory symptoms constitute more than 70% of the presentation
Cough, dyspnea , unresolved pneumonia, wheeze, hymoptysis, pain )
For a regional spread: ( pleural effusion, chest wall pain, pericardial effusion , Superior Vena Cava Syndrome, horner syndrome, horesness, dysphagea , phrenic nerve injury.
Signs and symptoms Distant metastasis : adrenal, liver, bone, brain.
Paraneoplastic syndrome: ACTH, ADH, GH, calcitonin , PTH.
SCLC : ACTH( cushing’s syndrome), ADH (SIADH)
Sqamous cell canrcinoma : PTH > hypercalcimia
Cachexia (weight loss, fatigue, and loss of appetite
Diagnosis Performing a chest radiograph is the first step if a patient reports symptoms that may suggest lung cancer.
CT Scan Has prove useful for assessing the primary tumor in relation to size and proximity to adjacent structure and surgical approaches
It is only 50% accurate in diagnosing tumor invasion into structures
Abdominal CT is mandatory ( adrenal and liver
MRI Has no advantage over CT , but better in visualazing tumor incasion of nearby structures.
Broncoscopy Rigid or flexible.
Dx , staging and treatment.
Cytology and biopsy can be taken.

The differential diagnosis For patients who present with abnormalities on chest radiograph includes lung cancer as well as nonmalignant diseases.

These include infectious causes such as:
Inflammatory conditions such as sarcoidosis.
The main types of lung cancer are :
small cell lung carcinoma (SCLC )
Non-small cell lung carcinoma (NSCLC ).
Types of Lung Cancer Accounts for about 20% of lung cancer.
A type of highly malignant carcinoma usually associated with the lung, though it can be associated with other topographies, such as in cervical cancer or prostate cancer
When associated with the lung, it is sometimes called "oat-cell carcinoma" due to the flat cell shape and scanty cytoplasm.

Small Cell Carcinoma It is thought to originate from neuroendocrine cells (APUD cells) in the bronchus called Feyrter cells (named for Friedrich Feyrter).
Hence, they express a variety of neuroendocrine markers, and may lead to paraneoplastic syndromes and Cushing's syndrome.
Paraneoplastic Syndromes: Small-cell carcinomas produce ACTH or ADH, which can lead to SIADH
Small Cell Carcinoma It is more metastatic than non-small-cell lung carcinoma (and hence staged differently) and is sometimes seen in combination with squamous-cell carcinomas. There is usually early involvement of the hilar and mediastinal lymph nodes.

Smoking is a significant etiological factor.
Small Cell Carcinoma Symptoms and signs are as for other lung cancers. In addition, because of their neuroendocrine cell origin, small-cell carcinomas will often secrete substances that result in paraneoplastic syndromes.

Small-cell lung cancer is pragmatically divided into two stages:
Limited Stage and
Extensive Stage depending on the presence of metastases
Small Cell Carcinoma combination chemotherapy (often consisting of a cyclophosphamide, cisplatinum, doxorubicin, etoposide, vincristine and/or paclitaxel) is administered together with concurrent chest radiotherapy.

Thoracic irradiation improves survival in limited stage small-cell lung carcinoma.
Small Cell Carcinoma combination chemotherapy is the standard of care, with radiotherapy added only to palliate symptoms such as dyspnen,pain from liver or bone metastases, or for the treatment of brain metastases, which, in small-cell lung
Carcinoma, typically have a rapid, if temporary, response to whole brain radiotherapy.
Combination chemotherapy consists of a wide variety of agents, including cisplatin, cyclophosphamide, vincristine and carboplatin.
Small Cell Carcinoma Response rates are high even in extensive disease, with up:
15-30%of patients having a complete response to combination chemotherapy
Vast majority of patients having at least some response to combination chemotherapy.
Small Cell Carcinoma In limited stage disease, median survival with treatment is 14–20 months, and about 20% live 5 years or longer.
The prognosis is far worse in extensive stage, with treatment, median survival is just 8–13 months, and only 1-5% live 5 years or longer.
No role for surgery in the treatment of SCLC because they metastasize early only chemo +/- radiation .
Small Cell Carcinoma is any type of epithelial lung cancer other than small-cell lung carcinoma (SCLC).

Sometimes the phrase non-small-cell lung cancer [Not Otherwise Specified, or NOS] is used generically, usually when a more specific diagnosis cannot be mad.
Non Small Cell Carcinoma Limited-stage small-cell lung carcinoma: Extensive Disease The most common types of NSCLC are:
Squamous-cell carcinoma
Large-cell carcinoma
but there are several other types that occur less frequently, and all types can occur in unusual histologic variants and as multiphasic combinations
Non Small Cell Carcinoma Definition The most common type (45%)
Tend to be in the peripheral lung parenchyma and the alveolar septa
Lymph node metastasis is common

Adenocarcinoma Also called epidermoid carcinoma
30% of cases
Men > Women.
It is closely correlated with a history of tobacco smoking
Tend to be centrally located ( major bronchi), may also be a Pancoast’s Tumor .
Ectopic PTH secretions
Invaded locally
Squamous Cell Carcinoma Injury to the cervical sympathetic chain:
Anhydrosis of ipsilateral face .
Horner’s syndrome Also non as Undifferentiated carcinoma
Accounts for 5-10% of cases
Tend to be in peripheral lung
Often cavitate
Early metastasis Large Cell Carcinoma Tumor at the apex of the lung or superior sulcus that may involve :
the brachial plexus
sympathetic ganglia
Vertebral bodies
Leading to pain, upper extremity weakness, and Horner’s Syndrome.
Pancost's Tumor (Syndrome) patients undergo staging as part of the process of considering prognosis and treatment.
The American Joint Committee on Cancer (AJCC) recommends TNM staging
Staging Primary tumor (T)
TX: The primary tumor cannot be assessed, or there are malignant cells in the sputum or bronchoalveolar lavage but not seen on imaging or bronchoscopy

Tis: Carcinoma in situ
T0: No evidence of primary tumor.
T1: 3cm or less in diameter and completely surrounded by lung parenchyma
Staging T2:is greater than 3cm OR invading the visceral pleura OR within a major bronchus OR Associated with atelectasis or obstructive symptoms
T3:is a tumor of any size with direct invasion of nonvital structure such as diaphragm, chest wall or pericardium
T4:is a tumor of any size with direct invasion of vital organs such as heart ,great vessels OR malignant pleural effusion or pericardial effusion

Staging Lymph nodes (N)
NX: Lymph nodes cannot be assessed.
N0: No lymph nodes involved.
N1: Metastasis to ipsilateral peribronchial or ipsilateral hilar lymph nodes.
N2: Metastasis to ipsilateral mediastinal or subcarinal lymph nodes
N3: Metastasis to any of:
Ipsilateral supraclavicular lymph nodes.
Ipsilateral scalene lymph nodes.
Contralateral lymph nodes.
Staging Distant metastasis (M)
MX: Distant metastasis cannot be assessed.
M0: No distant metastasis.
M1: Distant metastasis is present.
Staging Early/non-metastatic NSCLC:
are usually not very sensitive to chemotherapy and/or radiation, so surgery is the treatment of choice if diagnosed at an early stage, often with adjuvant (ancillary) chemotherapy involving cisplatin.
Treatment Contraindications of surgery Superior vena cava syndrome
Supraclavecular node metastasis
Scalene node metastasis
Tracheal carina involvement
Oat cell carcinoma
PFT shows FEV1<1
Myocardial infarction
Tumor elsewhere (metastatic disease )
Bilateral lung lesions
Acronym ( STOP IT )
Other Treatment Choices Treatment Chemotherapy,
Radiation therapy (radiotherapy), including radiosurgery (SRS), or targeted therapy (This means less radiation affects nearby healthy tissues.)
Neoadjuvant chemotherapy is done before surgery, then reassess the pt,if the tumor is resectable do surgery, but if not treat with chemo
Advanced/metastatic NSCLC
A wide variety of chemotherapies are used .
Some patients with particular mutations in the EGFR gene respond to EGFR tyrosine kinase inhibitors such as gefitinib.
Thank You A video of tumor invading the carina and using the bronchoscope to take a biopsy a photocopy of a book provided by the doctor if you want to read more
http://www.mediafire.com/?jtdd63kmm2zwyp1 Mediastinoscopy Visualization of the contents of the mediastinum
Usually for the purpose of obtaining a biopsy.
Used for staging of lymph nodes of lung cancer or for diagnosing other conditions affecting structures in the mediastinum such as sarcoidosis or lymphoma. After combined therapy of targeted cryoablation and chemotherapy. small bilobed mass (white arrow) in left lung apexLeft brachial plexus (arrowhead) Stage I (a) Axial CT image of enlarged lymph nodes consistent with N1 disease.
(b) Axial CT image of multiple enlarged lymph nodes which proved to be N2 disease. CT Scan and PET Scan of Stage III cancer
(N2 disease) Stage III Psoas Metastasis L2 Metastasis Left Adrenal Metastasis N2 disease : Right lower lobe mass (white arrow)
subcarinal lymph node (black arrow). N1 disease : enlarged Right hilar lymph node N2 disease : Enlarged right lower paratracheal lymph node More info and pictures about staging :
http://radiographics.rsna.org/content/30/5/1163.full N2 disease : Enlarged right upper lower paratracheal lymph node N1 disease : enlarged ontralobar lymph node N3 disease : Enlarged bilateral supraclavicular lymph node T1 : right upper lobe nodule T2 : centrally located lung nodule (arrow) causing airway obstruction T3 : left upper lobe mass with extension to mediastinal pleura T4 :right upper lobe mass (arrow) with mediastinal and carinal invasion, ipsilateral loculated pleural effusion, and thickening and enhancement of the pleura carcinoid lung tumor of the left mainstem bronchus and resultant left upper lobe atelectasis.
mass in the left lower lobe. Several small areas of calcification can be seen within the tumor Signs and symptoms
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