Cancers of the thorax

9 Cancers of the thorax




Lung cancer




Aetiology






Pathogenesis and pathology





Malignant lesions


Box 9.1 shows a classification of lung tumours, which is based on light microscopic assessment of patterns of differentiation. The most important distinction is between small cell carcinoma (SCLC: 15–25% of lung cancers) and other carcinomas, collectively called non-small cell carcinoma (NSCLC). These subgroups behave differently in their presentation, natural history and response to treatment.







Presentation


More than 90% of patients are symptomatic at presentation of which approximately 30% are due to tumour, 30% are due to non-specific systemic symptoms (anorexia, weight loss or fatigue) and 30% due to metastatic disease. Five percent of patients are asymptomatic and are detected incidentally.




Other symptoms


Symptoms due to compression of recurrent laryngeal nerve (hoarse voice), phrenic nerve (breathlessness), brachial plexus (shoulder pain and/or arm pain, sensory changes and muscle wasting in the distribution of C8 and T1–2 nerves) and sympathetic plexus (Horner’s syndrome) can occur. Four percent of lung cancer patients present with superior venacaval obstruction (SVCO) and is most common with small cell lung cancer. Pleuritic chest pain and pleural effusion occurs in pleural involvement. Pericardium involvement can present with pericardial effusion and rarely, tamponade. Rarely, dysphagia due to massive nodal disease compressing the oesophagus can occur.


Bone pain is the presenting symptom in up to 25% patients. Liver involvement usually leads to pain if there is massive metastasis. Clinical adrenal insufficiency is rare. Brain metastases at diagnosis occur in up to 10% and present with features of raised intracranial tension, focal neurologic deficits, fits and mental and personality changes.


Paraneoplastic syndromes occur in up to 10% of patients. Box 9.2 lists the paraneoplastic syndromes. SCLC is the most common type associated with paraneoplastic neurologic syndromes. Hypercalcaemia either due to excess parathyroid hormone (PTH) or PTH-related peptides is common in squamous cell carcinomas (15%). Hyponatremia occurs in up to 10% of patients, which is either due to syndrome of inappropriate secretion of ADH (SIADH) or to atrial natriuretic factor. SIADH is commonly associated with SCLC.





Investigations and staging (Figure 9.1)


Evaluation of a patient with suspected lung cancer is to:







Imaging


Chest X-ray (Figure 9.2A) may show lung lesion with or without lymphadenopathy. There can be associated lung collapse, pleural effusion, synchronous nodules or pericardial effusion. Bone metastases or bony destruction due to direct invasion can also been seen.



Contrast enhanced CT scan of chest, including upper abdomen (3–10% patients show asymptomatic liver and/or adrenal metastasis – Figure 9.2B&C) should be performed prior to further diagnostic investigations including bronchoscopy.


Lymph nodes of >1 cm in short axis diameter, a central low intensity suggesting necrosis and rounding of the contour of a hilar node where it meets the lung margin suggest malignant lymph nodes. CT is not reliable in assessing lymphadenopathy, to distinguish T3 from T4 disease and in demonstrating chest wall invasion, which all are important in making treatment decision.


CT scan is useful in assessing resectability. Encasement of proximal pulmonary arteries/veins, gross mediastinal involvement by tumour, widespread mediastinal lymphadenopathy and distant metastasis on CT scan suggest an unresectable tumour (96% accuracy). Tumour invasion of central pulmonary artery and vein, involvement of main stem bronchus and tumour extension across the major fissure (anywhere on the left side, above the minor fissure on right), all suggest the need for pneumonectomy for complete resection.


CT scan of brain is done if there is clinical suspicion of brain metastasis or patient is planned to undergo curative treatment.


Bone scan is indicated if there is bone pain or isolated raised alkaline phosphatase.




Staging


Stage determines prognosis and guides treatment. TNM staging of lung cancer is given in Box 9.3. Small cell lung cancer can also be staged using a simple staging classification (Box 9.4). SCLC can be classified as TNM staging or using the simplied.





Mediastinal staging in non-small cell lung cancer


Accurate distinction of stages II, IIIA and IIIB is important in deciding optimal surgical treatment in the potentially operable patients. Stage II disease is treated with lobectomy or pneumonectomy with mediastinal sampling or dissection. Stage IIIA disease may be treated with neoadjuvant chemotherapy followed radical surgery or radical chemoradiotherapy, whereas IIIB disease is unresectable. This necessitates both an accurate distinction of T3 from T4 tumours and an accurate staging of nodal status. A classification of mediastinal nodes is shown in Figure 9.3.




Methods of mediastinal staging


Positron emission tomogram (PET) (Figure 9.4) – PET is scan based on the principle of differential uptake of 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) by cancer cells. FDG is metabolized at a higher rate by tumour cells than normal cells and the areas of increased activity can be detected by a scanner. FDG-PET has higher sensitivity (87% vs. 68%), specificity (91% vs. 61%) and accuracy (82% vs. 63%) at detecting mediastinal disease than CT scan. PET also has a high negative predictive value in exclusion of N2/N3 disease, which helps to omit further mediastinal staging in case of a negative PET. Overall, there is 20% improvement in accuracy of PET over CT for mediastinal staging of NSCLC.



PET also detects distant metastases. The incidence of extra thoracic metastases on PET which are not suspected by CT scan is 9 to 11%. CT false-positive adrenal nodules have been correctly identified as negative on FDG-PET.


One of the limitations of PET is false-positive ‘hot spots’ in the mediastinum due to inflammatory processes (in up to 13 to 17%). It is less accurate when the lesion is <1 cm and in tumours of low metabolic activity such as carcinoid and bronchoalvelolar carcinoma.


PET scan is recommended for all NSCLC patients being considered for radical treatment. Patients with no lymphadenopathy on CT scan but with PET scan positive nodal disease needed mediastinoscopy prior to definitive treatment as 50% of patients can have false positive PET scan.


MRI scan – has limited role in staging. This may be useful to evaluate vascular and vertebral body invasion and to assess integrity of brachial plexus in Pancoast’s tumour.


Endobronchial ultrasound (EBUS) – EBUS is able to penetrate up to 5 cm and can identify lymph nodes and vessels. It is helpful in visualizing paratracheal (stations 2 & 4) and peribronchial lymph nodes (see Figure 9.3) and enables EBUS guided transbronchial needle aspiration (Figure 9.5). Sonographic features of malignant lymph node are round shape, sharp margins and hypoechoic texture. The advantage of EUS over CT and PET is that it can characterize lymph nodes smaller than 1 cm. It can also determine the depth and extent of tumour invasion of tracheobronchial lesions and helps to define the relationships to the pulmonary vessels and the hilar structures. EBUS has been found to predict the lymph node staging correctly in 96% of cases, with a sensitivity of 95% and specificity of 100%.



Endo-oesophageal US (EUS) with fine needle aspiration is useful to assess sub-aortic (station 5), subcarinal (station 7), and paraoesophageal (station 8) lymph nodes as well as the upper retroperitoneum, which are not accessed by mediastinoscopy. It is envisaged that EUS-FNA and EBUS will not replace but will complement surgical techniques like mediastinoscopy.


Transbronchial needle aspiration (TBNA) – TBNA using a flexible fibre optic bronchoscope has a sensitivity of 78% and high specificity (approaching 100%) for identifying mediastinal metastases. However, the diagnostic yield is operator dependent.


Mediastinoscopy is generally regarded as the gold standard for preoperative mediastinal evaluation. CT scan is helpful in guiding selection of patients for mediastinoscopy prior to surgery. Cervical mediastinoscopy allows better access to contralateral lymph nodes. It is useful in evaluating paratracheal (2 & 4), scalene and inferior mediastinal nodes (7, 8 & 9). It is not useful in evaluating aortic nodes (5 & 6). Mortality rates from mediastinoscopy are negligible, but morbidity rates especially arrhythmias are reported to be 0.5–1%. It has to be borne in mind that up to 30% of patients with lung carcinoma who have a negative mediastinoscopy prove to have mediastinal nodal metastasis at surgery.


Video-assisted thoracoscopy (VATS) is useful to evaluate aortic (5 & 6), paraoesophageal (8) and pulmonary ligament nodes (9). It is also useful in assessing the pleural cavity and obtaining pleural biopsies.



Management of lung cancer


Patients presenting with symptoms suggestive of lung cancer need urgent evaluation (Figure 9.1) and referral to a team specializing in the management of lung cancer. Treatment depends on type of lung cancer (NSCLC vs. SCLC), stage, performance status, co-morbidities and cardiopulmonary reserve.


Jun 18, 2016 | Posted by in ONCOLOGY | Comments Off on Cancers of the thorax

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