Transcript Document 307977

Tomasz Szczęsny, MD, PhD
Janusz Kowalewski, MD, PhD
Department and Clinic of Thoracic Surgery
Faculty of Medicine
Nicolaus Copernicus University in Toruń
Lung cancer invading vertebral body
Mediastinal Schwannoma
Thymoma? Hodgkin Lymphoma? Non-Hodgkin
Lymphoma? Yolk sac tumour? Other?
Pre-invasinve lung cancer
Disseminated cystadenocarcinoma
Clinical features, diagnosis and
treatment
Neuroendocrine tumours

Warren and Gould classification
Typical carcinoid (TC)
Atypical carcinoid (ATC)
Large cell neuroendocrine carcinoma (LCNEC)
Small cell lung cancer (SCLC)
Typical carcinoid
Mitotic index < 2/10 HPF
No necrotic focuses
Any age (max 60<x<70)
Cushing and carcinoid syndrome
Good prognosis: OS
5 y. – 90-98%
10 y. – 82-95%
Atypical carcinoid
Mitotic index < 2-10/10 HPF
Necrotic focuses
Peripheral location
Poorer prognosis than TC: OS
5 y. – 61-73%
10 y. – 35-59%
Large cell neuroendocrine carcinoma (LCNEC)
Cytological features like in NSCLC (nucleolus)
Mitotic index >10/10 HPF + necrosis
Older age, advanced stage.
Poor prognosis, similar to SCLC.
Carcinoid: central location
Main, lobar or segmental bronchus,
Cough, hemoptysis, wheezing,
Recurrent pneumonia,
Dyspnoea,
Cushing syndrome.
Carcinoid: peripheral location
Lung parenchyma,
Asymptomatic course.
Carcinoid syndrome
Secondary to carcinoid tumour (rare: 1/10)
Serotonin, kallicrein
Big tumour, distant metastases (liver),
Flushing,
Heart failure, diarrhea,
Bronchoconstriction.
,
Carcinoid: treatment
1. Surgical treatment
Typical carcinoid
Radical anatomical resection (lobectomy,
segmentectomy, wedge resecton).
Bronchoplastic procedures.
Laser therapy (ablation, cautery).
Atypical carcinoid
The same like NSCLC
Carcinoid: treatment
2. Radiotherapy
Efficacy of radical and paliative radiotherapy has
not been proven yet.
Carcinoid: treatment
3. Chemotherapy.
Cisplatin, etoposide, cyclophosphamide,
doxorubicin, vincristine.
Low chemosensitivity.
Partial response (PR) 10-20% - only AC
Mean Survival Time = several months.
Benign pulmonary neoplasms:
1. Hamartoma,
2. Cylindroma,
3. Fibroma,
4. Chondroma,
5. Fibroneuroma,
6. Cystadenoma,
7. Lipoma.
Bronchial lipoma
Solitary pulmonary nodule
SPN - definition
Round or oval,
Central or peripheral,
Smaller than 3 cm in diameter,
No pleural effusion, thoracic wall or mediastinum
invasion, lymph nodes enlargement.
SPN: statistics
1. Primary lung cancer:
2. Tuberculoma:
35%,
23%,
3. Hamartoma:
14%,
4. Other benign ndules: 13%,
5. Metastasis:
8%,
6. Inflammatory nodules: 7%.
Solitary Pulmonary Nodule:
benign or malignant ?
Age (<30 b., > 50 =% m.)
Diameter: 2-3 cm – mostly malignant,
≤ 0,5cm – mostly benign (observation),
0,6-1,9 cm ???
Calcifications.
Margins.
Stability.
Computed tomography - CT
CT – enhancement
Benign lesions: average 12 HU,
Malignant lesions: average 40 HU,
20 HU – threshold of malignancy
100% sensitivity,
77% specificity,
93% accuracy.
Radiology 2009; 194; 393-98
Positron Emission Tomography PET - CT
Sensitivity for malignant lesions: 0,9
Sensitivity for benign lesions : 0,72
Eur. J. Cardiothorac. Surg.: 2001; 20; 324-29
Solitary Pulmonary Nodule:
treatment
Surgical treatment (complete resection) ?
1. If surgery:
- thoracotomy or VT ?
- how to find a nodule during VT ?
- what type of resection if you detect NSCLC ?
2. If no surgery, what next ?
- no further follow up ?
- follow up (what kind of folow up ?)
- FNAB, bronchoscopy, PET-CT (cost, safety?).
Treatment of SPN depends on:
1. Risk of surgical procedure.
2. Probability of malignancy.
3. Well informed patient’s opinion.
4. Capabilities of the unit (hospital).
Approximate probability of malignancy
p
Clinical and
radiological
characteristics
Low (< 5%)
Moderate (5%-65%)
High (>65%)
Young age,
No smoker,
No previous
malig.,
Small nodule,
Smooth edge,
Lower or meedle
lobe.
Combination of the Older age,
characteristics from Smoker,
both groups
Previous cancer,
Big nodule,
Irregular
(rugged) edge
Upper lobe.
Exact probability of
malignancy
P =
x = - 6.8272 + (0.0391 x age) + (0.7917 x smoking)
+ (1.3388 x previous malign) + (0.1274 x diameter)
+ (1.0407 x rugged edge) + (0.7838 x upper lobe)
e base of natural logarithm = 2.72.
N Engl J Med. 2011; 365(5): 395-409.
Thorax 2012; 67(4): 296-301.
Exact probability of
malignancy
P =
x = - 6.8272 + (0.0391 x 70) + (0.7917 x 1)
+ (1.3388 x 1) + (0.1274 x 20)
+ (1.0407 x 1) + (0.7838 x 1) = 2.413
e= 2.72; x= 2.413; P = 0.917 = 92%
58 y. female smoker, no history of malignancy, good general condition,
diameter of the nodule 12 mm.
A. CT scan after 6 mths.
B. PET - CT
C. FNAB.
D. Resection.
E. Others.
PET-CT was performed: SUV 6,7
A. CT scan after 6 mths.
B. FNAB.
C. Resections.
D. Others.
Solitary pulmonary nodule in
patient with malignancy.
Problem for the doctor
and for...
the patient
Exact staging of the disease,
- metastases ?
Correct strategy of cancer treatment.
Prognosis ?
Solitary pulmonary nodule in patient
with malignancy
 70% metastasis.
 20% benign lesion.
 9% primary lung cancer.
 1% metastasis of unknown cancer.
Pulmonary metastases (PM)
In 30% of cancer patients PM occur.
Pulmonary Metastases
Hematogenous way:
Brest cancer,
Sarcomas,
Genitourinary tumours,
Colon cancer.
Pulmonary Metastases
Air way:
Laryngeal cancer,
Tracheal cancer,
Bronchioalveolar carcinoma.
PM - diagnosis
Accidental 80-90% cases,
- Chest X-Ray,
- Often the first sign of extrapulmonary neoplasm
PM - classification
I: Time
synchronous,
metachronous,
II: Number
single,
multiple,
unilateral,
bilateral.
Pulmonary Metastases
Is it justified to perform
radical metastasectomy or
it is useless.
Selection of patients for pulmonary resection
The primary tumour is controlled or is
controllable,
No extrapulmonary tumour exists,
No better method of proven treatment
value is available,
Adequate medical status for the planned
resection exists,
Complete resection is possible on CT
(PET) scan evaluation.
Long DFI .
Dtsch Arztebl Int 2012; 109(40): 645-51
P.M.
Wedge resection,
Anatomical resections,
segmentectomy,
lobektomy,
pneumonectomy
Approach for bilateral lesins?
History
Weinlechner J.
Wien Med Wochenschir 1882; 32: 598-591.
Resection of two metastatic lesions
accidentally detected during operation
of sarcoma of the thoracic wall.
History
Divis G.
Acta Chir Scand 1927; 62: 329-334.
The first planned resection of
pulmonary metastases
Right lung metastasis (CT, PET)
Surgical approach
Sternotomy, clamshell, thoracotomy,
VT/VATS:
- Thoracotomy or VATS ?
- How to find a nodule during VATS ?
Clamshell incision
Thoracotomy or VATS
How to find a nodule ?
Palpation,
Hook wires,
Metalic coils,
Itraoperative ultrasound,
Image-guided stereotactic navigation,
Technetium radiotracer scintigraphy.
Clinics in Colon and Rectal Surgery 2009; 22(4):233-41
Metalic coils and hook wire
Wedge resections
Reinforced wedge resection
Laser resection
P.M: Breast cancer
Very good response to chemotherapy, but:
Precise diagnosis of pulmonary nodules ???
In 50% of breast cancer patients new pulmonary
nodule is a primary lung cancer (DFI>3 years).
Hormons’ receptor status.
P.M: Colon cancer
50% of patients with PM develope liver metastases.
Different approaches: liver –lung, lung-liver,
simultaneous procedure ?
Poor prognosis if: nodal involvement, CEA
elevation.
P.M: Sarcomas
Isolated PM very often.
Recurrent PM very often.
Chemoresistance.
Complete resection: strong prognostic factor.
Chemotherapy alone – poor prognosis.
Multidiscyplinary approach is essential.
P.M: Malignant malanoma
Isolated p.m. very rare.
Complete resection questionable.
Mean survival time : 6 mths.
5 years OS : 5%.
Resection of P.M: effectiveness.
(Munich score): 202 patients with renal cancer
Complete resection: 87%.
Median survival time: 43 msc.
Poor prognostic factors (multivariate analysis):
- incomplete resection,
- diameter of the lesion (s) > 3 cm,
- nodal involvement detected during nephrectomy,
- synchronous metastases,
- pleural infiltration,
- hilar and mediastinal lymph nodesinvolvement.
The American Journal of Surgery 2011; 202: 158-67.
Alternative methods
SBRT: Stereotactic Body Radiation Therapy
RFA: Radiofrequency Ablation
Microwave Ablation
Cryoablation
RFA: Radiofrequency Ablation
Take home message
1. Complete resection of PM is an effective method
of treatment.
2. The most important prognostic factors are: type
of primary tumour and complete PM resection.
3. Multidisciplinary approach is essential.