Back to Basic in Thoracic Surgery

1. Back to Basic in Thoracic Surgery FM Shamji 31-03-2011

2. Solitary Pulmonary Nodule - SPN • Also called “coin lesion” • Radiologic diagnosis • Defined as: “Single nodular lesion within the lung substance, 3 cm or less in diameter, well defined, completely surrounded by normal-appearing lung tissue, not cavitated but may be calcified, usually of clinically undetermined etiology” • Its importance lies in its diagnosis and a significant number are malignant and resection is followed by good survival rate • Incidence of malignancy in mass survey varies from 3 to 6%

3. Classification of Solitary Pulmonary Nodules • Neoplasms (45%) Benign • Hamartoma (most common) • Fibroma • Leiomyoma • Localized fibrous tumor of visceral pleura • Bronchial adenoma Malignant • Bronchial carcinoma • Carcinoid tumor • Metastases • Lymphoma

4. 2. Granuloma (40%) Histoplasmoma Coccidiodomycoma Cryptococcoma Aspergilloma Tuberculoma 3. Inflammatory (4%) Lung abscess Pneumonitis Rheumatoid nodule 4. Miscellaneous (4%) Fluid-filled cyst Infarct Arteriovenous malformation Amyloid Classification of Solitary Pulmonary Nodules

5. Favour Benign Lesion Well demarcated Dense calcification Unchanged in size over 2y Absence of risk factors for primary lung cancer Absence of history of previous malignancy Size < 2cm (not absolute) Young age < 40y (not absolute) Favour Malignant Lesion Spiculated Not calcified Progressive growth over 2y Presence of risk factors for primary lung cancer History of previous malignancy Size > 2cm (not absolute) Older age >40y ( not absolute) Management of Solitary Pulmonary Nodules

6. Investigations for SPN • Attempt should be made to find any previous chest films for comparison – present before, same size or getting larger • CT scan chest is necessary to search for satellite lesions, enlarged nodes in the mediastinum • Percutaneous Fine Needle Aspiration Biopsy is more likely to establish diagnosis than by bronchoscopy • PET scan

7. Asymptomatic RLL Lesion found on routine CXR in 39y man

8. Questions • What is a solitary pulmonary nodule? • What is the differential diagnosis of this lesion? • Is it necessary to investigate further and how?

9. Primary Lung Cancer • Lung cancer is a LETHAL disease • Has profound effect on society USA each year about 170,000 new cases and 160,000 die • Leading cause of cancer-related mortality world-wide over 1.2 million people die of lung cancer each year

10. Histological Cell Types • WHO Committee (1999) pathologic classification into two groups 1. Small cell lung cancer 15 to 20% 2. Non-small cell lung cancer 80 to 85% • Squamous cell carcinoma 25 to 30% • Adenocarcinoma 40 to 50% • Large cell carcinoma 10 to 15%

11. Etiology and Risk Factors in Lung Cancer 1. TOBACCO (in 85% of the cases) :8 - to 12 - fold increased risk :Former smokers remain at an elevated risk for developing lung cancer even decades after they stop smoking. 50% of newly diagnosed lung cancer patients are former smokers :Smoking cessation is vital to reducing rate of lung cancer :10 years after smoking cessation, risk of lung cancer in former smokers is reduced to ½ of those who continue to smoke

12. Etiology and Risk Factors in Lung Cancer 2. Environmental Tobacco Smoke (ETS) • Reports in 1981and 1986, non-smoking spouses of active smokers are 30% more likely to develop lung cancer than those married to non-smokers 3. Asbestos is the first occupational carcinogen recognized to cause lung cancer 1955, as early as 1939 • Insulating and fire-proofing 4. Radiation 5. Previous lung disease - pulmonary fibrosis

13. Etiology and Risk Factors in Lung Cancer • Radiation • High linear energy transfer (LET) radiation is a risk • Creates ionization in higher tissue density and more tissue damage • RADON is an inert gas with high LET • Breakdown product in the decay of uranium emitting alpha particles – affects DNA of respiratory epithelium • Occupational risk factor in Uranium miners • Concern is its presence in indoor air of buildings • Prior treatment of thoracic malignancies (breast, lymphoma, esophagus) with radiotherapy increases risk for lung cancer

14. Scarring or fibrosis as a cause of lung cancer • Lung cancer can develop both in the vicinity of pre-existing localized areas of pulmonary scarring and in patients with more diffuse lung fibrosis • Microscopic examination of lung scar tissue reveals areas of epithelial hyperplasia  associated with unexpected carcinomatous change • ‘SCAR CANCERS’ • Personal smoking history and asbestos exposure in non-smokers are highly relevant • More adenocarcinoma cell type seen

15. Occupational causes of lung cancer

16. Clinical Presentation - Symptoms GROUP I Result of investigation of some new respiratory symptom or because their pre-existing respiratory state has worsened GROUP III Non-specific symptoms such as malaise, anorexia, weight loss, loss of taste for food, fatigue, depression or recurrent febrile flu-like illness episodes GROUP II No respiratory symptoms at diagnosis; chance finding of an opacity on CXR ordered for some other reason e.g. preoperative, unrelated complaint – angina, shoulder discomfort GROUP IV Specific Symptoms that are 1.LOCAL - bronchopulmonary 2.From DIRECT intrathoracic spread OR 3.From SYSTEMIC metastatic spread

17. Clinical Presentation: Group IV Specific Symptoms that are directly caused by the lung cancer 1.LOCAL – bronchopulmonary symptoms due to bronchial obstruction – atelectasis - infection, irritation - cough, ulceration - bleeding 2.From DIRECT intrathoracic spread pleura, chest wall, ribs, thoracic spine, SVC, recurrent laryngeal nerve, mediastinal lymph nodes, pericardium, diaphragm, sympathetic chain at the apex 3.From SYSTEMIC spread – metastases to bone, brain, liver, adrenal glands

18. Group 4: Symptoms from Systemic Metastasis • Lung cancer may already have spread to distant sites at initial presentation – Stage IV • Four most common sites of systemic spread are • Brain, Bone, Liver, and Adrenal gland • BRAIN metastasis – headaches, nausea, fatigue, motor weakness, seizures, visual change, ataxia, or personality change • BONE metastasis – continuous pain, pathological fracture, epidural spinal cord compression • Liver metastasis – nausea, vomiting, cachexia • Adrenals – often asymptomatic, lumbar pain

20. Five Types of Paraneoplastic Syndromes • Manifestations associated with malignancy but not directly related to distant metastasis • Very common in lung cancer occurring in • 10% of patients with NSCLC • 50% of patients with SCLC 1. ENDOCRINE manifestations (protein hormone) Cushing’s syndrome (SCLC), Syndrome of Inappropriate Antidiuretic hormone production (SCLC), hypercalcemia (NSCLC – squamous cell), ß –HCG (NSCLC – large cell) 2. HEMATOLOGIC (SCLC and NSCLC) Hypochromic anemia, Thrombocytosis,

21. Paraneoplastic Syndromes 3. NEUROLOGIC (SCLC) due to autoimmune reaction to “onconeural” antigen shared by the cancer and nervous system • Eaton-Lambert myasthenic syndrome • Subacute cerebellar degeneration – cerebellar ataxia • Peripheral neuropathies • Cancer-associated retinopathy 4. MUSCULOSKELETAL (NSCLC) • Digital clubbing • Hypertrophic pulmonary osteoarthropathy 5. DERMATOLOGIC (SCLC) • Acquired tylosis, erythema gyratum repens, triple palm, acanthosis nigricans

22. Local Symptoms: Cough and Hemoptysis - cavitating lung cancer Centrally located symptomatic lung cancer

23. Presenting Manifestation in Brain: Hemiparesis – abnormal CT/ PET Patient came to the ER with weakness in the leg and arm and persistent headache

24. Brain metastases – vasogenic edema MRI done after PET scan

25. Abnormal radiologic finding in patient with CNS symptoms: personality change and headache Patient brought to the ER by spouse because of concern about his behaviour

26. RUL cancer and Brain Metastases Fine Needle Aspiration Biopsy for peripheral lung cancer

27. Pancoast (Superior Sulcus) Tumour • Lung cancer - mass at the extreme apex of the lung • Pain - in the lower part of shoulder and inner aspect of the arm (C8 and T1) • Horner’s syndrome – stellate ganglion (T1) • Hand – weakness and muscle wasting

28. Pancoast Tumor: Persistent right chest pain  right arm Investigations needed are: CT scan Chest, Abdomen, Head MRI Thorax PET scan FNA biopsy Mediastinal LN Biopsy

29. Investigations are performed for Diagnosis and Staging • CHEST RADIOGRAPH is nearly always abnormal – hilar mass, solitary pulmonary nodule, partial or total atelectasis due to bronchial obstruction, pleural effusion, raised paralysed diaphragm, rib destruction, widening of mediastinum, cavitation in the lesion, ‘pneumonia-like’ changes • SPUTUM CYTOLOGY positive yield is increased when tumor is centrally situated with increasing size and when it is in lower lobe: positive cytology from single specimen is 40% and increases to 80% with four specimens

30. Investigations 3. BRONCHOSCOPY is very useful investigation a. providing diagnostic material in centrally placed tumors – main bronchus or lobar bronchus b. providing information about inoperability – paralysed vocal cord, definite tracheal involvement, definite carinal involvement, 4. FINE NEEDLE ASPIRATION is very useful for diagnosis in peripherally placed tumors that are beyond bronchoscopic vision 5. Spiral CT scan Chest and Abdomen for diagnosis and staging 5. Non-invasive preoperative staging by PET scan and MRI or CT head

31. Treatment for NSCLC

32. Treatment for Stage III NSCLC

33. Small Cell Lung Cancer • Highly malignant tumor • Distinct cell type • Most common lung cancer associated with ectopic hormone production • Strong relationship to cigarette smoking • >98% found in smokers • Only about 1% occur in non-smokers • Most chemosensitive and radiosensitive

34. Investigating and Managing Massive Hemoptysis

35. Pulmonary Disease a) Infection Pneumonia, Lung abscess, Bronchiectasis TB Mycosis Aspergilloma Mucormycosis b) Neoplasm Carcinoma, Carcinoid tumor, Endobronchial Metastases – sarcoma, renal cell ca, colon ca c) COPD d) Goodpasture’s syndrome 2. Cardiovascular Disease a) Mitral stenosis b) Pulmonary Infarction c) Thoracic aortic Aneurysm 3. Bleeding Diathesis a) Leukemia b) Anticoagulation Causes of Hemoptysis

36. Massive Hemoptysis • Sudden expectoration of large amounts of blood is an alarming development for patients and as well physicians • Patient is anxious and terrified at the sight of his own blood, and imagines death to be imminent • Hemoptysis, if copious, may cause SUDDEN DEATH by ASPHYXIATION

37. Definition: > 600 mls blood expectorated in 24 hours • Patient may become drowned in his own blood, which is partly coughed out and partly inhaled into all parts of the tracheobronchial tree and lungs Loss of Lung Function • Respiratory gas exchange deteriorates, sometimes too rapidly, causing death by ASPHYXIATION

38. Impending Asphyxiation – Blood Clots in the Airway Dead Space

39. Source of Bleeding • Cause is almost always bleeding from a ruptured abnormal BRONCHIAL ARTERY • Susceptible lung parenchymal lesions are • Cavity: usually of tuberculous origin • Bronchiectasis • Lung abscess • Necrotizing pneumonia • Aspergilloma • Centrally located bronchogenic cancer

40. Common Errors of Clinical Diagnosis and Treatment • Airway hemorrhage misdiagnosed as SEVERE HEMATEMESIS: patient arrived in the ER c/o of “throwing up” large amounts of blood and was found to be hypotensive. A bleeding peptic ulcer was suspected even though gastroscopy did not confirm the diagnosis. Readmitted after discharge from ER with same symptom. • Airway hemorrhage misdiagnosed as SEVERE EPISTAXIS and was referred by the ER physician to ENT specialist who performed nasopharyngeal endoscopy and discharged patient home when source of bleeding could not be seen. Severe bleeding recurred within 24 hours.

41. Common Errors of Clinical Diagnosis and Treatment • Severe airway hemorrhage correctly diagnosed but NOT managed properly. Respirologist consulted by ER physician. Flexible bronchoscopy performed was unsatisfactory because of active bleeding – it appeared to be coming from right lung from an area of “extrinsic compression” – missing information was previous right thoracoplasty for chronic pulmonary tuberculosis • Severe airway hemorrhage correctly diagnosed in the ER. Patient was advised by the ER physician to return to home town 400 km away. Hemoptysis continued enroute and arrived in the ER very requiring urgent operation

42. Life-threatening Airway Hemorrhage

43. Definition • Any hemoptysis should be considered massive when it ceases to be a sign of underlying lung disease and becomes a threat to life in its own right Volume > 600 ml/24 hr or Volume > 300 ml/expectoration or Impending airway obstruction or Need for transfusion

44. Serious problem that carries a high mortality rate

45. Massive hemoptysis and threat of asphyxiation Gas exchange is impaired by 2 mechanisms • Acute Bronchial Obstruction: as little as 150 mls of blood clot can fill the anatomical dead space causing proximal airway obstruction  asphyxiation • A large volume of blood can flood the entire lobe or lung  asphyxiation We are addicted to Oxygen

46. Impending Asphyxiation - Airway Dead Space Blood Clots We are addicted to Oxygen

47. Etiology of Massive Hemoptysis • Lung abscess • Bronchiectasis • Necrotizing pneumonia • Aspergilloma • Tuberculosis • Lung Cancer

48. Literature review of Causes

49. Sources of Bleeding • Rupture of a bronchial artery • most common source • Tuberculous cavity, aspergilloma, lung abscess, bronchiectasis, lung cancer, necrotizing pneumonia • Pulmonary artery erosion occasionally • Behcet’s syndrome, Rasmussen’s aneurysm in tuberculous cavity, sleeve lobectomy • Major systemic artery • Thoracic aortic aneurysm or graft eroding into lung • Tracheal-innominate artery fistula complicating tracheostomy, tracheal resection

50. Management is Urgent • Risk of Asphyxiation from proximal airway obstruction • You have a potential life threatening situation • Admission to hospital is mandatory • Resuscitation in the operating room • Inform interventional radiology after life-saving measures in the OR • Inform ICU for transfer after angiogram and bronchial artery embolization