CARDIOTHORACIC

CORE LECTURES
ADEGBOYE V.O.

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TUMOURS OF THE LUNG

AND MEDIASTINUM

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Topics of Discussion
TUMOURS OF THE LUNG:
PRIMARY MALIGNANT &
BENIGN.
SECONDARY METASTATIC.

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MALIGNANT LUNG.
1-BRONCHIAL GLAND TUMOURS.
2-LUNG CANCERS.
3- METASTATIC.

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BENIGN TUMOURS.
1- ORIGIN
UNKNOWN=Harmatoma,Teratoma
s,Clear cell .
2-Epithelial cells=papiloma &polyps.
3-Mesodermal=fibroma, Lipoma,
Leiomyoma
4-Others=mucosa associated
lymphoid tissue,xanthoma etc
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PRESENTATION AND
DIAGNOSIS OF BENIGN
TUMOURS.
Most asymptomatic,peripherally located ,

cxray finding.
Few endobronchial Are
symptomatic:effects of bronchial
occlusion.
Definite diagnosis ; Tissue . Cxray
sometimes characteristic most times not
specific.
Solitary Pulmonary nodule (SPN) -most
challenging, previous x rays ,FNAB when
ve not helpful , follow up, CT/MRI NOT
HELPFUL.
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MAMAGEMENT OF LESIONS
POSITIVE benignity has to be
established: excision= lung
conservation; bronchoplastic
procedure, segmental
resection,bronchoscopic resection.
Other methods:minimally invasive
techniques. Better than waiting.

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BRONCHIAL GLAND
TUMOURS.
USED TO BE CALLED BRONCHIAL
ADENOMA SUGGESTING BENIGNITY
NOT BENIGN
FIVE DISPARATE TUMOURS.
1-Bronchial Carcinoid
2-Adenoid Cystic CA.
3-Mucaepidermoid Ca.
4-Bronchial mucous gland adenoma.
5-Pleomorphic mixed tumour of
Bronchial gland
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Bronchial Carcinoid.

All bronchial gland tumours

arise from different cells.

BRONCHIAL CARCINOID-

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85% OF THIS GROUP.

90%-mainstem or lobar
bronchus: symptoms of
obstruction & inflamation.
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Symptoms of Bronchial
Carcinoid.

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Cough-90%,Dyspnoea66% &
Haemoptysis30%,Carcinoid
Syndrome 2-3%.
Not seen with peripheral
lesion.
Same clinical features as
APUD( amine precursor
uptake decarboxylate)
Tumours
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Diagnosis

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Cytology of bronchial brushing

low yield.
FNAC/Frozen section
differnciate between bronchial
carcinoid and small cell ca in
66% of cases.
Bronchoscopy & biopsy
haemorrage,
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TREAMENT.

RESECTION:
Endoscopic
Bronchotomy
Formal resection

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Radiotherapy
Chemotherapy.
Rapidly fatal diisease.
Carcinoid syndrome best treated
by resection of tumour.
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LUNG CANCER
95% of lung tumours
are malignant.
Majority can be
classified into: sq cell
ca;adeno ca; large
cell ca; small cell ca.
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CLINICAL PRESENTION.

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95% SYMPTOMATIC.
27% symptoms of primary tumour.
32% symptoms of metastatic
spread.
34% systemic symptoms(wt loss,
malaise,anorexia )
High % have symtoms of systemic
spread & INOPERABLE
5% OR LESS ASYMPTOMATIC
with abnormal c x ray.
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PRESENTATION
CONTNS.

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Symptoms and signs depend on:

Hystological findings
Intrinsic tumour biology.-growth
rate, paraneoplastic syndromes
Anatomic location
Stage of presentation

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HISTOLOGY AND
PRESENTATION

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SQ CELL CA AND SM CELL CACENTRALLY LOCATED.=

BRONCHIAL OCCLUSION
SUMPTOMS.
ADENO CA & LARGE CELL CA
ASYMPTOMATIC peripheral
nodule or parietal pleural or chest
wall invasion( pleural effusion
chest wall pain), not visible on
brchscope.
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PULMONARY
MANIFESTATION.

FROM BRONCHUS AND LUNG INVOLVEMENT.

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COUGH-75%,BRONCHIAL IRRITATION.
DYSPNOEA-50-60%,BRONCHIAL
OCCLUSION,EFFUSION- PERIPHERAL
LESION;
WHEEZING-LESS 50%,PARTIAL
OBTRUCTION PROX BRONCHUS.
HAEMOPTYSIS-25-40%. STREAKY
CENTRALLY LOCATED TUMOURS.
PNEUMONIC SYMPTOMS.
LUNG ABCESS.

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NON PULMONARY
THORACIC MANIFESTATION

PRIMARY TUMOUR INVASIONOF

CONTIGUOUS STRUCTURES.
ENLARGED TUMOUR BEARING
LYMPH NODES COMPRESSION OF

sTRUTURES.

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Diphragm,chest wall,phrenic
nerve,pericardial oesophageal invasion,
SVC COMPRESSION OR INVASION.

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PARANEOPLASTIC
SYNDROME

OCCUR WITH OTHER TUMOURS BUT

MOST FREQUENT WITH LUNG CA.
ESPECIALLY = SQ CELL CA AND SM
CELL CA.
MAY BE FIRST INDICATION OF
DISEASE LEADING TO EARLY
DIAGNOSIS.

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HYPERTROPHIC PULMONARY
OSTEOARTHROPATHY
ROLIFERATING PERIOSTITIS, END OF
LONG BONES.

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PARANEOPLASTIC
SYNDROME CONTNS

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Inappropriate ADH SECRETION = IN

70% of lung ca.Highest with sm cell ca.
Hypercalcemia
Myopathic neurologic syndrome(mns)
most common 16% have
neuromuscular.disability.
Carcinomatous myopathy (CM)-proximal
muscle weakness= most frequent sm
cell ca.
NEUROPATHIES- peripheral; motor
sensory .CNS unusual but could be
cortical cerebellar
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METASTATIC
SYMPTOMS

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CNS: MOST COMMOM are symptoms

of increased inracranial pressure
(headache, nausea,vomiting changes in
level of conciousness. LESS
COMMON=WEAKNES& SEIZURES.
BONE 25% OF CASES. OSTEOLYTIC
HEPATIC/ADRENAL
SKIN / SOFT TISSUE. -PAINLESS

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DIAGNOSIS OF LUNG
CANCER

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HISTORY AND PHYSICAL

EXAMINATION: SMOKING,
OCCUPATION(SMOKING+ASBES
TOS MULTIPLICATION
EFFECT); WT LOSS OF 70%
ADVANCED DISEASE.
SPUTUM CYTOLOGY82.5%
OVERAL YIELD MORE WITH
MULTIPLE SPECIMENS.
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DIAGNOSIS CONTNS

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CHEST RADIOGRAPHY
CT /MRI
FNAB
TRANSTHORACIC=FLUOROSCO
PIC OR CT GUIDED WITH
INCREASED YIELD IN
EXPERIENCED HANDS..
BRONCHOSCOPY
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OTHER DIAGNOSTIC
METHODS

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CERVICAL MEDISTINOSCOPY
LEFT ANTERIOR
MEDIASTINOTOMY.
SCALENE NODE BIOPSY
THORACOSCOPY.
THORACOTOMY.

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TREATMENT

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SURGERY(S) FOR LOCALISED

DISEASE.
CHEMOTHERAPY(Ct)- for
METASTATIC DISEASE.
RADIOTHERAPY (Rt)-LOCAL
CONTROL.
Ct combined with Rt better than
either alone for advanced disease
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TREAMENT CONTNS

SM CELL CA FREQUENLY
disseminated at time of presentation
surgery is not first line except in well
selected cases.

Others = Non-sm cell catreatment

depend on stage of disease.

Survival depends on cumulative

mechanical & biological effect 0f

treatment
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MEDIASTINAL
TUMOURS
MEDIASTINAL BORDERS:

MEDIASTINAL COMPARTMENTS
INITIALLY 4
NOW 3ANTEROSUPERIOR;
MIDDLE; AND POSTERIOR.

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PRIMARY TUMOURS

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PRESENT AS MYRIADS OF
SYMPTOMS AND SIGNS.
NATURAL HISTORY=
ASYMPTOMATIC TO BENIGN
SLOW GROWTH WITH MINIMAL
SYMPTOMS TO AGGRESSIVE,
INVASIVE NEOPLASM

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FREQUENCY OF
MASSES

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NEUROGENIC-20%
THYMOMAS-19%
PRIMARY CYSTS-18%
LYMPHOMAS -13%
GERM CELLS -10%

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LOCATION OF
TUMOURS

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ANTEROSUPERIOR-56%

POSTERIOR 25%

MIDDLE ---19%

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COMMONEST
MASSES:at locations.

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ANTEROSUPERIOR:Thymic,Lymp
homa,Germ cell, Carcinoma.
POSTERIOR: Neurogenic, Cysts.
MIDDLE:Cysts and Lymphomas.

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MALIGNANT
NEOPLASM

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25-42% OF MASSES.
FREQUENCY varies with anatomic
site:anterosuperior 59 %, middle
29%, posterior 16%.
FREQUENCY varies with age:
Higher rate between 2nd and 4th
decade of life.

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CLINICAL FEATURES.

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56 TO 65 % SYMTOMATIC AT
PRESENTATION.
Benign 54% asymptomatic at
presentation.
15% of Malignant asymptomatic
at presentation.
Children 75% symptomatic at
presentation or have signs.
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Clinical features contnS

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COMMON : Chest pain,fever

,cough , dyspnoea .
COMPRESSION OR INVASION:
SVC syndrome , severe pain,
hoarseness.etc.
PRODUCE HORMONE.

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DIAGNOSIS

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HISTORY AND PHYSICAL

EXAMINATION.
CX RAY PA AND LATERAL.
CT WITH CONTRAST
ROUTINE.
INVASIVENESS CAN BE
STUDIED BY CT /MRI
FNAB UNDER CT OR ECHO
GUIDIANCE.INCREASE YIELD.
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DIAGNOSISOTHERS.

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MEDIASTINAL USS= ECHO

IODINE 131 SCAN FOR
THYROID.
FDG POSITRON EMISSION.
POOL DATA AND APPLY
TREATMENT AS APPROPRIATE..

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