CURS NUMAI-Tumori Pulmonare Curs 2h

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<ul><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 1/105</p><p>Lung Tumors</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 2/105</p><p>Bronchogenic Carcinoma</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 3/105</p><p>Introduction</p><p> Brochogenic carcinoma is also called Lung cancer.</p><p> It is a frequent and important neoplasm in both</p><p>developed country and developing country. In recent years, it has been reported that lung</p><p>cancer is the leading fatal neoplasm of men and</p><p>women. It is strongly associated with the use of tobacco</p><p>products, particularly with cigarettes.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 4/105</p><p>Incidence and prevalence</p><p> Lung cancer is the leading cause of cancer-related death of men in 28 developed countries of</p><p>the world</p><p> Squamous cell carcinoma is thought to be themost frequent form of the tumor (30-50 percent of</p><p>all cases),followed by adenocarcinoma, large cell</p><p>carcinoma, and small cell carcinoma.</p><p> Nowadays an increase has occurred in the</p><p>incidence of adenocarcinoma, which is the most</p><p>common histologic subtype.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 5/105</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 6/105</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 7/105</p><p>Endobronchial leiomyoma</p><p>Tracheal lipoma</p><p>Endobronchial schwannoma</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 8/105</p><p>Etiology and pathogenesis</p><p> Cigarette smoking</p><p> Occupational associations: asbestos,</p><p>uranium (in miners), arsenical fumes,</p><p>nickel,radon gas ects.</p><p> Other factors include air pollutions ,</p><p>ionizing radiation .</p><p> Nowadays It is reported that tuberculosis is</p><p>associated with the incidence of lung</p><p>cancer.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 9/105</p><p>Pathogenesis</p><p> Many factors influence the formation oflung cancer. The development of lungcancer is a multistepp process. Thetransformation process of normalbronchial epithelial cells to malignantcells is unknown.</p><p> Perhaps It is related to: damage of</p><p>cellular DNA; alteration in cellularoncogen expression; tumor-derivedfactors that stimulate cellular division.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 10/105</p><p>Etiology and pathogenesis</p><p> Chronic inflammation of the lung, such</p><p>as from interstitial fibrosis and areas of</p><p>scarring is associated with the occurrenceof adenocarcinoma.</p><p> Genetic factors are also involved in the</p><p>formation of lung cancer.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 11/105</p><p> Major categories of genes that potentially</p><p>determine susceptibility to lung cancer, includeproto-oncogenes, tumor suppressor genes, ects.</p><p>Oncogene abnormalitiesOncogene SCLC NSCLC</p><p>Ki-ras 0 30-50% of adenocarcinomasH-ras 0 Rare mutation, over expression</p><p>N-ras 0 Rare mutation, over expression</p><p>Myc Majority Gene amplification and</p><p>overexpression</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 12/105</p><p>ClassificationsAccording to anatomy:</p><p>(1)Central lung cancer,mostly is squamous cellcarcinoma and small cell carcinoma.</p><p>(2) Peripheral lung cancer, mostly is adenocarcinoma.</p><p>According to histologic classification:</p><p>Small cell lung cancer(SCLC)</p><p>Non-small cell lung cancer(NSCLC).</p><p> Squamous cell carcinoma</p><p> Large cell carcinoma</p><p> Adenocarcinoma</p><p> Adenosquamous carcinoma.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 13/105</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 14/105</p><p>Small Cell Carcinoma</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 15/105</p><p>Small Cell Carcinoma</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 16/105</p><p>Adenocarcinoma</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 17/105</p><p>Adenocarcinoma</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 18/105</p><p>B. Non-Small Cell Carcinoma Squamous cell carcinoma: It is the most common</p><p>subtype.It arises from altered bronchial epitheliumand growth in situ.It is related to cigarettesmoking.Cavitation can occure distal to theobstructing mass.</p><p> Adenocarcinoma: It arises from the submucosalglands,located in peripheral airways andalveoli.Peripheral adenocarcinomas are usually well-circumscribed, grey-white masses that rarely cavitate.</p><p>Adenocarcinoma is usually a slow-growing cancer,but can be difficult to detect because the diseasetypically involves the periphery of the lung, resultingin fewer early symptoms than cancers that develop</p><p>centrally, near the airways </p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 19/105</p><p>Classification</p><p> Large-cell carcinoma, can be quite large and</p><p>not infrequently cavitate. The tumor cells have</p><p>large nuclei,prominent nucleoli and abundant</p><p>cytoplsma.</p><p>There are two types Giant-cell carcinoma</p><p>Clear-cell carcinoma.</p><p> Adenosquamouscc: There are definite featuresof adenocarcinoma and squamous ce carcinoma.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 20/105</p><p>Clinical Manifestations</p><p> Due to primary lesions:</p><p>cough, dyspnea, hemoptysis, sputum, wheezing,</p><p>weight loss, fever, pneumonia</p><p> Due to local extension:chest pain,hoarseness,superior vena cava</p><p>syndrome, horners syndrome, dysphagia,</p><p>pericardial effusion,pleural effusion,diaphragm paralysis</p><p> Only 5-15 percent of patients are asymptomaticwhen discovered to have bronchogenic carcinoma.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 21/105</p><p>Clinical manifestations</p><p>Regionnal spread to hilar and mediastinal</p><p>nodes may cause dysphagia due to esophageal</p><p>compression, horsenessdue to recurrent laryngealnerve compression, horners syndrome due to</p><p>sympathetic nerve involvement, and elevation of</p><p>the hemidiaphragm from phrenic nervecompression.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 22/105 </p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 23/105</p><p>Pancoasts Tumor</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 24/105</p><p>Clinical manifestations</p><p> Extrapulmonary manifestations. Including</p><p>metastasis to other organs, such as brain,</p><p>central nervous system, skeleton system,</p><p>liver,adrenal glands and lymph nodes ects.</p><p> Paraneoplastic syndromes are remote effects</p><p>of the tumor. They lead to metabolic and</p><p>neuromuscular disturbances unrelated to theprimary tumor, metastases, or treatment. They</p><p>may be the first sign of the tumor.They do not</p><p>indicate that a tumor has spread.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 25/105</p><p>Clinical manifestations</p><p>Paraneoplastic syndromesinclude:</p><p> hypertrophic pulmonary osteoarthropathy hypercalcemia</p><p> inappropriate antidiuretic hormonesecretion syndrome</p><p> polymyositis</p><p> subacute cerebellar degeneration peripheral neuropathies cushingssyndrome ects.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 26/105 </p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 27/105</p><p>Physical examinations</p><p> Endobronchial obstruction may result in</p><p>a localized wheeze</p><p> Lobar collapse may result in an area of</p><p>decreased breath sounds and dullness to</p><p>percussion.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 28/105</p><p>Diagnosis of lung cancer requires:</p><p>A:detecting the tumor</p><p>B:establish the cell type</p><p>C:define the stage of the tumor among</p><p>these, determing cell type is the most</p><p>important because it influences the</p><p>treatment.</p><p>Diagnosis of Bronchogeniccarcinoma</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 29/105</p><p>Available methods to detect the tumor: Chest X-ray</p><p> Computer Tomography(CT)</p><p> Magnetic Resonance imaging (MRI)</p><p> Positron Emission Tomography (PET)</p><p> Hystologic examination (mainly sputum</p><p>examination, bronchoscopy biopsy,bronchial</p><p>brushing , bronchial washings, transbronchialneedle aspiration and transthoracic needle).</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 30/105</p><p>Chest X-ray</p><p> Is the most important examination method. Itcan detect the presence of lung cancer. Themost frequent finding is a tumoral mass in thelung field.</p><p>Secondary manifestations seen on the chestradiograph include lober collapse,pneumonitisbecause of endobronchial obstruction,elevationof the hemidiaphragm, pleural effusion, hilar</p><p>and mediastinal adenopathy and erosion of ribsor vertebrae due to metastases.</p><p> Alveolar cell cancer can manifest as a localizedinfiltrate mimicking pneumonia.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 31/105</p><p>Chest X-ray</p><p>If a patient presents with chronic cough,</p><p>sputum with blood stipes, and dyspnea, lowfever we must perform a chest X-ray. The</p><p>most frequent finding is a mass in the lung</p><p>field.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 32/105</p><p> On chest X-ray, secondary manifestations</p><p>include lobar collapse, pleural effusion,</p><p>pneumonitis, elevation of the hemidiaphragm,hilar and mediastinal adenopathy, and</p><p>erosion of ribs or vertebrae due to metastases.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 33/105</p><p>Obstructive atelectasis</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 34/105</p><p>Central bronchogenic carcinoma</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 35/105</p><p>Central lung cancer manifestations</p><p>on chest radiography</p><p>Secondary manifestations we mentioned</p><p>above may be exist if metastases happen,including lobar collaps, obstuctive</p><p>pneumonitis, pleural effusion.</p><p>Mainly shows a mass locate in the one side</p><p>of hilar,some times it makes the mediastinum</p><p>widen.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 36/105</p><p>Peripheral lung cancer on chest</p><p>radiography</p><p>The most frequent finding is a mass in the</p><p>lung field. Sometimes the mass is not smooth,and with a cavity. Secondary manifestations</p><p>can be also seen on the chest X-ray, such as</p><p>pleural effusion.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 37/105</p><p>Alveolar cancer on chestradiography</p><p>The chest X-ray usually shows dissiminatedsmall nodules in the lung field.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 38/105</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 39/105</p><p>Lung cancer on CT</p><p>CT is the most useful in evaluating patientswith pulmonary and mediastinal masses.It is also useful for detecting multiple</p><p>metastases.CT can show the exact location and size ofthe tumoral a mass in the ( important fromthe surgical point of wiew) It also shows the</p><p>nodules in the mediastinum.Sometimes,when a mass locates behind theheart, chest X-ray can`t detect it .CT candetect some hidden sites of lung cancer.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 40/105</p><p>Peripheral carcinoma</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 41/105</p><p>BronchoscopyIt is important both for determining if a</p><p>tumor is present and for obtaining tissue for</p><p>histologic diagnosis.</p><p>Usually, the combination of bronchial</p><p>brushing and forceps biopsy is positive 90 to</p><p>93 percent of the tumors located in proximalairway.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 42/105</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 43/105</p><p>Bronchoscopic appearances of small</p><p>cell carcinoma</p><p>Thickened membranous portion of</p><p>posterior membrane with</p><p>prominent mucosal folds</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 44/105</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 45/105</p><p>Transbronchial lung biopsy It may be utilized when the tumor is located</p><p>in peripheral airways.</p><p> Transthoracic needle biopsy with CT guidance</p><p>can be used to detect lesions located near the</p><p>chest wall</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 46/105</p><p>Thoracotomy</p><p>If the methods mentioned above are not</p><p>useful for detecting the cell type of lung</p><p>cancer, thoracotomy may be used.We should analyse some other factors</p><p>before we adopt the method, for example the</p><p>age of the patient,the pulmonary function,and complicating illness.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 47/105</p><p> In some circumstances,a histologic diagnosis</p><p>can be made by biopsy of metastatic sites,such</p><p>as lymphy nodes, liver, bone or bone marrow.</p><p>Histologic examination</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 48/105</p><p>Small Cell Carcinoma</p><p>Adenocarcinoma</p><p>Squamosus cell carcinoma</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 49/105</p><p>Other laboratory examinations</p><p>tumor markers</p><p>CEA</p><p>CA199</p><p>CA211</p><p>NSEGene examination (p53gene, ras gene)</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 50/105</p><p>Medical history</p><p>Clinical manifestations</p><p>Physical examination</p><p>Laboratory and Imaging examinations</p><p>(chest X-ray, CT scanning, histologic</p><p>examination of sputum, biopsy tissueobtained by bronchoscopy, bronchial</p><p>brushing.)</p><p>Positive Diagnosis based on:</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 51/105</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 52/105</p><p>TNM classification of lung cancer</p><p>Primary Tumor(T)</p><p> TX:primary tumor can not be assessed. tumor present asdetermined by presence of malignant cells in</p><p>bronchopulmonary secretions, but not radiographicallyvisible; no evidence of primary tumor</p><p> T0:No evidence of primary tumor</p><p> Tis:carcinoma in situ</p><p> T1:Tumor 3 cm or less surrounded by lung or visceral pleura,but without evidence of invasion proximal to lobar bronchusat bronchoscopy</p><p> T2:Tumor more than 3 cm or tumor invading visceral pleuraor associated with obstructive pneumonitis or atelectasis;involving less than entire lung; at bronchoscopy, proximalextent of visible tumor must be within a lobar bronchus or atleast 2 cm distal to carina</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 53/105</p><p> T3:Tumor of any size with direct extension into chestwall, diaphragm, or mediastinal pleuraor pericardium</p><p>without involving heart, great vessels, trachea,</p><p>esophagus, or vertebral body; also includes superior</p><p>sulcus tumors and</p><p> T4:Tumor of any size invading mediastinum or</p><p>involving heart ,great vessels, trachea,esophagus,</p><p>vertebral body,or carina or presence of malignantpleural effusion</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 54/105</p><p>Nodal Involvement(N)</p><p>Nx: can not assess regional lymph node N0:No demonstrable metastasis to regional lymph</p><p>nodes</p><p> N1:metastasis to peribronchial or the ipsilateral, orboth,hilar lymph nodes,including direct extension</p><p> N2:metastasis to ipsilateral mediastinal lymphnodes and subcarinal lymph nodes</p><p> N3:metastasis to contralteral mediastinal lymphnodes,contralateral hilar lymph nodes,ipsilateral orcontralateral scalene or supraclavicular lymphnodes</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 55/105</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 56/105</p><p>Distant metastasis(M) Mx: distant metastasis can not be assessed</p><p> M0:No distant metastasis</p><p> M1:Distant metastasis present</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 57/105</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 58/105</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 59/105</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 60/105</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 61/105</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 62/105</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 63/105</p><p>Small cell lung cancer has often metastasized</p><p>at the time of diagnosis.TNM staging is not suited to small cell lung</p><p>cancer.</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 64/105</p><p>TreatmentIncluding:</p><p>A:Surgery</p><p>B:ChemotherapyC:Radiation therapy</p><p>D:Some other therapy</p><p>immunologic therapy</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 65/105</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 66/105</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 67/105</p><p>We must measure pulmonary function before</p><p>surgical therapy.</p><p>Forced vital capacity greater than 2 liters and a</p><p>forced expiratory volume in the first second</p><p>(FEV1)of greater than 50 percent of the forced</p><p>vital capacity predict that a patient can tolerate</p><p>the consequences of pneumonectomy.</p><p>Surgery</p></li><li><p>8/12/2019 CURS NUMAI-Tumori Pulmonare Curs 2h</p><p> 68/105...</p></li></ul>