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THE KURSK STATE MEDICAL UNIVERSITY
DEPARTMENT OF SURGICAL DISEASES № 1
LUNG CANCER
Information for self-training of English-speaking students
The chair of surgical diseases N 1 (Chair-head - prof. S.V.Ivanov)
BY ASS. PROFESSOR I.S. IVANOV
KURSK-2010
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I. INTRODUCTION
The question about etiology cancer of the lungs is difficult and unclean for today.
The lung is the major site of cancer in the world today. . Worldwide, lung cancer is
by far the commonest cancer in men (17.6% of all new cancers); it is in first place in
all areas of Europe, the former Russia, North America, the Caribbean, temperate
South America, Australia, New Zealand, western and south-east Asia and
Micronesia/Polynesia. In the European Community (EC), lung cancer accounts for
21% of all cancer cases in men, and, because the rate of fatality is high, the disease
causes 29% of all cancer deaths.
II. GENERAL AIM OF THE SESSION
General aim of the session includes acquisition the following by students:
1. Knowledges on clinical signs, diagnose, medicine treatment and surgical
management cancer of the lungs
2. Practical skills of disease anamnesis accumulation and objective examination of
the patients.
3. Opportunity to create plan of laboratory and instrumental investigation, ability to
create and to prove clinical diagnosis, to make indications and contra-indication for
surgical treatment and to choose the mode of it or conservative therapy in patient
with pancreatic cancer.
III. TRAINING-AIM TASKS FOR SELF-TRAINING
After individual studying of the material every student have to:
A/ to know:
• Classification of this diseases
• Pathogenesis of more spread forms of the diseases
• Clinical picture of this diseases
• Genetic predisposition
•Diagnostic value of different instrumental methods.
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• Indications and contra-indication for surgical treatment
•Complex conservative treatment
•Principles of surgical treatment
B/ be able
• To find main complains and accumulate anamnesis in cases cancer of the
lungs, symptoms and signs and staging of lung cancer
• To realize objective examination of patients with this diseases.
• Be able to assess received datas of US-scanning, X-Ray
examination, angiography, CT-examination laboratory datas
• To create indications and contra-indication for surgical treatment.
III. INITIAL LEVEL OF KNOWLEDGES
Anatomo-physiological datas about the lung cancer have been studied on 3-4-th
courses. Different modes of surgical procedures have been studied on course of
operative surgery. You should restore this study material.
IV. MATERIAL, IS OBL1GATIVE FOR TOPIC MASTERING
In clinical practice the following classification is more useful
Topography of the development of lung cancer is important for early detection,
surgical management and metastatic behaviour.
The following growth patterns are distinguished with a predelection for the upper
lobes:
1) central tumours and those close to the hilum (70-80%), originally developing
most commonly peripherally in the intermediate zone, i.e. the areas between
subsegmental and segmental bronchi;
2) peripheral, comparatively well-delineated tumours which may be detected
radiologically at an early stage (20-30%);
3) tumours growing within the parenchyma or multifocally within the
bronchioloalveolar region of the lung (1.5-2.5%).
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Histological classification of the lung cancer
The clinician expects the pathologist to give a short, clear-cut diagnosis of the
lung tumours, which will form the basis of therapy. Initially, an internationally
approved histological typing scheme of malignant lung tumours, according to a
classification offered by pathologists, has proved to be of value. This World Health
Organization (WHO) classification, is based purely on light microscopy findings.
However, the following important aspects must not be neglected when classifying
any given malignant lung tumour:
1) Generally, the evaluation made by the pathologist, which is of utmost
importance for both patient and choice of therapy, is based on only a small biopsy
specimen, measuring 1-3 mm in diameter if taken at fibreoptic bronchoscopy. In
some cases, only cytological samples are available, taken from the margin of a
tumour perhaps measuring some centimetres in diameter.
2) Morphometric, electron microscopic, immunohistochemical, biochemical, and
molecular genetic results collected over the last 10 yrs have shown beyond doubt that
there is gross tumour heterogeneity amongst bronchial carcinomas.
3) Today, the classification of a malignant lung tumour based on only a small
biopsy sample, sometimes also attempting differentiation of the tumour, is to be seen
as only a crude single parameter of the tumour biology for the creation of comparable
tumour groups.
Evaluable methods of study will in future assist light microscopy investigation to
achieve better diagnostic features for common lung tumours. These will comprise
histological typing and grading, immunohistochemical, cytometric and molecular
biological parameters; so-called prognostic factors.
Peripheral tumours
Approximately 40% of bronchial carcinomas arise beyond the larger segmental
bronchi and, in 30%, a peripheral mass is the sole radio-graphic finding. The mass
can be virtually any size, but it is rare for a bronchial carcinoma to be seen on plain
chest radiographs unless it is more than 1 cm in diameter, whereas computed
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tomography (CT), because of its better contrast resolution, will demonstrate lesions
less than 5 mm diameter.
Central tumours
The cardinal imaging signs of a central tumour are collapse/consolidation of the
lung beyond the tumour and the presence of hilar enlargement; signs which may be
seen in isolation or in conjunction with one another.Obstruction of a major bronchus
often leads to a combination of atelec-tasis and retention of secretions with
consequent pulmonary opacity, but collateral air drift may partially or completely
prevent these postobstructive changes.
Comparison of the distribution of predominant histological types of malignant
lung tumours (typing) in biopsy, surgical and autopsy samples:
1)squamous cell carcinoma;
Squamous cell carcinomas develop as isolated, nodular, round foci in the lung
parenchyma, or intraluminal and stenosing tumours within the bronchial system.
Their cut surface is of crumbly, sometimes granular and characteristically dry
appearance. Tumour necrosis, sometimes visible as large cavities, is common in
advanced stages.
Histologically, squamous cell carcinomas are screen:
 1)high differentiation.
 2)medium differentiation.
 3)poor differentiation
2)adenocarcinoma;
According to reports from the United States, there is evidence that
adenocarcinoma of the lungs is increasing in incidence. In our biopsy collection, they
occupy third place at 19%, behind squamous and small-cell carcinomas. It is not yet
clear whether this "change in frequency" is due to more sophisticated analytical
techniques and more differentiated morphological analyses.
According to the WHO classification, there are four subtypes:
 acinar adenocarcinoma;
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 papillary adenocarcinoma;
 solid adenocarcinoma with mucus formation;
 bronchioloalveolar carcinoma
3)small-cell carcinoma;
The lesions categorized as small-cell carcinoma may be seen as a clinical and
pathological entity only under certain conditions. Both the course of the disease and
the morphologically determined criteria reveal anextremely high grade of
malignancy.
4)large-cell carcinoma;
The WHO classification is still listing large-cell carcinoma as a single entity.
Recent investigations, however, show increasingly that large-cell carcinomas are
usually variants of adenocarcinomas, and sometimes squamous cell carcinomas
5)other types.
Early cancer of the lung
Early cancer of the lung is defined as a locally infiltrating carcinoma, which is still
confined to the bronchial wall (with no infiltration of lung or lymphatic tissue).
Histologically, this term is only being used for squamous cell carcinoma. The final
diagnosis of "early cancer of the lung" can only be made from the surgical sample.
Occult carcinoma
Here, tumour cells are found in sputum cytology, but X-ray findings are negative.
In these cases, immediate endoscopic clarification is necessary, which may identify a
carcinoma at an early developmental stage.
Micro carcinoma
The term "microcarcinoma of the lung" is used for primary tumours of the lung,
measuring 3-10 mm, with no clinical disease. Histologically, most pulmonary
microcarcinomas are small-cell carcinomas with already extensive, clinically
manifest metastatic spread. At autopsy, the minute primary lesion can in some cases
be detected only after careful preparation of the entire bronchial system.
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TMN classification:
Diagnostic and treatment procedures are based on stage development of the disease.
The clinical classification
Stage I disease. This stage includes subsets with significantly different prognostic
long-term survival, justifying subdivision into Stage IA for Tl tumours, stage IB for
T2 tumours.
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Stage II disease. In comparison to Stage I, Stage II disease includes involvement of
pulmonary, interlobar or hilar lymph node stations (N1).
Stage IIIa disease. This tumour stage is very heterogeneous. It includes tumours
with involvement of neighbouring organs and structures, such as chest wall,
diaphragm, pericardium; endobronchial tumours located near the bifurcation; and
lesions with mediastinal lymph node involvement.
Stage IIIb disease. Indications for surgery in Stage IIIb is disputed.
Stage IV disease. Stage IV is defined as tumours, irrespective of the extent of the
primary and lymph node metastases, which present with distant metastatic lesions.
Instrumental diagnose
There are 5 questions for answer. They are following:
• Is there lung tumor?
• Is this tumor malignant?
• What is its localization?
• What is its clinical stage?
• Are there any complications?
Chest radiography
The chest radiograph plays a central role in the detection of lung cancer in
asymptomatic patients, with a better sensitivity than pooled sputum cytology. Lung
cancer arises in the upper lobes more frequently than in the lower lobes and in the
right lung more often than in the left. The most common location of lung cancer is in
the anterior segment of the right upper lobe. Unfortunately, because the upper ribs are
projected closely together and the clavicles also overlie this region, the upper lobes
are the most difficult to evaluate radiographically.
Sputum cytology
With the ready availability of fibreoptic bronchoscopy, reliance on sputum
cytology has diminished. Nevertheless, it is occasionally useful, particularly in
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patients unsuitable for fibreoptic bronchoscopy, such as those with a recent
myocardial infarct or very poor lung function.
Bronchoscopy
The fibreoptic bronchoscopic technique was developed in 1968, and has
become the mainstay investigation in the evaluation of patients suspected of lung
cancer. Whilst it is employed mainly as a diagnostic tool, bronchoscopy has a role in
staging the disease, and an extended role in the deciding the therapeutic choice.
Transbronchial biopsy
Transbronchial biopsy (TBB) via the fibreoptic bronchoscope is a widely accepted
technique in the diagnosis of diffuse lung disease of characteristic histopathology,
such as sarcoidosis. Several studies have suggested a role for TBB in the diagnosis of
peripheral lung cancers.
Transbronchial needle aspiration
Transbronchial needle aspiration (TBNA) was first introduced by
and then adapted for use with the fibreoptic bronchoscope by
WAN.
SCHIEPPAT,
It involves the
insertion of a metal needle into the tissue to be sam pled, and whilst suction is
applied, the needle is moved back and forti to obtain an aspirate for cytological
examination.
Bronchoalveolar lavage
The main role of bronchoalveolar lavage (BAL) in patients with lung cancer is the
diagnosis of opportunistic infections in patients undergoing chemotherapy.
Endobronchial sonography and pulmonary microvascular cytology
Two novel methods of diagnosing peripheral lung tumours have recently been
described: endobronchial sonography and pulmonary microvascular
Percutaneous fine needle biopsy
Transthoracic aspiration biopsy was first employed by
LEYDEN
100 yrs ago to
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obtain micro-organisms from a patient with pneumonia, but it was not until 1886 that
MENETRIER
used the technique to make the diagnosis of bronchial carcinoma.
Plewal aspiration and biopsy
Pleural effusions are a common manifestation of primary and metastatic tumours
of the lung and pleura. This method is very effectiv.
Thoracoscopy
A substantial number (21-27%) of pleural effusions remain undiagnosed after
pleural fluid cytology, biopsy and other relevant investigations. The need to see and
biopsy under direct vision, coupled with improvements in endoscopic technology and
local anaesthesia has led to a resurgence of interest in thoracoscopy.
Mediastinoscopy and mediastmotomy
Mediastinoscopy was originally described by
CARLENS
in 1959. Utilizing a
cervical incision, the mediastinoscope allows access to the structures adjacent to the
trachea, carina and superior vena cava, facilitating assessment of high and low
paratracheal, pretracheal, and the most proximal aspects of the hilar and carinal
lymph nodes.
Complex conservative and surgical treatment:
• Indications and contra-indication for surgical treatment
•Complex conservative treatment (Chemotherapy+Radial therapy)
The combination of chemotherapy and radial therapy in cases of inoperable
patients with lung cancer patients give the positive results.
•Principles of surgical treatment
V. LITERATURE
1. Short Practice of Surgery by Charles v. Mann and al.
2. Lections
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VI. APPROXIMATE ACTIONS BASE
1. Introduction /5 min/
Teacher short characterizes topic actuality, meets students with main aims of
the study and its plan.
2. Initial knowledges control /15 min/
3. Individual students work with patients. /30 min/ The teacher explains some
more difficult and important parts of problem. The choice is realized by asking of
students and their answers correction.
4. Clinical analisys of topical patients. /100 min/
Students observe topical patients under teacher control. After it finishing, the
students report about receiving results.
Work in dressing-room and operational theater.
Teacher and students change the dressings of patients after different
surgical procedures on the pancreas
Study of X-Ray pictures, US- and CT-scanns, laboratory datas
5. Final knowledge control. Solution of test-questions /25 min/
6. Conclusion /5min/
The teacher concludes the session and gives new task for the next once.
VII. TEST QUESTION
1. Histologically, squamous cell carcinomas are subdivided except:
 bronchioloalveolar carcinoma
 medium differentiation.
 poor differentiation
 without differentiation
 solid adenocarcinoma with mucus formation
 high differentiation.
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2.There are following main etiological factors of lung cancer except:
 smoking
 advanced age
 drinking of strong alcohol
 cafe
 industrial agents (asbestos, metals, hydrocarbons and so on)
 tee
 genetic predisposition
3. Histologically, adenocarcinomas are subdivided except:
 acinar adenocarcinoma;
 high differentiation.
 papillary adenocarcinoma;
 poor differentiation.
 solid adenocarcinoma with mucus formation;
 bronchioloalveolar carcinoma
 medium differentiation.
4.Classification of TNM - Regional lymph nodes involved, except
 Regional lymph nodes cannot be assessed
 No regional lymph node metastasis
 Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes,
 including direct extension
 Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)
 Presence of distant metastasis cannot be assessed
 No (known) distant metastasis
5. Correct diagnosis of lung cancer may be created by:
 CT-scanning
 Laparoscopy
 X-ray examination
 US-scanning
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 Thoracoscopy
6. Where is the metastatic involvement of lung cancer is maximal:
 Central nervous system
 Cervical lymph nodes
 Bones
 Liver
 Skin and soft tissues
 Gastrointestinal tract
7.Classification of TNM - distant metastasis involved, except
 Presence of distant metastasis cannot be assessed
 No (known) distant metastasis
 Distant metastasis involvement present (specify site)
 Regional lymph nodes cannot be assessed
 No regional lymph node metastasis
VIII. CORRECT ANSWERS
1. 1, 4, 5
2. 3, 4, 6
3. 2, 4, 7
4. 6, 7
5. 2, 4
6. 5, 6
7. 4, 5