Neoplasms of the lung

We investigated the clinicopathological characteristics and survival of breast cancer lung metastases (BCLM) patients at initial diagnosis of metastatic breast cancer (MBC) in the Han population.

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Gastric (Nonlymphoid) Sarcoma Leiomyosarcomas and GISTs make up 1–3% of gastric neoplasms. They most frequently involve the anterior and posterior walls of the gastric fundus and often ulcerate and bleed. Even those lesions that appear benign on histologic examination may behave in a malignant fashion. These tumors rarely invade adjacent viscera and characteristically do not metastasize to lymph nodes, but they may spread to the liver and lungs. The treatment of choice is surgical resection. Combination chemotherapy should be reserved for patients with metastatic disease.

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Further Readings Black C et al: Population screening for lung cancer using computed tomography: Is there evidence of clinical effectiveness? A systematic review of the literature. Thorax 62:131, 2007 [PMID: 17287305] Eberhardt W et al: Chemoradiation paradigm for the treatment of lung cancer. Nat Clin Pract Oncol 3:188, 2006 [PMID: 16596143] Hayes DN et al: Gene expression profiling reveals reproducible human lung adenocarcinoma subtypes in multiple independent patient cohorts.

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Bronchial Adenomas Bronchial adenomas (80% are central) are slow-growing endobronchial lesions; they represent 50% of all benign pulmonary neoplasms. About 80–90% are carcinoids, 10–15% are adenocystic tumors (or cylindromas), and 2–3% are mucoepidermoid tumors. Adenomas present in patients 15–60 years old (average age 45) as endobronchial lesions and are often symptomatic for several years. Patients may have a chronic cough, recurrent hemoptysis, or obstruction with atelectasis, lobar collapse, or pneumonitis and abscess formation.

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Chemotherapy The chemotherapy combination most widely used for SCLC is etoposide plus cisplatin or carboplatin, given every 3 weeks on an outpatient basis for four to six cycles. Increased dose intensity of chemotherapy adds toxicity without clear survival benefit. Appropriate supportive care (antiemetics, fluid support with cisplatin, monitoring of blood counts and blood chemistries, monitoring for signs of bleeding or infection, and, as required, use of hematopoietins) and adjustment of chemotherapy doses on the basis of nadir granulocyte counts are essential.

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Chemotherapy Chemotherapy palliates symptoms, improves the quality of life, and improves survival in newly diagnosed patients with stage IV NSCLC, particularly in patients with good performance status. Whereas the median survival for untreated patients is roughly 4–6 months, and 1-year survival is 5–10%, with combination chemotherapy the median survival is 8–10 months, 1-year survival is 30–35%, and 2-year survival 10–15%. Combination chemotherapy produces an objective tumor response in 20–30% of patients, although the response is complete in ...

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Superior Sulcus or Pancoast Tumors Non-small cell carcinomas of the superior pulmonary sulcus producing Pancoast's syndrome appear to behave differently than lung cancers at other sites and are usually treated with combined radiotherapy and surgery. Patients with these carcinomas should have the usual preoperative staging procedures, including mediastinoscopy and CT and PET scans, to determine tumor extent and a neurologic examination (and sometimes nerve conduction studies) to document involvement or impingement of nerves in the region.

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Bulky NSCLC Stage IIIA and Dry IIIB (IIIB Without a Pleural Effusion) The presence of pathologically involved N2 nodes should be confirmed histologically because enlarged nodes detected by CT will be negative for cancer in ~30% of patients. Chemotherapy plus radiation therapy is the treatment of choice for patients with bulky stage IIIA or IIIB disease without pleural effusion (referred to as "dry IIIB"). Randomized studies demonstrate an improvement in median and long-term survival with chemotherapy followed by radiation therapy, compared with radiation therapy alone.

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Table 85-5 Randomized Studies of Adjuvant Chemotherapy in NSCLC Stu dy Treatment mber Nu of Year 5edian M zard Ha Value p Patients Survival Survival Ratio (%) (95% CI) EC OG Surgery 242 9% 246 3 39 months vs. 0.9 3 (0.74– .56 0 3590 →RT vs. Surgery + post-op concurrent (II–IIIA) 38 1.18) 3 RT + cis/etoposide 3% months AL Surgery 603 1% 606 5 R N 6 0.9 (0.8– .59 0 PI (I–IIIA) alone vs. Surgery + post-op mitomycin/vindesin e/cisplatin 3% 4 1.1) Big Surgery 189 33 months 1.0 2 (0.77– .90 1.35) 0 Lung Trial alone vs.

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Non-Small Cell Lung Cancer NSCLC Stages I and II Surgery In patients with NSCLC stages IA, IB, IIA and IIB (Table 85-2) who can tolerate operation, the treatment of choice is pulmonary resection. If a complete resection is possible, the 5-year survival rate for N0 disease is about 60–80%, depending on the size of the tumor. The 5-year survival drops to about 50% when N1 (hilar node involvement) disease is present. The extent of resection is a matter of surgical judgment based on findings at exploration.

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Management of Occult and Stage 0 Carcinomas In the uncommon situation where malignant cells are identified in a sputum or bronchial washing specimen but the chest radiograph appears normal (TX tumor stage), the lesion must be localized. More than 90% can be localized by meticulous examination of the bronchial tree with a fiberoptic bronchoscope under general anesthesia and collection of a series of differential brushings and biopsies. Often, carcinoma in situ or multicentric lesions are found in these patients.

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Staging of Small Cell Lung Cancer Pretreatment staging for patients with SCLC includes the initial general lung cancer evaluation with chest and abdominal CT scans (because of the high frequency of hepatic and adrenal involvement) as well as fiberoptic bronchoscopy with washings and biopsies to determine the tumor extent before therapy; brain CT scan (10% of patients have metastases); and radionuclide scans (bone) if symptoms or other findings suggest disease involvement in these areas.

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Chest radiographs and CT scans are needed to evaluate tumor size and nodal involvement; old radiographs are useful for comparison. CT scans of the thorax and upper abdomen are of use in the preoperative staging of NSCLC to detect mediastinal nodes and pleural extension and occult abdominal disease (e.g., liver, adrenal), and in planning curative radiation therapy. However, mediastinal nodal involvement should be documented histologically if the findings will influence therapeutic decisions.

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Small Cell Lung Cancer A simple two-stage system is used. In this system, limited-stage disease (seen in about 30% of all patients with SCLC) is defined as disease confined to one hemithorax and regional lymph nodes (including mediastinal, contralateral hilar, and usually ipsilateral supraclavicular nodes), while extensive-stage disease (seen in about 70% of patients) is defined as disease exceeding those boundaries. Clinical studies such as physical examination, x-rays, CT and bone scans, and bone marrow examination are used in staging.

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Table 85-2 Tumor, Node, Metastasis International Staging System for Lung Cancer 5-Year Survival Rate, % Stage TNM Descriptors Stage Clinical SurgicalPathologic Stage IA T1 N0 M0 61 67 IB T2 N0 M0 38 57 IIA T1 N1 M0 34 55 IIB T2 N1 M0 24 39 IIB T3 N0 M0 22 38 IIIA T3 N1 M0 9 25 T1–2–3 M0 N2 13 23 IIIB M0 T4 N0–1–2 7

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Clinical Manifestations Lung cancer gives rise to signs and symptoms caused by local tumor growth, invasion or obstruction of adjacent structures, growth in regional nodes through lymphatic spread, growth in distant metastatic sites after hematogenous dissemination, and remote effects of tumor products (paraneoplastic syndromes) (Chaps. 96 and 97). Although 5–15% of patients with lung cancer are identified while they are asymptomatic, usually as a result of a routine chest radiograph or through the use of screening CT scans, most patients present with some sign or symptom.

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Diagnosis and Staging Screening Most patients with lung cancer present with advanced disease, raising the question of whether screening would detect these tumors at an earlier stage when they are theoretically more curable. The role of screening high-risk patients (for example current or former smokers 50 years of age) for early stage lung cancers is debated.

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Inherited Predisposition to Lung Cancer While an inherited predisposition to develop lung cancer is not common, several features suggest a potential for familial association. People with inherited mutations in RB (patients with retinoblastomas living to adulthood) and p53 (LiFraumeni syndrome) genes may develop lung cancer. First-degree relatives of lung cancer probands have a two- to threefold excess risk of lung cancer or other cancers, many of which are not smoking-related.

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Major treatment decisions are made on the basis of whether a tumor is classified as a small cell lung carcinoma (SCLC) or as one of the non-small cell lung cancer (NSCLC) varieties (squamous, adenocarcinoma, large cell carcinoma, bronchioloalveolar carcinoma, and mixed versions of these).

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Harrison's Internal Medicine Chapter 85. Neoplasms of the Lung The Magnitude of the Problem In 2007, primary carcinoma of the lung affected 114,760 males and 98,620 females in the United States; 86% die within 5 years of diagnosis, making it the leading cause of cancer death in both men and women. The incidence of lung cancer peaks between ages 55 and 65 years. Lung cancer accounts for 29% of all cancer deaths (31% in men, 26% in women). Lung cancer is responsible for more deaths in the United States each year than breast cancer, colon cancer, and prostate cancer combined;...

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