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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2935_Библиотеки_им_академика_М_И_Перельмана
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Lung Malignancy96
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6. MANAGEMENT
Mesothelioma is considered incurable. Curative-intent multi-modality treat-
•
ment is no longer carried out as the results of clinical trials did not demonstrate a clear benefit and was associated with significant treatment-related
harm.
Treatment decisions should be made through a specialist mesothelioma
•
MDT (usually regional based).
Some patients may be offered palliative surgery (extra-pleural decortication).
•
e results of a UK-based clinical trial of this form of treatment are awaited.
Fitter patients may be offered SACT (chemotherapy or immunotherapy), or
•
may be entered into clinical trial.
For malignant effusions, drainage, and talc pleurodesis can be effective. Per-
•
formed by thoracoscopy or instillation of talc slurry via a closed chest tube.
• A long term in-dwelling pleural catheter can be inserted if repeated
drainage of a pleural infusion is needed (see Chapter 6)
Palliative care and symptomatic relief:
•
• Opiates, home oxygen and anxiolytics can have a role in parallel to
other palliative and symptomatic control measures described above.
7. PROGNOSIS
is is a highly lethal malignancy-median survival is 10 - 15 months.
•
• Only 51- 0% of patients survive to 5 years.
Outlook is better in patients without mediastinal involvement and with
•
epithelioid histology.
5.3 SECONDARY SPREAD OF SYSTEMIC
MALIGNANCY TO LUNG AND PLEURA
1. AETIOLOGY
Metastases to the lung from distant sites are common; most cancers have the
•
ability to spread to the lung.
e usual sites for the primary tumour are:
•
• Kidney
• Prostate
• Bone
• Breast
• Gastrointestinal (GI) tract
• Cervix
Respiratory Medicine
• Ovary
• yroid.
5.4 Mediastinal Masses
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Metastases usually occur in the parenchyma of the lung and can be relatively
•
asymptomatic even with extensive disease.
Lymphangitis carcinomatosa:
•
• An inflammation of the lymphatics secondary to malignancy which can
cause progressive breathlessness.
• Lymphangitis carcinomatosa is usually due to secondary spread from
stomach, pancreas or breast.
2. MANAGEMENT
Treatment options taken are dependent on the site, type and extent of the
•
primary tumour as well as the extent of the lung secondary.
• If the secondary is an isolated early metastases, surgical intervention
with curative intent can sometimes be performed.
• Choice of chemotherapy, hormonal therapy or novel drugs depends on
the histology and site of the primary tumour.
5.4 MEDIASTINAL MASSES
1. LYMPHOMA
Can either represent disease isolated to mediastinum or as part of a more dif-
•
fuse disease process:
• Hodgkin’s lymphoma.
• Diffuse large B-cell lymphoma.
• Lymphoblastic leukaemia/lymphocytic lymphoma.
• Mucosal-associated lymphoid tissue (MALT) lymphoma.
50% of patients with disease limited to the thorax will be symptomless.
•
2. THYMOMA
97
A primary pulmonary thymoma is a tumour originating from thymic tissue
•
that presents in the lung of a patient with a normal thymus gland.
Usually asymptomatic and often discovered as an incidental radiological
•
anomaly.
Patients may present with symptoms of myasthenia gravis and all should be
•
screened for this.
Relatively rare, they have no distinctive radiological features and immunohis-
•
tochemistry studies are used for diagnosis.
Surgical resection is usually curative unless the tumour is very extensive.
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Prognosis can be very good and is dependent upon complete resection and
•
presence of local invasion.
Post thymectomy, patients seem to be at increased risk of developing separate
•
cancers, most commonly colorectal cancer.
Respiratory Medicine
Lung Malignancy98
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3. EXTRAGONADAL GERM CELL TUMOURS (GCT)
Mediastinal tumour of germ cell origin.
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ere is an absence of primary disease within the testes or ovaries.
•
Tumours are present in the midline and can be distributed in the following
•
regions:
• Retroperitoneum
• Anterior mediastinal space
• Pineal gland
• Suprasellar cistern.
Benign mature teratomas are the most common mediastinal GCT (%> 50 )
•
and tend to occur in adolescents.
• ough benign, surgical excision is offered as they can transform to
aggressive sarcomas and carcinomas.
Seminomas are the most common malignant GCT and occur mainly in males.
•
• Associated with elevated serum beta human chorionic gonadotrophin
(bHCG) but not alpha fetoprotein (AFP).
• Often has spread to lymph nodes and distant sites at presentation.
• Usually very responsive to chemotherapy (>90% 5-year survival without
extra-pulmonary distal metastases).
• Malignant non-seminomatous GCTs include choriocarcinoma, egg
yolk tumour and embryonal carcinoma.
• ey are likely to secrete serum (AFP).
• Treatment is often multimodality with prognosis at 5 years being poor
compared to seminomas.
4. OTHER MEDIASTINAL MASSES
ymic cancer.
•
Retrosternal extension of thyroid mass.
•
Cystic masses including:
•
• Bronchogenic
• Upper gastrointestinal
• Pericardial.
Neurogenic tumours:
•
• Schwannomas
• Ganglioneuromas.
Respiratory Medicine
6
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Pleural Disease
6.1 PNEUMOTHORAX
1. DEFINITION
A pneumothorax is an accumulation of air in the pleural space.
•
• Primary spontaneous pneumothorax (PSP): A pneumothorax occur-
ring in the presence apparently normal lungs.
• Secondary spontaneous pneumothorax (SSP): A pneumothorax
occurring in the presence of pre-existing underlying lung disease.
Tension pneumothorax: Occurs when air is drawn in to the pleural space
•
on inspiration but has no means of escape on expiration.
• e increase in volume pushes the mediastinum into the contralateral
hemithorax.
• is leads to circulatory collapse and potential cardiorespiratory arrest.
2. EPIDEMIOLOGY
Hospital admission rates for both PSP and SSP combined:
•
• Men: 16.7/100000.
• Women: 5.8/100000.
Mortality rates:
•
• Men: 1.26/million.
• Women: 0.62/million.
MICRO-references
Gupta etal. Epidemiology of pneumothorax in England. Thorax 2000;
55 (8): 666–671
3. AETIOLOGY AND RISK FACTORS
Primary:
•
• Smoking tobacco and other illicit drugs (e.g. cannabis).
• Tall, thin young males.
DOI: 10.1201/9781315113937-7
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• Inherited disorders of collagen e.g. Marfan’s syndrome.
• Some cases of PSP will be found to have evidence of small apical bullae
if investigated with CT scan, even if no definite underlying lung disease
is present.
Secondary:
•
• Often occurs due to rupture of emphysematous bullae in COPD.
• Cystic lung disease e.g. Langerhans cell histiocytosis, pulmonary
lymphangioleiomyomatosis (LAM).
• Cystic fibrosis.
• Pneumocystis jirovecii pneumonia.
Traumatic:
•
• Follows penetrating chest trauma.
Iatrogenic:
•
• Mechanical ventilation
• Cardiac pacemaker implantation
• Central line placement
• Lung biopsy.
Female gender:
•
• Pulmonary ectopic endometriosis can cause rupture of a pleural bleb at
time of menstruation (catamenial pneumothorax).
• LAM is a rare condition characterised by abnormal smooth muscle
proliferation leading to pneumothoraces and chylous effusions.
4. PATHOPHYSIOLOGY
A communication is formed between an alveolus and the pleural space, or
•
between the atmosphere and the pleural space.
• is could be due to the rupture of a “bleb” or a penetrating chest
injury.
Gases flow along a pressure gradient into the pleural space.
•
• Alveolar pressure > intrapleural pressure.
• Atmospheric pressure > intrapleural pressure.
is flow continues until the pressure gradient no longer exists or the com-
•
munication is sealed.
As a result of the accumulation of air in the pleural space, the lung reduces in
•
volume.
Respiratory Medicine
6.1 Pneumothorax
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5. CLINICAL FEATURES
Symptoms:
•
• Sudden onset chest pain (often pleuritic).
• Shortness of breath.
Signs:
•
• Tachycardia.
• If the pneumothorax is large enough:
– Reduced chest expansion.
– Hyper-resonant upon percussion of the affected side.
– Quiet breath sounds on auscultation.
• Hamman’s sign: “Click” on auscultation in time with heart sounds.
Occurs in left sided pneumothorax.
• Tension pneumothorax:
– Deviation of the trachea towards contralateral hemithorax.
– Displaced apex beat.
– Pulsus paradoxus: accentuated fall of systolic blood pressure with
inspiration.
– In latter stages: signs of poor cardiac output due to reduced venous
return.
6. INVESTIGATIONS
Chest X-ray (CXR)
•
• Diagnostic in most cases, but look carefully around the periphery of the
lung; always check the contralateral side because bilateral pneumothorax can occur (see Figures 6.1 and 6.2).
• Features:
– Visible lung edge against absent peripheral lung markings
(See Figure 6.1).
– May be difficult to visualise on supine films.
– To measure size, estimate the horizontal distance between lung edge
and chest wall at level of hilum.
– A common mistake is to spot a “hilar mass” which is the completely
collapsed lung.
101
Respiratory Medicine
Pleural Disease102
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Figure 6.1 CXR of patient with a pneumothorax; the right lung field is radiolucent with a
visible lung marking near the right heart border and no lung markings peripherally to this.
Respiratory Medicine
Figure 6.2 CXR of patient with pneumothorax; the right lung is partially collapsed and
a chest drain has been inserted to treat the pneumothorax.
6.1 Pneumothorax
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• Tension pneumothorax:
– Deviation of trachea and mediastinum to the contralateral side.
◯
N.B. under normal circumstances a CXR should NEVER be
performed if a tension pneumothorax is suspected, as this is a
respiratory emergency.
Ultrasound can detect even small pneumothoraces in skilled and experi-
•
enced hands.
Arterial blood gas (ABG)
•
• Hypoxia.
• Hypercapnia: may be present in secondary pneumothorax if it triggers
decompensation of the pre-existing lung disease or in the late stages of
tension pneumothorax development.
Computed tomography (CT) thorax
•
• Can be used to differentiate pneumothorax from bullous disease.
• Use to search for underlying lung disease.
7. DIFFERENTIAL DIAGNOSIS (OF PRESENTING SYMPTOMS)
Pleural effusion.
•
Pulmonary embolus.
•
Pleuritic chest pain from other causes e.g. pneumonia.
•
8. MANAGEMENT
Depends on the presence or absence of symptoms, patient preference,
•
whether the pneumothorax is of sufficient size to intervene safely, and
whether it is primary or secondary.
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Pleural Disease104
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Figure 6.3 Management of pneumothorax.
Respiratory Medicine
6.1 Pneumothorax
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MICRO-references
Flowcharts adapted from the British Thoracic Society Pleural Disease
Guidelines 2023, available at:
https://www.brit-thoracic.org.uk/quality-improvement/guidelines/
pleural-disease/
e British oracic Society has produced guidelines, updated in 2023.
•
ese are shown in Figure 6.3.
For individuals with persistent air leak at 3–5 days, consider referral for
•
definitive closure of air leak.
Surgical management of spontaneous pneumothorax is usually undertaken
•
via VATS and might include bullectomy, wedge excision of the part of the
lung causing the air leak, as well as pleurectomy/pleural abrasion and talc
insufflation to affect a permanent pleurodesis.
Elective surgical management may be considered for a first episode of
•
pneumothorax if in a high-risk occupation (e.g. airline pilot) or for tension
pneumothorax at the first episode.
Elective surgical management may also be considered for patients with a
•
second ipsilateral or first contralateral pneumothorax.
Pleurodesis:
•
• Introduction of chemicals into the pleural space, used in the treatment
of recurrent pneumothoraces.
• Chemicals used include talc (most common), bleomycin, tetracycline
and povidone iodine. A patient’s own blood can also be used (“blood
patch”).
• For pneumothorax, chemical pleurodesis is usually reserved for
individuals not suitable for surgery.
Consider definitive surgical management in individuals presenting with
•
a second pneumothorax.
For the management of tension pneumothorax, see Chapter 16: Respiratory
•
Emergencies.
105
Respiratory Medicine
MICRO-facts
Chest Drain Indications and Insertion
Indications:
Pneumothorax in a ventilated patient.
•
Tension pneumothorax.
•
PSP not resolving with needle aspiration.
•
continued…
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