Chapter 19: Chest Wall, Lung, Mediastinum, and Pleura

KEY POINTS

1. Historically, non-small cell cancer (NSCLC) subtypes were considered to be a uniform group based on limited understanding of the distinct clinical behaviors of the subtypes as well as the fact that there were few treatment options available. With increasing understanding of the molecular biology underlying these tumor subtypes, however, the approach to diagnosis and management and the terminology used in describing these tumors are evolving rapidly. In particular, the evaluation and management of adenocarcinoma of the lung has shifted dramatically and firm establishment of NSCLC cell type prior to chemotherapy for advanced stage lung cancer is essential.

2. A multidisciplinary approach to evaluation of NSCLC, with standardized criteria and terminology for diagnosis in cytologic and small biopsy specimens, and routine molecular testing for known mutations, such as EGFR mutations and EML4-ALK fusion oncogenes is now recommended for the evaluation and management of lung nodules due to major advances in targeted therapy. Adequate tissue acquisition at the time of diagnostic workup is critical and facilitates patient care while minimizing the number of procedures to which the patient is subjected.

3. The terms bronchioloalveolar carcinoma and mixed subtype adenocarcinoma have been eliminated from the classification of lung adenocarcinoma as a result of increased understanding of important clinical, radiologic, pathologic, and genetic differences between mucinous and nonmucinous adenocarcinomas, The new classification system delineated a stepwise pathologic progression, from AAH to invasive adenocarcinoma based on the predominant histologic growth patterns.

4. Lung cancer continues to be a highly lethal and extremely common cancer, with 5-year survival of 16%. Lung cancer incidence is second only to the incidence of prostate cancer in men and breast cancer in women. Squamous cell carcinoma and adenocarcinoma of the lung are the most common subtypes and are rarely found in the absence of a smoking history. Nonsmokers who live with smokers have a 24% increased risk of lung cancer compared to nonsmokers who do not live with smokers.

5. Navigational bronchoscopy is a valuable new tool that can be used to obtain tissue diagnosis for intraparenchymal lesions or small, peripherally located lesions that have historically been difficult to biopsy with transbronchial or transthoracic approaches. It is also a useful tool for tattooing the lung lesion for subsequent operative resection and for placement of fiducial markers for stereotactic body radiation. This technique should become part of the surgeon’s armamentarium for the diagnosis and treatment of lung cancer.

6. Impaired exchange of carbon monoxide is associated with a significant increase in the risk of postoperative pulmonary complications, independent of the patient’s smoking history. In patients undergoing pulmonary resection, the risk of any pulmonary complication increases by 42% for every 10% decline in the percent carbon monoxide diffusion capacity (%Dlco), and this measure may be a useful parameter in risk stratification of patients for surgery.

7. Maximum oxygen consumption (V.o2 max) values provide important additional information in those patients with severely impaired Dlco and forced expiratory volume in 1 second. Values of <10 mL/kg per minute generally prohibit ...