In the US, Lung Cancer Kills More People Than Breast Cancer, Colon Cancer, and Prostate Cancer Combined.

For the last few decades, survival for other cancers have significantly improved, and in just the last few years, screening and new treatments have finally started to improve survival rates for lung cancer.

The American Cancer Society’s estimates for lung cancer in the United States for 2019 are:

• About 228,150 new cancer cases diagnosed
• About 142,670 deaths from lung cancer

Overall, the chance that a man will develop lung cancer in his lifetime is about 1 in 15; for a woman, the risk is about 1 in 17. Black men are about 20% more likely to develop lung cancer than white men. The rate is about 10% lower in black women than in white women.

Both black and white women have lower rates than men, but the gap is closing. The lung cancer rate has been dropping among men over the past few decades, but only for about the last decade in women.

The Rate of Esophageal Cancer Continues to Increase in Western Countries Due to the Epidemic of Gastro-Esophageal Reflux Disease.

The esophagus links the mouth to the stomach, forming an important part of the body’s digestive system. Although esophageal cancers make up a small percentage of all cancers diagnosed annually, one form, esophageal adenocarcinoma, is increasing at a faster annual rate than any other cancer. It is diagnosed most frequently in an advanced state.

Causes

It is not clear what causes esophageal cancer. It is known that esophageal cancer occurs when cells in your esophagus develop errors (mutations) in their DNA. The errors make cells grow and divide out of control. The accumulating abnormal cells form a tumor in the esophagus that can grow to invade nearby structures and spread to other parts of the body.

Types of Esophageal Cancer

What is the mediastinum?

The mediastinal is surrounded by the middle part of the chest, defined by the breastbone in front, the spine in back, and the lungs on each side. The mediastinal contains the heart, aorta, esophagus, thymus and trachea. It is divided into 3 parts: the anterior (front), middle, and posterior section (back):

Aneterior Mediastinum

• Thymoma: The most common anterior mass is a thymoma. There are different types of thymomas. They are generally seen on CT as a round, encapsulated mass, and rarely recur. The larger irregular masses, malignant thymic carcinomas are much more aggressive and have a much worse prognosis.
• Lymphoma: is a cancer that arises in cancer-fighting cells called lymphocytes. Lymphoma usually starts in lymph nodes, the spleen or the bone marrow. Infrequently, lymphoma starts in the anterior mediastinum. There are 2 categories of lymphoma: Hodgkin’s disease and non-Hodgkin’s lymphoma.
• Germ cell: A rare mediastinal mass is a germ cell a tumor. They are very rare. They are usually benign (60 to 70%) and are found in both males and females.
• Thyroid mass: substernal goiter remains a significant consideration in the differential diagnosis of mediastinal masses, particularly those located in the anterior mediastinum. Substernal goiter is generally defined as a thyroid mass that has 50% or more of its volume located below the thoracic inlet.

Middle Mediastinum

• Bronchogenic cyst: Bronchogenic cysts are congenital in nature. They are part of a spectrum of congenital abnormalities of the lung, including pulmonary sequestration, congenital cystic adenomatoid malformation, and congenital lobar hyperinflation (emphysema)
• Pericardial cyst: Pericardial cysts are an uncommon benign congenital anomaly in the middle mediastinum. They represent 6% of mediastinal masses, and 33% of mediastinal cysts.

Posterior Mediastinum

Neurogenic tumor: The most common cause posterior mediastinal tumors arise from nerves. They are usually benign, especially in adults. They are usually on the side of the backbone.

In general, mediastinal tumors are rare. They occur in patients aged 30 to 50 years. In children, tumors are most often found in the posterior (back) mediastinum, arising from the nerves. These mediastinal tumors are typically benign (not cancer).

Most are found when a chest x-ray is performed for another reason.

• Cough
• Shortness of breath
• Wheezing
• Chest pain or fullness
• Fever
• Chills
• Night sweats
• Coughing up blood
• Hoarseness
• Weight loss

The tests most commonly used to diagnose and evaluate a mediastinal tumor include:

• Blood Tests:
  • Alpha feto protein (AFP), beta HCG, LDH
• Tissue Biopsy
  • CT-guided needle biopsy: may make the diagnosis
  • Mediastinoscopy: provides a sample of the tissue for the middle mediastinum. Does not help with posterior or anterior mediastinum. This is an out patient procedure under general anesthesia done through a 1-inch incision in the neck.
  • Anterior mediastinotomy (Chamberlain procedure): Just beside the sternum, an incision is made in the chest to get a piece of tissue from the mass.
  • EBUS (EndoBronchial UltraSound): is an outpatient procedure done without incisions. The tissue is obtained with a needle aspiration so only a small amount of tissue can be obtained so often enough tissue in not obtained through with a procedure.
  • The choice of test for diagnosis depends on the appearance on the CT scan. If an anterior mediastinal mass looks like a thymoma, the mass is usually resected if it does not look to be invading surrounding body parts. If an anterior mediastinal mass looks like lymphoma, the biopsy approach is mediastinoscopy (if nodes look involved) or anterior mediastinotomy if there is an anterior mediastinal mass and if the nodes look normal.

Staging

Modified Masaoka clinical staging of thymoma

Stage Definition

• I Macroscopically and microscopically completely encapsulated
• IIA Microscopic trans capsular invasion
• IIB Macroscopic invasion into surrounding fatty tissue or grossly adherent to but not through mediastinal pleura or pericardium
• III Macroscopic invasion into neighboring organs (ie, pericardium, great vessels, or lung)
• IVA Pleural or pericardial dissemination
• IVB Lymphogenous or hematogenous metastasis
• WHO histologic classification

Diaphragmatic plication, a surgical procedure that sews the diaphragm down so it does not compress the lung. It does not help the diaphragm work; it just gets it out of the way.

• If the patient is not showing symptoms, or the symptoms are mild, and the patient is in otherwise good health, no treatment beyond temporary ventilator support may be necessary

Diaphragm pacemakers may be used in patients who have no phrenic nerve injury but may not be appropriate for patients with ALS or muscular dystrophy. The devices may result in improved respiratory function and lower infection rates

• Thoracoscopic diaphragm plication may be an option for some patients, resulting in a shorter hospital stays than other techniques
• In severe cases of bilateral diaphragmatic paralysis, patients may need to be placed permanently on ventilator support which can include treatment with a portable ventilator.
• Patients who are diagnosed following a sudden onset of symptoms, may have an underlying respiratory condition that benefits from treatment with antiviral medications
• Prophylactic plication or phrenic nerve repair or grafting may return function to the phrenic nerve
• A tracheostomy, the surgical formation of an opening in the trachea, helps allow the passage of air. This approach is commonly used for patients with a life threatening disease or a diagnosis of high quadriplegia