Bronchogenic carcinoma

Bronchogenic Carcinoma

Bronchogenic CarcinomaFOYEZ AHMED HASANBATCH : K-68

Global situation30,000 new cases of lung cancer per year in England (6,000 in Scotland)Commonest cause of cancer death (33%) in menCommonest cause of cancer death in women in Scotland (20%)90% mortality 1 year after diagnosisThe most rapidly increasing cancer in developing countries

classsificationPrimaryBenign (rare)Hamartoma Squamous papillomatosisPleomorphic adenomaBronchial carcinoid

Malignant (very common)

Metastatic (Very common)

Risk factors Tobacco smoke- active or passiveAsbestosNickelChromatesCadmiumRadiation Atmospheric pollution(genetics)

The most simple classification of lung cancer:Based on the characteristics of the disease and its response to treatment - Small cell lung cancer (SCLC) Non-small cell lung cancer (NSCLC)

Squamous or epidermoid carcinoma The commonest type, Accounting for approximately 40% of all carcinomas. Most present as obstructive lesions of the bronchus leading to infection. Occasionally cavitates (10%) at presentation. The cells are usually well differentiated Occasionally anaplastic. Local spread is common Widespread metastases occur relatively late.

Squamous carcinoma (keratinising)

Adenocarcinoma Arises from mucous cells in the bronchial epithelium.

Invasion of the pleura and the mediastinal lymph nodes is common, as are metastases to the brain and bones.

Accounts for approximately 10% of all bronchial carcinomas.

The most common bronchial carcinoma associ ated with asbestos

Proportionally more common in Non-smokersWomen Elderly Far East.

Adenocarcinoma (gland forming)

Adenocarcinoma with mucin (blue stained)

Large cell carcinomasLess-differentiated forms of squamous cell and adenocarcinomas. Account for about 25% of all lung cancers Metastasize early.

Large cell carcinoma

Small-cell carcinomaOften called oat-cell carcinoma, Accounts for 20-30% of all lung cancers. Arises from endocrine cells(Kulchitsky cells). Small-cell carcinoma spreads early and is almost always inoperable at presentation.Rapidly growing and highly malignant. Responds to chemotherapy Prognosis remains poor

Small cell carcinoma

Clinical features

Lung cancer presents in many different ways, reflecting local, metastatic or paraneoplastic tumour effects. Cough: This is the most common early symptom. It is often dry but secondary infection may cause purulent sputum Haemoptysis Haemoptysis is common, especially with central bronchial tumours.

Clinical features

Clinical featuresBronchial obstructionComplete obstruction causes collapse of a lobe or lungBreathlessnessmediastinal displacementdullness to percussion reduced breath sounds. Partial bronchial obstruction may causemonophonic, unilateral wheeze that fails to clear

Clinical features with coughing & impair the drainage of secretions to cause pneumonia or lung abscess Pneumonia that recurs at the same site or responds slowly to treatment, particularly in a smoker, should always suggest an underlying bronchial carcinoma. Stridor (a harsh inspiratory noise) occurs when the larynx, trachea or a main bronchus is narrowed by the primary tumour or by compression from malignant enlargement of the subcarinal and paratracheal lymph nodes.

Clinical featuresBreathlessness.Breathlessness may be caused by collapse or pneumoniatumour causing a large pleural effusion or compressing a phrenic nerve and leading to diaphragmatic paralysis. Pain and nerve entrapment. Pleural pain usually indicates malignant pleural invasionIntercostal nerve involvement causes pain in the distribution of a thoracic dermatome.

Clinical featuresCarcinoma in the lung apex may cause Horners syndrome (ipsilateral partial ptosis, enophthalmos, miosis and hypohidrosis of the face) due to involvement of the sympathetic chain at or above the stellate ganglion. Pancoasts syndrome (pain in the inner aspect of the arm, sometimes with small muscle wasting in the hand) indicates malignant destruction of the T1 and C8 roots in the lower part of the brachial plexus by an apical lung tumour.

Clinical featuresMediastinal spread

Dysphagia (Involvement of the oesophagus )Arrhythmia or pericardial effusion (If the pericardium is invaded)Superior vena cava obstruction by malignant nodes causes suffusion and swelling of the neck and face, conjunctival oedema headache dilated veins on the chest wall

Clinical featuresInvolvement of the left recurrent laryngeal nerve by tumours at the left hilum causes vocal cord paralysis, voice alteration and a bovine cough (lacking the normal explosive character). Supraclavicular lymph nodes may be palpably enlarged or identified using ultrasound

Clinical featuresMetastatic spreadfocal neurological defects epileptic seizures personality changeJaundicebone pain skin nodulesLassitude, anorexia and weight loss usually indicate metastatic spread.

Clinical featuresFinger clubbing Overgrowth of the soft tissue of the terminal phalanxincreased nail curvature nail bed fluctuationHypertrophic pulmonary osteoarthropathy (HPOA)painful periostitis of the distal tibia, fibula,radius and ulnalocal tendernesssometimes pitting oedema over the anterior shin. X-rays reveal subperiosteal new bone formation.

Clinical features

PANCOAST TUMOR

Pancoast syndrome

Physical ExaminationGeneral Examination :Appearance: ill looking, may be grossly emaciatedNutrition: below averageAnaemia: moderately anemicClubbing: generalized clubbing involving all the fingers an toes (HPOA present/not)Cyanosis,jaundice,edema: absentKoilonychia,leukonychia: absentLymphadenopathy:Rt supraclavicular lymph node are enlarged,hard in consistency,non tender,fixed with underlying structure and overlying skinBony tenderness:Skin condition:

Physical Examination Systemic Examination :Respiratory system examination:Evidence of pneumonia, pleural effusion, lung abscess.CVS:Arrythmia, pericardial effusionNervous system examination:Higher psychic function: confusion, fitsCranial nerves: focal neurological signs, papilloedemaMotor functions: hemiplegiaSensory functions: mono/polyneuropathyCerebellar dysfunctionMusculoskeletal system examination: Proximal myopathy, dermatomyositis

Expanded Clinical Evaluation Symptoms Elicited in History:Constitutionalweight loss greater than 10 lb Musculoskeletalfocal skeletal pain Neurologic-headaches, syncope, seizures, extremity weakness, recent change in mental status Signs Found on Physical Examination: Lymphadenopathy (>1 cm) Hoarseness, superior vena cava syndrome Bone tenderness Hepatomegaly (>13-cm span)Focal neurologic signs, papilledema Soft tissue mass

INVESTIGATIONS

INVESTIGATIONS

INVESTIGATIONS

InvestigationsRoutine Laboratory Tests : CBC with PBF: Hematocrit less than 40% in males Hematocrit less than 35% in femalesLFT: Elevated alkaline phosphatase, GGT, AST, calcium AST, aspartate aminotransferase ; GGT, - glutamyl transpeptidase.Imaging: CxR PA view: The features of bronchial carcinoma on plain X-rays are variable: CT is usually performed early, as it may reveal mediastinal or metastatic spread, and helps to direct histological sampling procedures. also indicates whether a tumour is likely to be accessible by bronchoscopy.

InvestigationsUSG: evidence of tumour spread to sites. Pleural biopsy: Pleural fluid aspiration and biopsy is the preferred investigation FNAC:lymph node biopsy: to give histology Bronchoscopy: to give histology and operabilityWhere facilities exist, thoracoscopy increases yield by allowing targeted biopsies under direct vision.bone marrow biopsy: evidence of tumour spread to sites.Combined CT and PET imaging is used increasingly to detect metabolically active tumour metastases Radioneuclide bone scanning: if suspected metastasisLung function tests:

Radiological Clues to Suspect Malignancy

1. Mass lesion or coin shadow..fig 12. Mediastinal widening due to enlargement oflymph nodes fig 53. Rib erosion and rib fracture.fig 34. Phrenic nerve paralysis in the presence ofmediastinal mass5. Presence of pleural effusion.fig 66. Cannon ball shadows.fig 4

Large cavitated bronchial carcinoma in left lower lobe..fig:1

Collapse of the right lung: Fig2

Bronchogenic carcinoma. Left upper/zoneconsolidation due to tumor and collapse. Rib erosion (arrow)suggests malignant lesionbronchogenic carcinoma.Fig 3

Pulmonary metastases. Bilateral cannon ballshadowscommon primaries thyroid, bone and viscera..FIG :4

Lymphoma. Note: The bilateral paratracheal lym-phadenopathy (arrowheads) is a common cause of mediastinalsyndrome..Fig: 5

Pleural effusion right. Note: Hazy opacity occupying the right lower part, rising in the axilla (long arrow 1). The costo-phrenic (short arrow 2) and cardiophrenic angle (arrowhead 3) are obliterated in massive effusions, mediastinum is displaced to the opposite sidefig 6

Common radiological presentations of bronchial carcinoma1. Unilateral hilar enlargement: Central tumour. Hilar glandular involvement. However, a peripheral tumour in the apical segment of a lower lobe can look like an enlarged hilar shadow on the PA X-ray

2. Peripheral pulmonary opacity: Usually irregular but well circumscribed, and may contain irregular cavitation. Can be very large

3. Lung, lobe or segmental collapse: Usually caused by tumour within the bronchus leading to occlusion. Lung collapse may be due to compression of the main bronchus by enlarged lymph glands 4. Pleural effusion: Usually indicates tumour invasion of pleural space; very rarely, a manifestation of infection in collapsed lung tissue distal to a bronchial carcinoma

Common radiological presentations of bronchial carcinomaBroadening of mediastinum, enlarged cardiac shadow, elevation of a hemidiaphragmParatracheal lymphadenopathy may cause widening of the upper mediastinum. A malignant pericardial effusion will cause enlargement of the cardiac shadow.Raised hemidiaphragm is caused by phrenic nerve palsy, screening will show it to move paradoxically upwards when patient sniffs

8. Rib destruction: Direct invasion of the chest wall or blood-borne metastatic spread can cause osteolytic lesions of the ribs

Lung cancer in right lung(CTofthorax)

Lung cancer in right lung(Positronemissiontomographyshowingincreaseduptakeintumour.)

Lung cancer in right lung(Lungcancerseenthroughabronchoscope(arrow))

Lungcancerseenthroughabronchoscope

Surgical treatment

Surgery isperformed in early stage non-small cell lung cancer (stage I, II and in selected IIIA)with curative intent.Many patients with stage III disease are treated with chemo-radiationwitha view to downstaging disease and render it amenable to surgical resection

Surgical treatment

Accurate pre-operative staging, coupled with improve-ments in surgical and post-operative care now offers 5-year survival rates of over 75% in stage I disease (NO, tumour confined within visceral pleura) 55% in stage II diseasewhich includes resection in patients with ipsilateral peribronchial or hilar node involvement.

Radiotherapy For curepatients who are fit and who have a slowly growing squamous carcinoma,treatment of choice if surgery is declined.For symptomatic reliefBone painHaemoptysisSuperior vena cava obstruction

Chemotherapy

Mainly for SCLC, less effective for NSCLC.Combination chemotherapy i.v. Cyclophosphamide Doxorubicin Vincristine or i.v. cisplatinEtoposide

TREATMENT

TREATMENT

TREATMENT

TREATMENT

Contraindication of surgery

RADIOTHERAPY Indications:

ROLE OF CHEMOTHERAPY

prognosis