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Bronchial Carcinoma

Ñ    Bronchial Carcinoma

Definition

Ñ    Carcinoma

Arising from

Ñ    Bronchial epithelium

Pathogenesis

Risk Factors

Ñ    Cigarette smoke:

Active

Passive

Ñ    Occupational exposure:

Asbestos

Arsenic

Chromium

Iron oxide

Petroleum products

Coal and its products

Radiation

Histopathology

Ñ    Non-small cell carcinoma:

·          Squamous carcinoma:

Most common

·          Large cell carcinoma

·          Adenocarcinoma

·          Alveolar cell carcinoma:

Commonly arises within an area of lung that has been previously damaged

Ñ    Small-cell carcinoma:

Secretes hormones

Pathological process

Growth

Ñ    Growth begins in an area of cytological atypia

The tumour grows to form:

Ñ    Intraluminal mass

Ñ    Peribronchial infiltrate

Ñ    Intraparenchymal mass

Spread

The tumour spreads and causes:

Ñ    Local invasion:

Adjacent structures

Ñ    Lymphatic spread:

Local and regional lymph nodes

Ñ    Haematogenous spread

Commonly to:

·           Adrenal

·           Liver

·           Brain

·           Bone

These tumours may also cause:

Non-metastatic manifestations

Ñ    Non-metastatic manifestations most frequently complicate small cell carcinoma

Ñ    Mediators:

Hormones

Peptides

Prostaglandins

Antibodies

Cytokines

Clinical Features

History

E&M

Ñ    Weight loss

Ñ    Malaise

RS

Ñ    Cough

Ñ    Bronchorrhoea:

Copious amounts of clear, watery sputum:

·          Alveolar cell carcinoma

Ñ    Haemoptysis

Ñ    Chest pain

Ñ    Breathlessness

Ñ    Hoarseness

Examination

E&M

Ñ    Loss of weight

Ñ    Adrenal metastases

Ñ    Ectopic ACTH

Ñ    SIADH

Ñ    Thyrotoxicosis

Ñ    Hypoglycaemia

IS

Ñ    Clubbing:

Most frequent with squamous carcinoma

Ñ    Dermatomyositis

Ñ    Acanthosis nigricans

Ñ    Herpes zoster

CVS

Ñ    Pericardial effusion

Ñ    Superior vena cava obstruction

Ñ    Thrombophlebitis migrans

Ñ    Non-bacterial thrombotic endocarditis

RS

Ñ    Collapse

Ñ    Consolidation

Ñ    Cavitation

Ñ    Pleural effusion

GIT

Ñ    Dysphagia:

Direct invasion

Ñ    Liver deposits

RAG

Ñ    Gynaecomastia

HS

Ñ    Lymphadenopathy

Ñ    Microcytic or normochromic anaemia

Ñ    Disseminated intravascular coagulation

Ñ    Thrombotic thrombocytopaenic purpura

Ñ    Haemolytic anaemia

CNS

Ñ    Recurrent laryngeal nerve palsy

Ñ    Phrenic nerve palsy

Ñ    Horner’s syndrome

Ñ    T₁ root lesion

Ñ    Metastases

Ñ    Encephalopathy

Ñ    Subacute cerebellar degeneration

Ñ    Motor neurone disease

Ñ    Peripheral neuropathy

Ñ    Polymyopathy

Ñ    Eaton-Lambert syndrome

Non-metastatic manifestations most frequently complicate small cell carcinoma

LMS

Ñ    Bone metastases

Ñ    Hypertrophic pulmonary osteoarthropathy

Investigations

Fluids

Blood

Biochemistry

Ñ    Hypercalcaemia:

Caused by:

·          Parathyroid hormone related peptide:

Squamous carcinoma 

·          Bone metastases

Ñ    Hyponatraemia (SIADH):

·          ADH like peptides:

Secreted by small cell cancer

Sputum

Ñ    Cytology

Imaging

Chest X-ray

Ñ    Lesions more than 1 cm in diameter may be seen

CT scan

Ñ    Smaller lesions

Ñ    Mediastinal and metastatic disease

MRI

Ñ    Staging

Nuclear Medicine

PET scan

Ñ    Differentiates benign from malignant nodules

Ñ    Staging

V/Q scan

Ñ    Determines the contribution to pulmonary function that is made by the lung that is to be resected

Endoscopy

Bronchoscopy

Ñ    Specimens for histology

Ñ    Define anatomy

Physiological Assessment

Pulmonary function tests

Ñ    Determine adequacy of lung function to cope with major surgery and resection

Surgery

Transthoracic Biopsy

Ñ    Peripheral lesions

Mediastinoscopy

Ñ    Biopsy tumour within mediastinum

Thoracoscopy

Ñ    Lung and pleural biopsy

Management

Control

Drugs

Chemotherapy

Ñ    Small cell cancer (mainstay of treatment):

Single or combination chemotherapy

Ñ    Non-small cell cancer

Treatment or adjuvant chemotherapy

Surgery

Ñ    Only curative treatment for non-small cell cancer

Radiotherapy

Ñ    High dose radiotherapy produces results as good as surgery in slow growing squamous cancer

Symptom relief

Surgery

Palliation of tracheobronchial narrowing (intraluminal tumour or extrinsic compression):

Ñ    Laser

Ñ    Tracheobronchial stent

Radiotherapy

Ñ    Bone pain

Ñ    Haemoptysis

Ñ    SVC (superior vena cava) obstruction

Ñ    Breathlessness caused by narrowing of major airways

Prognosis

Ñ    Poor compared to other cancers

Ñ    80% dead within 1 year

Ñ    6% 5 year survival

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