This document provides information on tumors of the bronchus and lung, including bronchogenic carcinoma. It discusses: - The majority (99%) of lung tumors are malignant, while less than 1% are benign. Non-small cell carcinoma accounts for 80% of lung cancers, while small cell carcinoma makes up 20-25%. - Risk factors for bronchogenic carcinoma include tobacco smoking, industrial hazards, air pollution, and scarring from old infections. Symptoms depend on the location and size of the tumor. Diagnostic tests include chest imaging, biopsy, and PET scans. - Treatment options are based on cancer type and stage. They include surgery, radiation, chemotherapy, targeted therapy, or a combination. Out

1. Tumors of Bronchus & lung
including Bronchogenic Carcinoma
DR RISHI SAINI
MBBS, MD
CONSULTANT CHEST
PHYSICIAN, INTERVENTIONAL
PULMONOLOGIST.
ROHILKHAND MEDICAL
COLLEGE & HOSPITAL

2. Lung tumours
Benign lung
Tumours(<1%)
Malignant lung
tumours(99%)

3. Lung Nodules vs Lung Tumors
Benign vs Malignant
Profile of Benign Nodule Profile of Malignant
Nodule
< 40 yr > 40 yr
Non smoker Smoker
Presence of calcification Absent
> 90% nodule with size < 2cm Large size
smoother edges
more even color throughout
more regular shape
Irregular shape with
spiculation
repeated X-rays for > 2 yrs if the nodule is < 6
mm and risk is low. Nodule remains the same
size for at least two years.
Usually double in size
every 1-6 months
Upper portion of lung

4. LUNG TUMORS
BENIGN <1% MALIGNANT 99%
Bronchial Adenoma Lung cancer
Fibroma Lymphoma
Hamartoma Carcinoid
Neurofibroma Sarcoma
Blastoma Mets

5. Definition
 The term lung cancer is used for tumors
arising from the respiratory epithelium
(bronchi, bronchioles, and alveoli).
 Bronchial carcinoma accounts for 95% of
all primary tumors of the lung.

6. Lung cancer
 Lung cancer is one of the commonest cancers
 It accounts for 13 %of all new cancer cases
and 19 % of cancer related deaths worldwide.

7. Lung cancer in India
Lung cancer constitutes -
 ~6.9 % of all new cancer cases and
 ~9.3 % of all cancer related deaths in both sexes.
The overall 5-year survival rate of lung cancer is
approximately
 ~15 % in developed countries and
 ~5 % in developing countries.

9. Lung tumours
Benign lung
Tumours(<1%)
Malignant lung
tumours(99%)

10. Benign tumors or ‘benign neoplasms’
 Uncommon
 usually of epithelial and mesenchymal origin.
 usually small (< 3 cm) and may be found in the bronchi (endobronchial) or
the lung parenchyma.
 Majority are asymptomatic, and endobronchial location was found in 6 %.
 In an study following types of benign tumor were found:
– lung hamartoma (76 %),
– benign fibrous mesothelioma/solitary fibrous tumor (12.3 %),
– inflammatory pseudotumor (5.4 %),
– leiomyoma (1.5 %),
– lipoma (1.5 %),
– and single cases of hemangioma, adenoma of the mucous glands, and
‘mixed’ benign tumor.

11. Malignant lung
tumours
Primary lung
tumours
Secondary lung
tumours
Non small cell
carcinoma
Small cell carcinoma
Other than
Bronchogenic Ca
(3-5%)

12. Etiology of bronchogenic carcinoma
1. Tobacco smoking:
 A pack year is defined as twenty cigarettes that are smoked
every day for one year
 RISK 20 times greater among habitual heavy smokers.
 Cessation of cigarette smoking for at least 15 years brings the
risk down.
 Passive smoking the risk to approx. 2x than nonsmokers.
 Experimental evidence – more than 1200 carcinogenic
substances.

13. ETIOLOGY of bronchogenic carcinoma
2. Industrial hazards:
 Certain industrial exposures increase the risk of
developing lung cancer.
3. Air pollution:
Biomass fuel exposure
Radon.
4. Scarring:
Due to old infarcts, wounds, scar, granulomatous infections
Adenocarcinoma.

14. Classification
According to Anatomy-
1. Central lung cancer- mostly Squamous cell CA and Small cell CA.
2. Peripheral lung cancer - mostly Adeno CA.
According to WHO -
1. Non-Small Cell Lung Cancer (NSCLC) (80%)
– Squamous cell carcinoma (SCC) (25%-40%)
– Adenocarcinoma (LADC) (25%-40%)
– Large-cell undifferentiated ca(10%-15%)
2. Small Cell Lung Cancer
(SCLC) (20%-25%)
Primarily due to smoking
Other rarer tumour types
include carcinoids (typical or
atypical), carcinosarcomas,
pulmonary blastomas, giant
and spindle cell
carcinomas.

15.  Squamous or epidermoid carcinoma:
– Smokers:
Squamous metaplasia of bronchial epithelium
Squamous carcinoma in-situ
Invasive squamous cell carcinoma
Non-small cell carcinoma

16. Non-small cell carcinoma
Adenocarcinoma :
 Arises from mucous cells in the bronchial epithelium.
 25-40% of all bronchial carcinomas.
 most common bronchial carcinoma associated with
asbestos and is proportionally more common in
non-smokers, in women, and in the elderly.
 Invasion of the pleura and the mediastinal lymph nodes is
common, as are metastases to the brain and bones.
Large cell carcinomas:
 less-differentiated forms of squamous cell and
adenocarcinomas.
 10-15% of all lung cancers and metastasize early.

17. Small cell carcinoma
 It has three subtypes
– oat-cell carcinoma
– intermediate cell type
– combined oat- cell carcinoma.
 SCLC belongs in a group of tumors derived
from neuroendocrine cells that are
responsible for the production and secretion
of specific peptide product.
 They may related to Paraneoplastic syndrome.

18.  Limited Stage (confined to one area of the chest)
– Defined as tumor involvement of one lung, the mediastinum and
ipsilateral hilar and supraclavicular lymph nodes.
 Extensive Stage (not confined to one area of the chest)
– Defined as tumor that has spread beyond one lung,
mediastinum, and supraclavicular lymph nodes.
– Common distant sites of metastases are the adrenals, bone, liver,
bone marrow, and brain.
Small cell carcinoma

19. Metastases to the lung
 breast cancer
 bladder cancer
 kidney cancer
 colon cancer
 melanoma
 pancreatic cancer
 head & neck cancer
 thyroid cancer
 lymphoma
 neuroblastoma (found in
infants and children)
 prostate cancer
 sarcoma (from bone, muscle,
or connective tissue)
 Wilms’ tumor (a childhood
kidney tumor)
The primary tumors that commonly spread to the lungs include:
Sometimes, cancer may spread to the lung, but the original ‘primary’ location of
the cancer is not known; this is called ‘cancer of unknown primary‘ (CUP).

20. Neuroendocrine tumors- Bronchial Carcinoid
 Tumor with neuroendocrine differentiation arising from
Kulchitsky cells in the bronchial mucosa.
 Appear at an early age (mean 40 years) with equal sex
incidence.
 1-5% of all pulmonary neoplasms.
 Often resectable and curable.
 No relation with cigarette smoking or other environmental
factor.
 Carcinoid syndrome- skin flushing, facial skin lesion
(purplish areas of spider like veins may appear on the
nose and upper lip), diarrhea, breathlessness, tachycardia

21.  Due to primary lesions:
 Fatigue (tiredness)
 Cough
 Shortness of breath
 Chest pain
 Loss of appetite
 Coughing up phlegm
 Hemoptysis (coughing up blood)
Clinical manifestations

22.  Due to local extension:
 Esophageal compression - Dysphagia
 Laryngeal nerve paralysis - Hoarseness
 Sympathetic nerve invasion - Horner’s syndrome
 Cervical/thoracic nerve invasion - Pancoast syndrome.
 Lymphatic obstruction - Pleural effusion
 Vascular obstruction - SVC syndrome
 Pericardial/cardiac extension - Effusion, Tamponade
Clinical manifestation

23. Clinical manifestation
 Superior sulcus or pancoast’s tumor :
• It may involve the brachial plexus, resulting in a
C7-T2 neuropathy with pain, numbness, and
weakness of the arm.
 Horner’s syndrome : Compression of sympathetic
ganglion
• Unilaterally constricted pupil, Enophthalmos
Narrowed palpebral fissure , Anhydrosis and
loss of ciliospinal reflex.

24. Clinical manifestation (Extra pulmonary
manifestations:- )-
Distant metastasis-
 liver (30-50%),
 adrenals (>50%),
 brain (20%) and
 bone (20%)
 Other lung

25. Paraneoplastic syndromes
 Paraneoplastic syndromes affect up to 8% of patients with
cancer
 They lead to metabolic and neuromuscular disturbances
unrelated to the primary tumor, metastases or treatment.
 They may be the first sign of the tumor.
 They do not indicate that a tumor has spread.
 The most commonly associated malignancies include small
cell lung cancer, breast cancer, gynecologic tumors, and
hematologic malignancies.

26. Common Paraneoplastic Phenomena in
SCLC
Syndrome Biologically Active
Agent
Laboratory Finding Frequency
SIADH Antidiuretic hormone
(ADH)
Hypo-osmolar
hyponatremia
10%–15% in
limited
30% in extensive
Cushing’s Ectopic
adrenocorticotropic
(ACTH)
Hypercortisolemia 1.6%–4.5% with
clinical syndrome
∼50% with
elevated cortisol
levels
Humoral
hypercalcemia
Calcitonin Elevated calcium
Low-Normal PTH-rP
10% with
hypercalcemia
50% with elevated
calcitonin

27. Syndrome Biologically
Active Agent
Laboratory
Finding
Frequency
Lambert-Eaton
myasthenic
syndrome
(LEMS)
IgG auto-
antibodies to
P/Q-type voltage
gated
calcium channels
Positive antibody
titers
∼5%
Paraneoplastic
cerebellar
degeneration
Auto-antibodies
against
cerebellar Purkinje
cells
anti-Yo antibodies ∼2%
Paraneoplastic
encephalomyelitis
Neuronal nuclear
antibody
Type 1
anti-Hu (ANNA-1)
antibodies
Antibodies present
in ∼25% of pts

28. Physical examination
 Usually in early stage, most of the patients with lung
cancer have no positive physical findings.
 General findings include abnormal percussion, breath
sounds changes, moist rales .
 Digital clubbing, superior vena cava syndrome.
 Endo-bronchial obstruction may result in a localized
wheeze.
 Lobar collapse may result in an area of decreased
breath sounds and dullness to percussion.

29. Workup includes
1. Chest X-ray
2. CT scan chest and upper abdomen
3. Fiber optic bronchoscopy
4. Cyto/histological diagnosis if possible – sputum cytology,
bronchoalveolar lavage/brushings cytology, post bronchoscopy
sputum cytology, CT guided biopsy
5. Pulmonary function test and diffusion coefficient of carbon
monoxide (DLCO)
6. Ventilation-perfusion (V/Q) scan – if pulmonary function tests
reveal borderline pulmonary reserve

30. Workup includes…
7. Resting 2D ECHO/ Stress 2D ECHO may be performed to
assess cardiac status in patients planned for major resections
or have pre-existing cardiac co-morbidity
8. Mediastinoscopy is indicated in all patients with potentially
operable NSCLC. Peripherally located T1a squamous
cancers with negative mediastinal imaging on PET-CECT
may be excluded. If available combined EUS/EBUS with
guided FNAC is an acceptable alternative.
9. Metastatic workup – PET-CT scan, MRI scan brain –
indicated in all patients with potentially operable NSCLC.
10. Patients with T1(T< 10mm), N0 NSCLC with no symptoms of
metastatic disease do not require a routine metastatic
workup.

31. CHEST X-RAY
Small Cell Lung Cancer Non-Small-Cell Lung Cancer
Squamous cell Adenocarinoma

33. Bronchial Obstruction

34. Malignant Cavity
Large cavitated
bronchial
carcinoma in
left lower lobe

35. CT showing lung carcinoma not
seen on routine chest radiograph
 Large mass
narrowing the
right main stem
bronchus

36. Percutaneous needle aspiration

37. BRONCHOSCOPY
Introduced by Shiketo Ikeda since the 70’s

38. Bronchoscopy
 Positive diagnosis in 60% of cases if
tumour mass is > 2cm
 The various bronchoscopic modalities
used in the diagnosis of lung cancer are
– Bronchial washings
– Bronchoalveolar lavage
– Bronchial brushings
– Endobronchial biopsy
– Transbronchial aspiration
– Endobronchial ultrasound

39. Squamous cell carcinoma

40. Radhey Shyam 58 yr m- growth in
mediastinum, compessing oesophagus
and infiltrating into left main bronchus

41. PET SCAN
 F-18-fluorodeoxy-d-glucose (FDG), a glucose analogue is used
 Malignant tumors have increased uptake of FDG
 Sensitivity 85-91% / > CT
 Specificity 86-88% / >CT
 PET has higher sensitivity than CT for evaluation of
mediastinum
 A (-) PET may obviate need for mediastinoscopy PPV 87-100%
 A (+) PET should not be taken as unresectability, because of
false positives, PPV 74-80%

42. PET scan

43. Sputum cytology
 Definitive diagnosis can be made in 60 to
70 % of cases
 More diagnostic in centrally placed tumors
with 50 – 80 % accuracy
 Single specimen-40% yield
 Four specimens-80% yield
 False positive results < 1%

44. Induced sputum showing squamous
cell carcinoma
Orange staining keratinized sq.ca cell with prominent hyperchromatic nucleus.

46. • Non-small lung cancer stages
• Subsets of T, N and M categories are grouped into certain stages, because
these patients share similar prognosis [1].
• For example cT1N0 disease (stage IA) has a 5-year survival of 77-92%.
On the other end of the spectrum is any M1c disease (stage IVB) that has a
5-year survival of 0%.

47.  Treatment options depends upon-
1. Stage of disease
2. Pulmonary reserve and
3. Performance status

48.  Treatment depends on the stage and type of lung
cancer
1. Surgery
2. Radiation therapy
3. Chemotherapy (options include a combination
of drugs)
4. Targeted therapy
5. Lung cancer is usually treated with a
combination of therapies.
How is lung cancer treated ?

50.  Adjuvant means treatment
given after the main
treatment and
 neo-adjuvant means
treatment given before the
primary treatment.

53. Treatment of small cell lung cancer
 Limited stage: Chemo+ xrt =standard of care
• Etoposide + Cisplatin along Radiation
• Cisplatin + Irinotecan
 Extensive stage: first-line chemotherapy
– Etoposide (VP-16) + Cisplatin (or carboplatin)+
– Radiation.

54. STOP SMOKING
THANK YOU.