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Bronchogenic carcinoma


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Mediicine, respiratory system, bronchial carcinoma

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Bronchogenic carcinoma

  2. 2. Global situation  30,000 new cases of lung cancer per year in England (6,000 in Scotland)  Commonest cause of cancer death (33%) in men  Commonest cause of cancer death in women in Scotland (20%)  90% mortality 1 year after diagnosis  The most rapidly increasing cancer in developing countries
  3. 3. classsification  Primary  Benign (rare)  Hamartoma  Squamous papillomatosis  Pleomorphic adenoma  Bronchial carcinoid  Malignant (very common)  Metastatic (Very common)
  4. 4. Risk factors  Tobacco smoke- active or passive  Asbestos  Nickel  Chromates  Cadmium  Radiation  Atmospheric pollution  (genetics)
  5. 5. Based on the characteristics of the disease and its response to treatment -  Small cell lung cancer (SCLC)  Non-small cell lung cancer (NSCLC)
  6. 6. 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.
  7. 7. Squamous carcinoma (keratinising)
  8. 8. 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-smokers •Women •Elderly •Far East.
  9. 9. Adenocarcinoma (gland forming)
  10. 10. Adenocarcinoma with mucin (blue stained)
  11. 11. Large cell carcinomas  Less-differentiated forms of squamous cell and adenocarcinomas.  Account for about 25% of all lung cancers  Metastasize early.
  12. 12. Large cell carcinoma
  13. 13. Small-cell carcinoma  Often 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
  14. 14. Small cell carcinoma
  15. 15. 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.
  16. 16. Clinical features
  17. 17. Clinical features Bronchial obstruction Complete obstruction causes  collapse of a lobe or lung  Breathlessness  mediastinal displacement  dullness to percussion  reduced breath sounds. Partial bronchial obstruction may cause  monophonic, unilateral wheeze that fails to clear
  18. 18. 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.
  19. 19. Clinical features Breathlessness. Breathlessness may be caused by  collapse or pneumonia  tumour 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 invasion  Intercostal nerve involvement causes pain in the distribution of a thoracic dermatome.
  20. 20. Clinical features  Carcinoma in the lung apex may cause Horner’s syndrome (ipsilateral partial ptosis, enophthalmos, miosis and hypohidrosis of the face) due to involvement of the sympathetic chain at or above the stellate ganglion.  Pancoast’s 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.
  21. 21. Clinical features Mediastinal 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
  22. 22. Clinical features  Involvement 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
  23. 23. Clinical features Metastatic spread  focal neurological defects  epileptic seizures  personality change  Jaundice  bone pain  skin nodules  Lassitude, anorexia and weight loss usually indicate metastatic spread.
  24. 24. Clinical features Finger clubbing  Overgrowth of the soft tissue of the terminal phalanx  increased nail curvature  nail bed fluctuation Hypertrophic pulmonary osteoarthropathy (HPOA)  painful periostitis of the distal tibia, fibula,radius and ulna  local tenderness  sometimes pitting oedema over the anterior shin.  X-rays reveal subperiosteal new bone formation.
  25. 25. Clinical features
  27. 27. Pancoast syndrome
  28. 28. Physical Examination  General Examination :  Appearance: ill looking, may be grossly emaciated  Nutrition: below average  Anaemia: moderately anemic  Clubbing: generalized clubbing involving all the fingers an toes (HPOA present/not)  Cyanosis,jaundice,edema: absent  Koilonychia,leukonychia: absent  Lymphadenopathy:Rt supraclavicular lymph node are enlarged,hard in consistency,non tender,fixed with underlying structure and overlying skin  Bony tenderness:  Skin condition:
  29. 29. Physical Examination  Systemic Examination :  Respiratory system examination:  Evidence of pneumonia, pleural effusion, lung abscess.  CVS:  Arrythmia, pericardial effusion  Nervous system examination:  Higher psychic function: confusion, fits  Cranial nerves: focal neurological signs, papilloedema  Motor functions: hemiplegia  Sensory functions: mono/polyneuropathy  Cerebellar dysfunction  Musculoskeletal system examination: Proximal myopathy, dermatomyositis
  30. 30. Expanded Clinical Evaluation Symptoms Elicited in History:  Constitutional—weight loss greater than 10 lb  Musculoskeletal—focal 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
  34. 34. Investigations  Routine Laboratory Tests :  CBC with PBF: Hematocrit less than 40% in males Hematocrit less than 35% in females  LFT: Elevated alkaline phosphatase, GGT, AST, calcium AST, aspartate aminotransferase ; GGT, γ- 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.
  35. 35. Investigations  USG: 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 operability  Where 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 metastasis  Lung function tests:
  36. 36. Radiological Clues to Suspect Malignancy 1. Mass lesion or coin shadow…..fig 1 2. Mediastinal widening due to enlargement of lymph nodes ……fig 5 3. Rib erosion and rib fracture….fig 3 4. Phrenic nerve paralysis in the presence of mediastinal mass 5. Presence of pleural effusion….fig 6 6. Cannon ball shadows….fig 4
  37. 37. Large cavitated bronchial carcinoma in left lower lobe……..fig:1
  38. 38. Collapse of the right lung: Fig…2
  39. 39. Bronchogenic carcinoma. Left upper/zone consolidation due to tumor and collapse. Rib erosion (arrow) suggests malignant lesion—bronchogenic carcinoma….Fig 3
  40. 40. Pulmonary metastases. Bilateral cannon ball shadows—common primaries thyroid, bone and viscera..FIG :4
  41. 41. Lymphoma. Note: The bilateral paratracheal lym- phadenopathy (arrowheads) is a common cause of mediastinal syndrome…..Fig: 5
  42. 42. 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 side……………………………………fig 6
  43. 43. Common radiological presentations of bronchial carcinoma  1. 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
  44. 44. Common radiological presentations of bronchial carcinoma  Broadening of mediastinum, enlarged cardiac shadow, elevation of a hemidiaphragm  Paratracheal 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
  45. 45. Lung cancer in right lung (CT of thorax)
  46. 46. Lung cancer in right lung( Positron emission tomography showing increased uptake in tumour. )
  47. 47. Lung cancer in right lung(Lung cancer seen through a bronchoscope (arrow))
  48. 48. Lung cancer seen through a bronchoscope
  49. 49. Surgical treatment Surgery is performed 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-radiation with a view to ‘downstaging’ disease and render it amenable to surgical resection
  50. 50. 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 disease which includes resection in patients with ipsilateral peribronchial or hilar node involvement.
  51. 51. Radiotherapy  For cure  patients who are fit and who have a slowly growing squamous carcinoma,  treatment of choice if surgery is declined.  For symptomatic relief  Bone pain  Haemoptysis  Superior vena cava obstruction
  52. 52. Chemotherapy  Mainly for SCLC, less effective for NSCLC.  Combination chemotherapy  i.v. Cyclophosphamide  Doxorubicin  Vincristine or i.v. cisplatin  Etoposide
  53. 53. TREATMENT
  54. 54. TREATMENT
  55. 55. TREATMENT
  56. 56. TREATMENT
  57. 57. Contraindication of surgery
  58. 58. RADIOTHERAPY Indications:
  60. 60. prognosis