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Bronchial carcinoma and Mesothelioma
- 2. ETIOLOGY Smoking – MAIN - 90% cases - 40 times more in smoker Atmospheric pollution Asbestosis >> Silicosis Radiation (Radon)
- 3. PATHOLOGY – READ ROBINS FOR DETAILED PATHOLOGY Arise from bronchial epithelium or mucus glands Cell types – Squamous – MC in India Adenocarcinoma – associated with mutation of EGFR - MC overall in the world Small cell – Type of carcinoid tumor - Poor prognosis, common in smokers Large cell Spread – Direct – Pleura, Chest wall, Mediastinum, Pericardium Lymphatic – Pleura; Hilar, Mediastinal & Supraclavicular LN Hematogenous - Liver, Adrenal, Bone, Brain, Skin
- 4. CLINICAL FEATURES Involvement of main bronchus leads to early presentation, but involvement of peripheral bronchus leads to delayed presentation Signs & Symptoms Dry Cough Hemoptysis Airway Obstruction Complete Bronchial Obstruction – Atelectasis of lobe / lung, breathlessness, mediastinal displacement, compensatory emphysema of other lung, dullness on percussion, reduced breath sounds Partial Bronchial Obstruction – Unilateral wheeze Obstruction of main bronchus, larynx, trachea – Stridor Due to impaired excretion of secretions – Pneumonia/ abscess
- 5. Breathlessness Pain - Due to pleural invasion, Intercostal nerve involvement Nerve entrapment – Intercostal nerve involvement Phrenic nerve – elevated diaphragm Horner’s Syndrome - Seen in Apical lung carcinoma - Due to involvement of cervical sympathetic chain - Mild ptosis, anhidrosis, miosis Pancoast Syndrome – Seen in Apical lung carcinoma - Due to destruction of C8 – T2 roots - Pain in the inner aspect of arm Mediastinal Spread – Pericardium Oesophagus Superior Vena Cava Syndrome RLN involvement Supraclavicular LN enlargement
- 6. Metastatic Spread – Liver – Jaundice Bone – Bone pain Brain – Seizures, Personality Changes Other – Lassitude, wt loss, anorexia PNS – SIADH – mcly in small cell Cushing’s Syndrome – mcly in small cell Hypercalcemia – due to PTH related peptide & mcly in adenoca Hypertrophic Osteoarthropathy Venous Thrombosis Dermatomyositis Eaton Lambert Myasthenia – mc in small cell Finger clubbing
- 7. INVESTIGATIONS Imaging – Chest x ray – 1. Hilar lymphadenopathy 2. Peripheral opacities 3. Collapse 4. Pleural effusion 5. Broadening of mediastinum 6. Enlarged cardiac shadow 7. Elevation of diaphragm 8. Rib destruction CT
- 10. Biopsy and HPE – If midline – bronchoscopy If peripheral – Percutaneous CT / USG guided needle biopsy If pleural involvement – Pleural biopsy and aspiration Sputum cytology
- 11. STAGING Best – Combined CT and PET
- 12. TREATMENT Surgical resection – Involvement of affected part and involved LN Radiotherapy – Less effective than surgery Radical RT indicated in patients with localized disease in whom surgery is contra-indicated Radical RT combined with chemo if LN involvement is present Stereotactic RT is preferred for small lesions RT + chemo is efficient in small cell ca
- 13. Chemotherapy – IV Cyclophosphomide, Vincristine/IV Cysplatin, Doxorubicin, Etoposide Adenocarcinoma asso with EGFR mut are responsive for tyrosine kinase inhibitors like Gefitinib and Erlotinib S/E – N, V – Rx in first 24 hrs – Ondonsetron - later - Aprepitant Laser therapy – for palliation of symptoms caused by major airway obstruction Stenting – for maintaining airway in case of extrinsic compression
- 15. SOME IMP POINTS MC malignancy in men overall – Lung cancer MC lung cancer in non and light smokers – Adenocarcinoma smokers – Small and Squamous carcinoma For high risk guys Low Dose CT is better than HR CT to screen Hypertrophic Osteoarthropathy (HOA) is seen in Primary lung cancer, Metastatic lung cancer, Mesothelioma, Bronchiectasis, Hepatic cirrhosis HOA is mcly asso with adenocarcinoma type of lung cancer Lack of calcification and Asymmetric calcification is seen in Malignancy. Other types of calcification is seen in Benign Hypercalcemia causes shortened QT interval Tumor Lysis Syndrome – occurs 1-5 days after chemo - Hyperuricemia, Hyperkalemia, Hyperphosphatemia and Hypocalcemia - Rx is Rasburicase
- 16. C/I of Surgical resection – Tumor within 2cm of carina Malignant pleural effusion Main PA involvement SVC syndrome Exta thoracic mets Vocal cord paralysis Phrenic nerve paralysis Cardiac tamponade Mets to c/l lung, supraclavicular LN, c/l mediastinal node mets
- 17. MESOTHELIOMA
- 18. Mesothelioma arises from pleura In 99% cases it is associated with past asbestos exposure There is very long latent period b/w exposure and cancer FEATURES – Increasing breathlessness due to increasing pleural effusion Chest pain – if chest wall is involved As it progresses, it encases entire lung parenchyma pericardium mediastinum Treatment – Mainly palliative Surgery is done in only selected patients Chemo is associated with a 3 month survival RT can be used to control pain and limit mets Pleural effusion – drainage and pleurodesis