Bronchogenic carcinoma

Bronchial Carcinoma is by far the most common, more than 90% lung tumour by comparison; benign tumour of the lungs is rare. The common cell types of bronchial carcinoma are as follows:

a. Squamous cell      35%

b. Adenocarcinoma     30%

c. Small cell    20%

d. Larger cell    15%

Primary carcinoma of other organs in particular the Breast, Kidney, Uterus, Ovary, Testes and Thyroid may give rise to metastatic pulmonary deposits as may an osteogenic or other sarcoma.

Bronchial

Tumours also represent a most common cause of obstruction to a major bronchus. The incidence of Bronchial Carcinoma increased dramatically during the 20th century and it is now the most common fatal malignancy in the developed world with escalating incidences in the less developed world as the prevalence of cigarettes smoking increases. It accounts for more than 50% of all male deaths from malignant diseases and the incidence of lung cancer death is expected to climb over the next 10 (ten) years with an increasing number unrelated to smoking.

Cigarette smoking is by far the most important single factor in the causation of lung cancer. Other causes are occupational hazards (asbestos exposure), atmospheric pollution, genetic factor and radiation. The male female ratio is 4:1. It may involve the lung centrally, peripherally and diffusely.

General symptoms

Fever, anorexia, nausea, weight loss lassitude and tiredness are the general symptoms of lung cancer.

Local symptoms

Cough is the most common early symptoms; sputum is purulent if secondary infection. A change in the character of the regular cough of a smoker, particularly if associated with other new respiratory symptoms is very important.

Haemoptysis: Recurrent scanty Haemoptysis or blood-streaking sputum in smoker is highly suggestive.

Breathlessness: (due to large pleural effusion or tumour occludes a large bronchus).

Stridor: (Tumour compress the main bronchi).

Symptoms due to metastasis

Pleural pain

Pain in the shoulder and arm

Homer's syndrome due to involvement of superior cervical ganglion,

- ptosis, miosis,

- anhydrosis, enophthalmus

Lymphadenopathy of sup. Cervical lymph node, Hoarseness of voice -due to compression over left recurrent laryngeal

Nerve

Superior vena caval obstruction

Dysphagia - due to esophagus involvement

Stridor- due to involvement of trachea,

Focal neurological signs -due to intracranial metastasis,

Jaundice- due to liver involvement,

Bone pain - due to bone involvement.

Non-metastatic extra-pulmonary manifestation

a. Endocrine:

Inappropriate ADH secretion causing hyponatremia

Ectopic ACTH secretion (Cushing's syndrome)

Hypercalcaemia

Carcinoid syndrome

Gynaecomastia

b. Neurological:

Polyneuropathy

Myelopathy

Cerebellar degeneration

Myasthenia gravis (Eaton-Lambert syndrome)

c. Others:

Digital clubbing

Hypertrophic pulmonary osteoarthropathy

Nephrotic syndrome

Polymyositis and dermatomyositis and

Eosinophilia

Signs

A. Peripheral signs:

1. Anaemia

2. Weight loss

3. Clubbing

4. Lymphadenopathy

5. Homer's syndrome

6. Features of SVC obstruction

B. Lung signs:

Depends on the characteristics of tumour.

1. Unilateral hilar enlargement: Central tumour- Hilar glandular enlargement. Peripheral tumour-In apical segment of a lower lobe can look like an enlargement hilar Shadow on the straight X-ray.

2. Peripheral pulmonary opacity: Usually irregular but well circumscribed may have irregular cavitation within it.

3. Lung lobe or segmental collapse: Usually caused by tumour within the bronchus causing occlusion.

4. Pleural effusion: Usually indicates tumour invasion ofpleural spaces.

5. Broadening of mediastinal invasion.

6. Enlarged cardiac shadow- Manifestation of mediastinal invasion.

7. Elevation of hemidiaphragm.

8. Rib destruction- Direct invasion of the chest wall or blood born metastatic spread can cause osteolytic lesion of the ribs

A lung tumour patient when suspected the following investigations may be done for confirmation:

Investigations:

1. Blood:

    Hb%-reduced

    ESR- raised markedly

2. X-ray chest: Solitary nodule, collapse, consolidation, hilar lymphadenopathy, mediastinum broadening, pleural effusion, rib destruction etc.

3. Cytological examination for malignant cells: Sputum, bronchial washing and pleural fluid.

4. Lymph node biopsy.

5. Bronchoscopy & pleural (tumour) biopsy.

6. Transthoracic FNAC.

7. Others: CT scan of thorax, USG of liver, radionuclide, bone scanning, Ba swallow X-ray.

Treatment of lung cancer

A. Supportive measures:

1. Nutritional supplement.

2. Blood transfusion (for correction of anaemia)

3. Analgesic (for pain)

B. Therapeutic treatment:

-Surgery

-Radiotherapy

-Chemotherapy

-Laser therapy

Surgical treatment

1. Stage I & II: Fit for surgical removal

* Lobectomy: For localized Tumours

* Pneumectomy: For localized Tumours.

2. Stage III &IV.

* No surgery

* Radiotherapy given.

Radiotherapy

1. Curative therapy- usually for stage I & II.

2. Palliative therapy- usually for stage III & below-

* SVC syndrome.

* Skeletal metastatic deposits.

* Obstruction in trachea & bronchi

Chemotherapy: (only used in)

* Undifferentiated carcinoma

* Small cell carcinoma.

Drugs used in chemotherapy are:

* Cyclophosphamide (750 mg/m square in day1),

* Etoposide (120 mg/ m square in day 1,2,3)

* Adriamycin (60 mg/m square in day 1)

(The above regimens are given every 3 weeks for 3-6 cycles. Nausea and vomiting peak for 3 days after each cycle of chemotherapy).

Laser therapy:

Used as palliative measure via fibroptic bronchoscope to destroy tumour tissue. Best result achieved in tumour of main bronchi.

The burden of lung cancer:

36000 deaths/year in UK

25% of all cancer deaths

8% of all male deaths and

4% of all female deaths.

More than threefold increase in deaths since 1950.

Most rapidly increasing cause of cancer death in women.

Most common cause of cancer death in men.

After breast cancer, the second most common cause of cancer Death in women in England and Wales.

Prognosis

The overall prognosis in bronchial carcinoma is very Poor, with around 80% of patients dying within a year of diagnosis and less than 6% of the patients surviving 5 years after diagnosis.

 The best prognosis is with well differentiated squamous cell Tumours which have not metastasised and are amenable to surgical treatment.

Bronchogenic carcinoma

Bronchial Carcinoma is by far the most common, more than 90% lung tumour by comparison; benign tumour of the lungs is rare. The common cell types of bronchial carcinoma are as follows: a. Squamous cell 35% b. Adenocarcinoma 30% c. Small cell 20% d. Larger cell 15% Primary carcinoma of other organs in particular the Breast, Kidney, Uterus, Ovary, Testes and Thyroid may give rise to metastatic pulmonary deposits as may an osteogenic or other sarcoma. Bronchial Tumours also represent a most common cause of obstruction to a major bronchus. The incidence of Bronchial Carcinoma increased dramatically during the 20th century and it is now the most common fatal malignancy in the developed world with escalating incidences in the less developed world as the prevalence of cigarettes smoking increases. It accounts for more than 50% of all male deaths from malignant diseases and the incidence of lung cancer death is expected to climb over the next 10 (ten) years with an increasing number unrelated to smoking. Cigarette smoking is by far the most important single factor in the causation of lung cancer. Other causes are occupational hazards (asbestos exposure), atmospheric pollution, genetic factor and radiation. The male female ratio is 4:1. It may involve the lung centrally, peripherally and diffusely. General symptoms Fever, anorexia, nausea, weight loss lassitude and tiredness are the general symptoms of lung cancer. Local symptoms Cough is the most common early symptoms; sputum is purulent if secondary infection. A change in the character of the regular cough of a smoker, particularly if associated with other new respiratory symptoms is very important. Haemoptysis: Recurrent scanty Haemoptysis or blood-streaking sputum in smoker is highly suggestive. Breathlessness: (due to large pleural effusion or tumour occludes a large bronchus). Stridor: (Tumour compress the main bronchi). Symptoms due to metastasis Pleural pain Pain in the shoulder and arm Homers syndrome due to involvement of superior cervical ganglion, - ptosis, miosis, - anhydrosis, enophthalmus Lymphadenopathy of sup. Cervical lymph node, Hoarseness of voice -due to compression over left recurrent laryngeal Nerve Superior vena caval obstruction Dysphagia - due to esophagus involvement Stridor- due to involvement of trachea, Focal neurological signs -due to intracranial metastasis, Jaundice- due to liver involvement, Bone pain - due to bone involvement. Non-metastatic extra-pulmonary manifestation a. Endocrine: Inappropriate ADH secretion causing hyponatremia Ectopic ACTH secretion (Cushings syndrome) Hypercalcaemia Carcinoid syndrome Gynaecomastia b. Neurological: Polyneuropathy Myelopathy Cerebellar degeneration Myasthenia gravis (Eaton-Lambert syndrome) c. Others: Digital clubbing Hypertrophic pulmonary osteoarthropathy Nephrotic syndrome Polymyositis and dermatomyositis and Eosinophilia Signs A. Peripheral signs: 1. Anaemia 2. Weight loss 3. Clubbing 4. Lymphadenopathy 5. Homers syndrome 6. Features of SVC obstruction B. Lung signs: Depends on the characteristics of tumour. 1. Unilateral hilar enlargement: Central tumour- Hilar glandular enlargement. Peripheral tumour-In apical segment of a lower lobe can look like an enlargement hilar Shadow on the straight X-ray. 2. Peripheral pulmonary opacity: Usually irregular but well circumscribed may have irregular cavitation within it. 3. Lung lobe or segmental collapse: Usually caused by tumour within the bronchus causing occlusion. 4. Pleural effusion: Usually indicates tumour invasion ofpleural spaces. 5. Broadening of mediastinal invasion. 6. Enlarged cardiac shadow- Manifestation of mediastinal invasion. 7. Elevation of hemidiaphragm. 8. Rib destruction- Direct invasion of the chest wall or blood born metastatic spread can cause osteolytic lesion of the ribs A lung tumour patient when suspected the following investigations may be done for confirmation: Investigations: 1. Blood: Hb%-reduced ESR- raised markedly 2. X-ray chest: Solitary nodule, collapse, consolidation, hilar lymphadenopathy, mediastinum broadening, pleural effusion, rib destruction etc. 3. Cytological examination for malignant cells: Sputum, bronchial washing and pleural fluid. 4. Lymph node biopsy. 5. Bronchoscopy pleural (tumour) biopsy. 6. Transthoracic FNAC. 7. Others: CT scan of thorax, USG of liver, radionuclide, bone scanning, Ba swallow X-ray. Treatment of lung cancer A. Supportive measures: 1. Nutritional supplement. 2. Blood transfusion (for correction of anaemia) 3. Analgesic (for pain) B. Therapeutic treatment: -Surgery -Radiotherapy -Chemotherapy -Laser therapy Surgical treatment 1. Stage I II: Fit for surgical removal * Lobectomy: For localized Tumours * Pneumectomy: For localized Tumours. 2. Stage III IV. * No surgery * Radiotherapy given. Radiotherapy 1. Curative therapy- usually for stage I II. 2. Palliative therapy- usually for stage III below- * SVC syndrome. * Skeletal metastatic deposits. * Obstruction in trachea bronchi Chemotherapy: (only used in) * Undifferentiated carcinoma * Small cell carcinoma. Drugs used in chemotherapy are: * Cyclophosphamide (750 mg/m square in day1), * Etoposide (120 mg/ m square in day 1,2,3) * Adriamycin (60 mg/m square in day 1) (The above regimens are given every 3 weeks for 3-6 cycles. Nausea and vomiting peak for 3 days after each cycle of chemotherapy). Laser therapy: Used as palliative measure via fibroptic bronchoscope to destroy tumour tissue. Best result achieved in tumour of main bronchi. The burden of lung cancer: 36000 deaths/year in UK 25% of all cancer deaths 8% of all male deaths and 4% of all female deaths. More than threefold increase in deaths since 1950. Most rapidly increasing cause of cancer death in women. Most common cause of cancer death in men. After breast cancer, the second most common cause of cancer Death in women in England and Wales. Prognosis The overall prognosis in bronchial carcinoma is very Poor, with around 80% of patients dying within a year of diagnosis and less than 6% of the patients surviving 5 years after diagnosis. The best prognosis is with well differentiated squamous cell Tumours which have not metastasised and are amenable to surgical treatment.