Bronchial carcinoma
الدكتور خلدون ذنون- كلية طب نينوى- المرحله الرابعهObjectives the following should be understood:
1. Cause: smoking
2. Most common fatal malignancy.
3. Four types, local and distant metastasis.
4. Cough and haemoptysis are the main features. Know the local complications, the metastatic and the non-metastatic features.
5. Diagnosis: imaging, bronchoscopy, biopsy.
6. Management: surgery, radiotherapy and chemotherapy. Know the indications of each.
7. Prognosis is poor, <6% survive 5 years. Stage 1 carries the best prognosis.
8. There are other types of primary lung tumors. The lung is one of the main sites of secondary tumors arising from e.g: breast, stomach, bowel, kidney and gonads.
Aetiology
Cigarette smoking 90%Passive smoking 5% of cancer death
Radon exposure 5%
Urban > rural e.g atmospheric pollution,asbestos,beryllium ,cadmium &chromium.
Prevalence Most common fatal malignancy,50% of all male deaths from malignancy.
pathology
Bronchial epith.or mucus gland origin.
Squamous 35%,adenocarcinoma 30%,small cell carcinoma 20%,large cell 15%.
Large bronchus obstruction (early symptoms) &peripheral (late symptoms).
Necrosis &cavity.
Local invasion &distant blood metastasis.
Clinical features
Cough: most common early symptom.Haemoptysis: mild ,severe.
Bronchial obst., pneumonia ,collapse: SOB.
Pleural: pain, effusion, SOB.
Enlarged lymph nodes compress trachea & bronchi (stidor
Obstructive emphysema(unilateral rhonchus.
Left recurrent nerve paralysis ( hoarsness of voice
Superior sulcus tumor: Horners synd.
Pancoast synd.: shoulder pain.
Mediastinum: dysphagia.
CNS, jaundice, bone pain, skin nodule.
Metastasis: lassitude, anorexia,weight loss.
Superior vena cava synd.( neck&facial congestion, dilated veins, SOB.
Phrenic nerve paralysis ( diaphragmatic paralysis.
Non metastatic (paraneoplastic):
1. Endocrine: ADH, ACTH, PTH-rp, carcinoid, gynaecomastia.
2. Neurological: neuropathy, myelopathy, cerebellar degeneration,
Eaton Lamberts synd.
nephrosis,polymyositis&dermatomyositis,eosinophilia
4. Squamous cell ca.: hypercalcaemia( polyuria, noctuia,constipation,
fatigue,confusion&coma.
Hypertrophic pulmonary osteoarthropathy:
clubbing, periosteitis,x-ray:subperiosteal new bone formation.
Investigations
Chest x-ray: may show the following
Unilateral hilar enlagement.
Collapse of lung, lobe, or segment.
Pereipheral pulmonary opacity.
Pleural effusion
Wide mediastinum, enlarged heart, elvated hemidiaphragm.
Rib destruction
Bronchoscopy: most useful,biopsy, bronchial brush&washing.
3. Percutaneous needle biopsy under CT or U/S for peripheral tumors.
pleural aspiration and biopsy for pleural effusion, or better by thoracoscopy.
Mediastinoscopy or endobronchial U/S for mediastinal metastasis.
6. PET scan to detect metabolically active tumor metastasis.
7. Needle aspiration or biopsy of lymph node, skin, liver, or bone marrow.
Assess operability: spread & metastasis ,heart & lung function.
Preoperative staging : CT head, bone scan, U/S liver,&bone marrow biopsy.
Investigation for paraneoplastic conditions
e.g serum calcium, ADH, ACTH, neurological .
Management
A. Surgery: aiming cure but in over 75% surgery is not possible.Contraindications to surgical resection are:
1. Distant metastasis.
2. Invasion of central mediastinal structures.
3. Malignant pleural effusion.
4. Contralateral mediastinal L.N.
5. FEV1 <0.8L.
6. Unstable cardiac condition & other medical conditions.
B. Radiotherapy
Palliative, can offer long term survival, indicated in:
1.SVC obstruction.
2.Recurrent haemoptysis.
3.Pain:chest wall,bone.
4.Obstruction of trachea&main bronchi.
5.Prevention of brain metastasis in small cell CA. Treated by chemotherapy.
C. Chemotherapy
Effective for small cell cancer, increase survival from 3M to more than one year.Combination of cytotoxics are used & is better than single
agent.e.g cycles of i.v cyclophosphamide, doxorubicin &
vincristin. Vomiting is treated by 5-HT3 antagonist.
Neoadjuvant and adjuvant chemotherapy: given to non-small cell cancer pre-operatively and postoperatively can improve survival
D. Laser therapy and stenting
Through fibreoptic bronchoscopy: palliative, destroy tumor obstructing major airways. Endobronchial stents in extrinsic lymph node compression.General aspect of management
Pain relief.Diet.
Treatment of depression & anxiety.
Hypercalcaemia:i.v fluids, bisphosphonates,
Steroids & mithramycin.
Demeclocycline for inappropriate ADH & malignant Pleural effusion.
Prognosis
Very poor, 70% die within ayear,7% survive 5years.
Best : well diff.sqamous cell CA. without metastasis.
5year survival is more than75% in stage one disease &
55%in stage two disease.
Rarer types of lung tumors
Adenosquamous CA.peripheral or central.Carcinoid:low grade malig.,neuroendocrine,
bronchial obs.&cough,95% 5Y.survival with resection.
Bronchial gland adenoma,benign,resection curable.
Bronchial gland CA., local recurrence.
Hamartoma:benign, peripheral lung nodule,cured by
local resection.
Bronchoalveolar CA.malignant, cough,variable prognosis, worse if multifocal.
Secondary tumors of the lung
Blood borne,multiple,bilateral,no symptoms,diagnosis: CXR. SOB if metastasis is dense,
endobronchial deposits:uncommon, haemoptysis&lobar collapse.
Pulmonary lymphatic carcimatosis
Breast, stomach, bowel, pancreas,bronchus:
severe progressive SOB with marked hypoxia.
CXR: diffuse pulmonary shadowing radiating from hilum with
septal lines.
Tumors of the mediastinum(M)
Superior M. Above line between the lower border of the 4th thoracic vertebra&the upper end of the body of the sternum.
E.g: retrosternal goiter, vascular lesions, thymic tumors,
Dermoid cysts,lymphoma, thoracic aneurysm.
Anterior M. In front of the heart.E.g: retrosternal goiter, dermoid, thymic T., lymphoma, aortic aneurysm,germ cell T., pericardial cyst, diaphragmatic hernia.
Posterior M.Behind the heart.E.g: neurogenic T., paravertebral abscess, oesophageal lesions, aortic aneurysm,
forgut duplication.
Middle M.: Between anterior & posterior M. e.g:bronchial CA ,lymphoma, sarcoidosis, bronchogenic cyst, hiatus hernia.
Benign M.T: CXR diagnosis, may compress trachea or SVC, dermoid may rupture into abronchus.
Malignant M.T: lymphoma, leukemia, aneurysm may compress trachea
,main bronchi,oesophagus.phrenic nerve, left recurrent laryngeal nerve,
sympathetic chain(Horners synd.), SVC, pericardium(effusion)
Investigation
CXR: benign-sharply defined opacity in M.or LungMalignant: ill defined, broad M.
CT& MRI: of choice.
Bronchoscopy: CA.bronchus causes M. lymphadeopathy.
Endobronchial U/S EBUS.
Surgical exploration: mediastinoscopy & L.N biopsy, remove
part or whole tumor.
Management
Benign M.T: Surgical removal.If left e.g cyst becomes infected&neural tumors become malignant
Malignant M.T: treat lymphoma & leukemia, remove thymoma, radiotherapy or chemotherapy for L.N of CA. Of bronchus.
Superior vena cava obstruction & tracheal obstruction treated by radiotherapy or radiotherapy&chemotherapy with placement of internal stents.