Bronchogenic Carcinoma

Epidemiology
• Bronchial carcinoma is the most common malignant tumour
worldwide

• The most common cause of cancer-related death

• It is the fifth most frequent cause of death in the UK

• 90% of cases are related to tobacco smoking

• Risk factors- other than smoking
- Environmental: radon exposure, asbestos, polycyclic aromatic
hydrocarbons and ionizing radiation; occupational exposure to
arsenic, chromium, nickel, petroleum products and oils.

- Host factors : underling lung disease IPF, genetic factors

Pathology
• Histology of lung cancer
1- small cell lung cancer (SCLC)

2- non small cell lung cancer(NSCLC)

a. Squamous cell carcinoma
b. Adenocarcinoma
c. Large cell carcinoma

3- other primary lung cancers

1. Small cell lung cancer (SCLC) 20%
arises from neuroendocrine cells (APUD cells)
can secrete polypeptide hormone
metastasizes early, poorer prognosis
often arise centrally
2.a. squamous cell carcinoma 35%
 arises from epithelial cells
often arise centrally
 cavitation with central necrosis is common
 can causes bronchial compression with post obstructive infection
 local spread is common, often metastasize late
2.b. adenocarcinoma 30% and increasing
 arises from mucus secreting glandular cells
 the most common lung cancer in non-smokers
 often arise peripherally
2.c. large cell lung cancer 10-15%
 poorly differentiated cells
 often arises peripherally
 metastasizes early

3. Other types of primary lung cancer less than 3%

carcinoid tumours, bronchoalveolar carcinoma, sarcomatoid carcinomas and others
Clinical features
• Symptoms caused by local effects
 cough ✓ recurrent infections
 breathlessness ✓ invasion of the phrenic nerve
 hemoptysis ✓ superior vena cava
obstruction
 chest pain ✓ stridor (tracheal tumor)
 wheeze
 hoarseness of voice
 nerve compression
 Pancoast’s tumor
- Tumor of the pulmonary apex
- It can invades the roots of the brachial plexus causing C8/T1 palsy
- Present with hand weakness and muscle wasting, with pain radiating
down the arm
- If the sympathetic ganglia are invaded by the tumor, Horner’s
syndrome occurs (myosis, ptosis, anhidrosis)
- Pancoast’s syndrome: apical tumor with arm pain, muscle wasting
and Horner's syndrome
 superior vena cava obstruction
- swelling of the neck and face, conjunctival oedema, headache and
dilated veins on the chest wall
- Severity of swelling varies over the daytime
- Most commonly caused by lymphoma
Clinical features
• Metastatic spread
 lymph nodes (mediastinal, cervical and axillary)
skin
 liver
 bone
 adrenal gland
 brain
 malignant pleural effusion
Clinical features
• Non metastatic extrapulmonary manifestations
(paraneoplastic syndromes)
 caused by the tumor production of signaling molecules (hormones or
cytokines) or immune response (antibodies) to the tumor cells that
cross-react with other normal cells
 unlike the mass effect of tumor itself or the effect of the metastasis
 sometimes the symptoms of paraneoplastic syndrome show before
the diagnosis of malignancy
 metabolic:
anorexia, lethargy, weight loss
 endocrine:
 syndrome of inappropriate ADH secretion (SIADH): SCLC
 ectopic ACTH secretion: SCLC
 hypercalcemia:
- due to either osteolysis of metastasis or due to release of PTH-like peptide
- PTH-like peptide secretion is associated with squamous cell lung cancer
 gynecomastia
 neurological manifestations
 Lambert- Eaton syndrome:
- associated with SCLC
- Antibodies against the tumor cells are cross-reactive against acetylcholine
receptors at neuromuscular junctions
- Present with proximal muscle weakness of the limbs
 Myelopathies
 Encephalopathies
 Neuropathies (sensory or motor)
 vascular and hematological:
 thrombophlebitis migrans
 microcytic/normocytic anemia
 musculoskeletal:
 hypertrophic pulmonary osteoarthropathy: associated with
adenocarcinoma
 finger clubbing : common with all types of lung cancer
 dermatological:
 dermatomyositis
 acanthosis nigricans
 herpes zoster
Investigations
• Goals of investigations
1. Obtain a tissue diagnosis
2. Stage the extent of disease
3. Assess fitness to undergo treatment
• Chest Xray
- Can be normal if the lesion is small or if it is confined to a central
structure like the trachea, but it can show:
- Mass lesion
- Pleural effusion
- Unresolving consolidation
- Collapse
- Hilar lymphadenopathy
- Reticular shadowing
Cxr lung ca
• Computed tomography
Chest CT and CT of other site that are common for metastasis, i.e. liver,
adrenals and brain

• PET-CT

• Bone scan: for bone metastasis

Ct lung ca
• obtain cytology and histology
 flexible bronchoscopy
 endobronchial ultrasound with transbronchial biopsy
 CT/US guided transthoracic lung biopsy
 ultrasound guided biopsy of liver metastasis, lymph node or skin
lesion
 mediastinoscopy
 thoracoscopy
 thoracentesis
Flex brscpy ca
Staging of the disease
• To evaluate the extent of the disease and then guide the treatment
• Staging is normally based on PET-CT
• Further evaluation with biopsies may be needed
• In non-small cell lung cancer TNM system is used for staging
• In small cell lung cancer is classified into limited and extensive stage
disease
Treatment
• Surgery
- Surgery with curative intent is limited to early stages (stage I and II)
non-small cell lung cancer and limited extent small cell lung cancer
• Radiation
- Radiation with curative intent in early stages of non-small cell lung
cancer if the patient has contraindication for surgery
- Palliative radiation therapy help relieve the symptoms, e.g. bronchial
obstruction, bone metastasis, chest wall metastasis
• Chemotherapy, targeted therapy and immunotherapy
- Adjuvant chemotherapy with radiotherapy in advanced non-small cell
lung cancer prolongs survival
- In late stages of NSLC particularly adenocarcinoma, Targeted agents
against EGFR (Epidermal growth factor receptor), tyrosine kinases and
anaplastic lymphoma kinase (ALK) can be used as second line to
chemotherapy
- Immunotherapy (monoclonal antibodies)
• Cryotherapy, laser therapy and tracheobronchial stents
- Can be used as palliative treatment if a large bronchus is obstructed
causing dyspnea or cough

• Palliative treatment
- Goal is to relieve of symptoms and improve the patient’s wellbeing
- Involves emotional support to the patient and family
Prognosis
• Very poor prognosis, because it is usually diagnosed at a late
inoperable stage (75% of patients)

• 70% die within a year of diagnosis

• Overall 5-year survival is less than 10%

• Best results seen in operable squamous cell carcinoma