Bronchial carcinoma

Definition: Malignancy of lung parenchyma.

Aetiology:

·         Cigarette smoking (at least 90%).

·         Occupational e.g. Asbestosis exposure.

·         Atmospheric pollution.

·         Genetic factor.

·         Radiation.

·         Common age in between 50-75 years.

·         Male: Female =4:1

Sites:

·         Centrally…….55%

·         Peripherally….40%

·         Diffuse………5%

Clinical Presentation: When the tumour obstructs a large bronchus. It causes pulmonary collapse and infection and symptoms arise early:

Patient profile: Middle aged or elderly, cigarette smoker.

Symptoms:

[A]General symptoms:

1.      Fever.

2.      Anorexia.

3.      Nausea.

4.      Weight loss. (Usually late symptom)

5.      Lassitude.

6.      Tiredness.

[B]Local symptoms:

1.      Cough: Most common early symptoms, sputum is purulent if secondary infection.

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

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

4.      Stridor (tumour compress the main bronchi)

[C]Symptoms due to metastasis:

1.      Pleural pain.

2.      Pain in the shoulder and arm.

3.      Hoarseness of voice-Due to compression over left recurrent laryngeal nerve.

4.      Superior vena caval obstruction.

5.      Dysphagia: Due to esophagus involvement.

6.      Stridor: Due to involvement of trachea.

7.      Bone pain: Due to bone involvement.

[D]Non-metastatic extra-pulmonary manifestation:

1.      Endocrine: Inappropriate ADH secretion causing hyponaturemia.

·         Cushing’s syndrome.

·         Carcinoid syndrome.

·         Gynaecomastia.

2.      Neurological: Polyneuropathy, Myelopathy, Myasthenia gravis.

3.      Others: Digital clubbing, Eosinophilia.

Signs:

[A]Peripheral signs:

·         Anaemia, Weight loss, clubbing.

·         Lymphadenopathy.

·         Horner’s syndrome.

[B]Lung signs: Depends on the characteristics of tumour:

·         Peripheral pulmonary opacity: Usually irregular but well circumscribed may have irregular cavitations in it.

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

·         Pleural effusion: Usually indicates tumour invasion of pleural spaces.

·         Broadening of mediastinal invasion.

·         Enlarged cardiac shadow: Manifestation of mediastinal invasion.

·         Elevation of hemidiaphragm.

Investigations:

1.      Blood: Hb%-ruduced, ESR-raised marked.

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 & pleural fluid.

4.      Lymph node biopsy.

5.      Fibroptic bronchoscopy and pleural (tumour) biopsy.

6.      MRI: Very useful for staging lung tumours.

7.      Transthoracic FNAC.

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

Treatment:

[A] Supportive measure:

1.      Nutritional supplement.

2.      Blood transfusion (for correction of anaemia)

3.      Analgesic (for pain).

[B]Therapeutic treatment:

1.      Surgery.

2.      Radiotherapy.

3.      Chemotherapy.

4.      Laser therapy.

Surgical treatment:

1.      Stage I & II: Fit surgical removal-

·         Lobectomy (for localized tumours)

·         Pneumoectomy (for localized tumours)

2.      Stage III & IV: No surgery, only radiotherapy.

Radiotherapy:

1.      Curative therapy: Usually for stage I, II.

2.      Palliative therapy: Usually for stage III & below

·         SVC syndrome.

·         Skeletal metastatic deposit.

·         Obstruction in trachea & bronchi.

Chemotherapy: Only used in undifferentiated and small cell carcinoma. Drugs used in chemotherapy (standard combination): are

·         Cyclophosphamide +Doxorubicin+Vincristin Or

·         Cisplantin+Etoposide (given every 3 weeks for 3-6 cycles)

Laser therapy & stenting:

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

2.      Endobronchial stent is used to maintain airway patency in the face of extrinsic compression by malignant nodes.

Palliative care: As compared with fatal cancer at other sites, patients with lung cancer remain relatively independent and pain-free, but die more rapidly-once they reach the terminal phase.

Daily treatment with:

1.      Prednisolone up to 15 mg daily (improves appetite)

2.      Morphine/Diamorphine: for pain.

3.      Opiates (S/C injection) with regular laxatives.

4.      Short course of palliative radiotherapy: for bone pain, severe cough or haemoptysis.

Complications:

[A]Local effects:

1.      Bronchial obstruction: Collapse, consolidation, abscess.

2.      Malignant pleural effusion.

3.      Superior vena caval (SVC) obstruction.

4.      Erosion of large vessels.

5.      Direct spread to chest wall, brachial plexus.

6.       Horner’s syndrome from cervical sympathetic compression.

[B]Metastases:

1.      Specially hilar-nodes.

2.      Liver, brain, bones.

3.      Adrenal glands and skin.