Bronchial Carcinoma Flashcards
How common is it?
- Accounts for ~1% of all cancers and 27% of cancer deaths. (40,000 cases/yr in UK).
Who does it affect?
Smokers, ex-smokers, people exposed to occupational carcinogens. Women who have never smoked at greater risk than men. Risk increases with age. Black men who have never smoked at greater risk.
What causes it?
Histology – Squamous (35%); adenocarcinoma (27%; small (oat) cell (20%); large cell (10%); alveolar cell carcinoma (rare, <1%). Clinically the most important division is between small cell (SCLC) and non-small cell (NSCLC).
What risk factors are there (and how can they be reduced)?
Cigarette smoking is major risk factor.
- Others = asbestos, chromium, arsenic, iron oxides and radiation (radon gas).
How does it present?
Symptoms
Cough (80%); haemoptysis (70%); dyspnoea (60%); chest pain (40%); recurrent or slowly resolving pneumonia; lethargy; anorexia; weight loss.
Signs
Cachexia; anaemia; clubbing; HPOA (hypertrophic pulmonary osteoarthropathy, causing wrist pain); supraclavicular or axillary nodes.
Chest signs
None, or: consolidation; collapse; pleural effusion.
Metastases
Bone tenderness; hepatomegaly; confusion; fits; focal CNS signs; cerebellar syndrome; proximal myopathy; peripheral neuropathy.
Complications
Local – recurrent laryngeal nerve palsy; phrenic nerve palsy; SVC obstruction; Horner’s syndrome (Pancoast’s tumour); rib erosion; pericarditis; AF.
Metastatic – brain; bone; liver; adrenals.
Endocrine – ectopic hormone secretion (eg SIADH and ACTH) by small cell tumours; PTH by squamous cell tumours.
Non-metastatic neurological – confusion; fits; cerebellar syndrome; proximal myopathy; neuropathy; polymyositis; Lambert-Eaton syndrome.
Other – clubbing, HPOa, dematomyoairia, acanthosis nigricans, thrombophlebitis migrans.
Which other conditions may present similarly?
Differential diagnoses of a nodule in lung on a CXR
- Malignancy (1⁰ or 2⁰)
- Abscesses
- Granuloma
- Carcinoid tumour
- Pulmonary hamartoma
- Aterio-venous malformation
- Encysted effusion (fluid, blood, pus)
- Cyst
- Foreign body
- Skin tumour
How would you investigate the patient?
Cytology – sputum and pleural fluid.
CXR – peripheral nodule, hilar enlargement, consolidation, lung collapse, pleural effusion, bony secondaries.
Peripheral lesions and superficial lymph nodes may be amenable to percutaneous fine needle aspiration or biopsy.
CT – to stage tumour and guide bronchoscopy.
Bronchoscopy – to give histology and assess operability ± endobronchial ultrasound for assessment and biopsy.
F-deoxyglucose PET or PET/CT scan – to help in staging.
Radionuclide bone scan – if suspected metastases.
Lung function tests – to assess suitability for lobectomy.
What treatment/s would you consider? What risks and benefits of treatment are there?
Non-small cell tumours
- Excision is treatment of choice for peripheral tumours, with no metastatic spread: stage I/II.
- Curative radiotherapy is an alternative if respiratory reserve is poor.
- Chemotherapy ± radiotherapy for more advanced disease.
Small cell tumours =almost always disseminated at presentation. They may respond to chemotherapy but invariably relapse (cyclophosphamide + doxorubicin + vincristine + etoposide; or cisplatin ± radiotherapy if limited disease).
Pallitation
- Radiotherapy – used for bronchial obstruction, SVC obstruction, haemoptysis, bone pain and cerebral metastases.
- SVC stent + radiotherapy + dexamethasone for SVC obstruction.
- Endobronchial therapy – tracheal stenting, cyrotherapy, laser, brachytherapy (radioactive source placed close to tumour).
- Pleural draining/pleurodesis – for symptomatic pleural effusions.
- Drugs – analgesia; steroids; antiemetics; cough linctus (codeine); bronchodilators; antidepressants.
Prognosis
- Non-small cell: 50% 2 yr survival without spread; 10% with spread.
- Small cell: median survival 3 months if untreated; 1-1½ yrs is treated.
