Bronchial carcinoma Flashcards
How common is bronchial carcinoma?
13% of cancer cases in UK (2013).
Most common malignant tumour worldwide.
Who is affected by bronchial carcinoma?
Adults - more common in men than in women (due to exposure?)
What causes bronchial carcinoma?
Multifactorial (combination of risk factors)
What are the risk factors, (and how can they be reduced)?
- Tobacco smoking (cessation)
- Passive smoking (avoidance/legislation)
- Radon exposure (detectors)
- Asbestos (avoidance)
- Heavy Metals
- Polycyclic aromatic hydrocarbons
- HIV infection (treatment)
- Pulmonary fibrosis
- Genetic factors
How does bronchial carcinoma present (local effects)?
Cough - most common
Breathlessness
Haemoptysis
Chest pain - chest wall/pleural involvement = sharp, large mediastinal nodal disease = dull ache
Wheeze
Hoarse voice - mediastinal node or mediastinal tumour compressing left recurrent laryngeal nerve
Nerve compression - Pancoast tumours in lung apex invade brachial plexus (C8/T1 palsy) causing hand wasting/weakness + radiating pain. Also Horner’s syndrome (compression of sympathetic chain)
Recurrent infections
Phrenic nerve invasion - paralysis of ipsilateral hemidiaphragm
How does bronchial carcinoma present (metastatic effects)?
Liver - anorexia, nausea, weight loss
Bone - pain, fracture
Brain - raised intracranial pressure, headache, confusion
What signs may the patient have on examination?
- Supraclavicular masses (uncommon)
- Horner syndrome (Pancoast)
- Superior vena cava syndrome
- Chest dullness to percussion/absent breath sounds (atelectasis and/or pleural effusion)
- Asymmetric breath sounds
- Pneumothorax
- Orthopnea, cyanosis etc
- ## Tender hepatomegaly
What are the differential diagnoses for bronchial carcinoma?
Bacterial Pneumonia Bronchitis Carcinoid Lung Tumors Mycoplasmal Pneumonia Pleural Effusion Pneumothorax Small Cell Lung Cancer Superior Vena Cava Syndrome in Emergency Medicine Tuberculosis (TB) Viral Pneumonia
How would you investigate this patient?
Plain chest x-ray
CT Thorax and abdomen - look for extent of disease, staging
PET/CT - for characterising extent of mediastinal nodal involvement and distant mets
Fibreoptic bronchoscopy + biopsy
Percutaneous aspiration and bronchoscopy
What would you tell the patient and how would you explain the condition to them?
The tests show possible/definite lung cancer
If unconfirmed explain Ddx
Refer to support service?
How do you think the patient and/or family might be affected by the diagnosis? Will it affect their
ability to work/care for themselves?
A devastating diagnosis - most likely lethal
Will most certainly affect work/care
What questions might the patient have?
How long have I got?
Is it curable?
What is the treatment?
What are side-effects of the treatment?
What pharmacological treatments would you discuss with them? What risks and benefits of treatment are there?
Chemotherapy (adjuvant) - improves response rate and extends median survival in NSCLC. Usual chemotoxic side effects that may be unwanted if disease very advanced
Newer agents targeting epidermal growth factor receptors and tyrosine kinases
What non-pharmacological treatments would you discuss with them? What risks and benefits of treatment are there?
Radiotherapy - palliation/cure - alternative to surgical resection in early stage NSCLC
Laser therapy, endobronchial irradiation and tracheobronchial stents - palliation
What surgical treatments would you discuss with them? What risks and benefits of treatment are there?
Surgical resection is performed in early stage NSCLC (I, II and selected IIIA) with curative intent.
Chemoradiation used in stage III disease to ‘downstage’ disease and make it more amenable to surgery.
