Bronchial Carcinoma Flashcards
BRONCHIAL CARCINOMA
• Most Common Malignant disease; 1.4 million deaths worldwide; 3rd most common cause of
death in the UK after IHD and Stroke; Commonest cause of cancer-related death in both sexes
• Cigarette smoking accounts for >90% of Lung Cancer; Higher Incidence of Bronchial
Carcinoma in Urban compared to Rural areas
• 20% Mortality Benefit for screening in high risk populations 55-74yrs with low dose CT
• Divided into Small Cell Lung Cancer (SCLC; 20%) and Non-Small Cell Lung Cancer (NSCLC);
Distinction important for guiding treatment and prognosis
o NSCLC divided into Adenocarcinoma (Most common), Squamous Cell Carcinoma
(Second most common), Large Cell Carcinoma and Large Cell Neuroendocrine
Presentation of Bronchial Carcinoma
• Cough – Most commonly encountered symptom; “Three Week Cough” merits CXR
• SOB – Central tumours occlude Large Airways resulting in Lung Collapse and SOBOE; May be
due to coexistent COPD in smokers
• Haemoptysis – Fresh or old blood due to tumour bleeding into airway
• Sharp Pleuritic Chest Pain due to tumour invasion into Chest Wall or Pleura; Large Volume
Mediastinal Nodal disease might present with characteristic Central Chest Ache
• Wheeze – Monophonic due to partial obstruction of airway by tumour
• Nerve Compression and Invasion – Hoarseness of Voice (Left Recurrent Laryngeal Nerve) and
Horner’s Syndrome of Ptosis, Miosis, Anhidrosis (Pancoast Tumour on Sympathetic chain);
Also, can produce C8/T1 Brachial Plexus Palsy; Phrenic Nerve involvement
• Recurrent, Post-obstructive Pneumonia due to partial obstruction; Dysphagia and Pericardial
Effusion, Malignant Dysrhythmia due to Oesophagus and Pericardial invasion
• SVC Obstruction, Tracheal Obstruction (Leads to Stridor)
• Normocytic Anaemia, Thrombocytosis, Finger Clubbing and Hypertrophic Osteoarthropathy
Metastatic Spread of Bronchial Carcinoma
• Commonly spreads to Mediastinal, Cervical, Axillary or even Intraabdominal Nodes;
• Liver – Anorexia, Nausea, Weight Loss, RUQ pain
• Bone – Bony pain, Pathological fractures, Spinal Cord Compression
• Adrenal Glands – Usually Asymptomatic
• Brain – Present as Space Occupying Lesions; Mass Effect and raised ICP; Can also cause
Carcinomatous Meningitis with CN compression, Headache and Confusion
• Malignant Pleural Effusion – SOB associated with Pleuritic pain
Staging and Diagnosis of Bronchial Carcinoma
• CXR – Initial radiograph might be normal either because
lesion is small or is centrally confined
• CT – Should include Adrenal Gland and Liver; for TNM
o Lymph nodes <1cm not classified as enlarged but
might still contain malignant cells; Enlarged nodes
do not always contain malignant cells
o Direct sampling of affected nodes and PET to
assess distant spread
• PET – Investigation of Choice for Mediastinal Nodal
Involvement, Highlighting Distant Metastases; Combined
as PET/CT; Positive Predictive Value of positive nodes is low
• MRI not useful for diagnosis other than Pancoast with
Nerve Invasion, or assessing chest wall
• Bronchoscopy – For obtaining tissue and cytology; If
Carcinoma involves first 2cm of either main bronchus,
inoperable as insufficient resection margins from
Pneumonectomy; Loss of Carina angle might be either
Malignant or Reactive Lymphadenopathy
• Percutaneous Aspiration and Biopsy – For peripheral lung
lesions; Complications include Pneumothorax (10% of
patients); Implantation Metastasis does not occur
• Endobronchial Ultrasound – Visualise majority of
Mediastinal Lymph nodes then guide FNAC;
Transoesophageal for sampling Left Adrenal and harder to
reach Mediastinal nodes
• Ultrasound Guided Supraclavicular Node Sampling
• Video-assisted Thoracoscopic Surgery (VATS) – Biopsy and Drainage of Effusion via Minimally
Invasive Surgery; Pleurodesis can also be performed to prevent recurrence of effusion
TREATMENT OF BRONCHIAL CARCINOMA
• Assessing Fitness to Treat – Full Lung Function Testing, Cardiopulmonary Exercise Testing,
Stress Echocardiography, Preoperative Angiography if CVD present
• Majority of cases are incurable at presentation or have comorbidities which preclude radical
treatment; Horrible Prognosis for Lung Cancers in general
• Surgery – Performed for Early Stage NSCLC with curative intent; Neoadjuvant Chemotherapy
to reduce tumour size and increase likelihood of complete resection
o If Surgical Staging shows Nodal Involvement, Patients require adjuvant Chemotherapy
• Radiotherapy – For patients with adequate lung function and early stage NSCLC, High Dose
Radiotherapy or Continuous Hyperfractionated Accelerated Regimens (CHART) for curative
intent with results comparable to surgery
o Radiation Pneumonitis – Acute Infiltrate confined to radiotherapy area occurring
within 3 months of Radiotherapy in 10-15% of cases
o Radiation Fibrosis – Fibrotic change occurring within a year, not precisely confined to
area occurs to some degree in all cases
o Stereotactic Radiotherapy and RF Frequency Ablation also possible
o Also given as Consolidation treatment in SCLC at the end of Chemotherapy
• Palliative Radiotherapy – Bone and Chest Wall pain from Metastases or direct Invasion,
Haemoptysis, Occluded Bronchi and SVC obstruction response favourably in short term
• Chemotherapy – Adjuvant Chemotherapy with Radiotherapy improves response rate and
extends median survival in NSCLC
o EGFR and Tyrosine Kinase Inhibitors in NSCLC (Especially Adenocarcinoma)
Techniques for Palliation
o Nd-Yag Laser to vaporise inoperable fungating Intraluminal Carcinoma; Also, useful
for benign tumours, strictures and vascular lesions for
symptomatic relief
o Endobronchial Brachytherapy – Reduced tumour size
occurs in 70-95% of cases
o Tracheobronchial Stents – Silicone or Expanding
Metal Stents to maintain lumen patency against
strictures, external compression or wall collapse
o Psychological and Emotional Support by MDT
SECONDARY LUNG TUMOURS
• Common site of Metastases from Renal, Prostatic, Breast, Bone, GI, Cervical or Ovarian Ca,
presents as round shadows; Detected on CXR
o Solitary Round Shadow on CXR most commonly Renal
o DDX: Primary Cancer, TB, Benign tumour, Hydatid Cyst
• Nearly always develop in Parenchyma and mostly asymptomatic; Rarely in Bronchus where it
may present as Haemoptysis
• Lymphatic spread from Stomach, Pancreas and Breast (Lymphangitis Carcinomatosis) leading
to progressive SOB; BHL and Streaky Basal Shadowing
• Surgical removal of Single Pulmonary Metastases possible but PET/CT due to possible
presence of small metastases not detectable on CXR
CYSTIC FIBROSIS
• Increased Viscosity and Tenacity of Epithelial Mucus; Classical form presents with
Bronchopulmonary infections and Pancreatic Insufficiency with High Sweat Na+
and Cl-
• Autosomal Recessive disorder with carrier frequency of 1 in 22 in Caucasians
• Gene Mutation affecting 7q31.2; Most commonly ΔF508 Deletion (70%) resulting in Defect in
CF Transmembrane Conductance Regulator (CFTR) leads to failure of opening of Chloride
Channel in response to cAMP
o Decreased Chloride excretion into airway lumen and Increased Sodium reabsorption
into Epithelial cells results in less excretion of salt
o Less excretion of Water leads to increased viscosity
• Progressive Respiratory Failure; Life expectancy about 40yrs
• Infection with Burkholderia cepacia associated with accelerated disease and rapid death
Presentation of Cystic Fibrosis
• Lungs structurally normal at birth but develops frequent respiratory infections; Commonest
cause of Recurrent Bronchopulmonary Infection in childhood
• Sinusitis and Nasal Polyps are common; SOB and Haemoptysis as Airflow Limitation and
Bronchiectasis develops
• Spontaneous Pneumothorax, Respiratory failure and Cor Pulmonale might develop
• Meconium Ileus due to Meconium viscosity; Might develop Meconium Ileus Equivalent
Syndrome later in life (Small Intestinal Obstruction)
• Symptomatic Steatorrhoea (85% of patients) due to Pancreatic Insufficiency
• Cholesterol Gallstones with increasing frequency, Cirrhosis (5% of patients) and increased
incidence of Peptic Ulcers and GI Malignancy
• Malnutrition due to Malabsorption/Maldigestion; Associated with risk of pulmonary sepsis
o Puberty and Skeletal Maturity delayed in most CF patients
o Males infertile due to failure of Vas Deferens and Epididymis development
o Females might be able to conceive but secondary amenorrhoea as disease progresses
Investigations for Cystic Fibrosis
- Establish Family History, Blood DNA Analysis of gene defect
- High Sweat Sodium Concentration (>60mmol/L)
- CXR Bronchiectasis
- Absent Vas Deferens and Epididymis
- Blood Immunoreactive Trypsin Levels for screening
Treatment of Cystic Fibrosis
• Smoking cessation, Influenza and Pneumococcal Vaccination, Pulmonary Rehabilitation
• Oxygen Therapy as needed; Antibiotic therapy for infections
o Non-invasive O2 therapy as bridge to surgery
• Nebulised Anti-Pseudomonas antibiotic therapy (e.g. Piperacillin)
• β2 Agonists and Inhaled Corticosteroids for symptomatic relief
• Inhaled Dornase Alfa (Recombinant DNAse) and Hypertonic saline for short term benefit;
Acetylcysteine and Amiloride (Inhibits ENaC) have poor results
• Treatment for Pancreatic Insufficiency (e.g. Creon) and Malnutrition
