Bronchial Carcinoma Flashcards
How common is bronchial tumour?
2nd most common cancer in the UK
Most common malignant cancer worldwide
5th most common cause of death in the UK
What is the most common cause of bronchial carcinoma?
What are the other causes of bronchial carcinoma?
Cigarette smoking = 80% in men and 90% in women
Other causes
Environmental: Passive smoking Asbestos exposure Radon exposure Polycyclic aromatic hydrocarbons Ionizing radiation Occupational exposure to arsenic, chromium, nickel, petrolium & oils
Host factors:
Pre-existing lung disease i.e. pulmonary fibrosis, HIV, genetics
Who does bronchial tumour most commonly affect?
Smoker - both men and women equally
Urban > rural
What are the two broad types of lung cancer?
*The distinction is based on the behaviour of the tumour and useful for prognostic information and determining the best treatment.
Small cell carcinoma
Non small cell carcinoma
What are the 3 sub-types of non-small cell carcinoma?
Adenocarcinoma (27%)
Squamous carcinoma (35%)
Large cell carcinoma (10%)
Where do small cell carcinoma arise from and which syndrome do they result in?
Small cell carcinoma arise from endocrine cells (kulchitsky cells) => secreting polypeptide hormones => resulting in paraneoplastic syndrome.
*70% of small cell carcinoma disseminated at presentation.
What are bronchial carcinomas?
Bronchial carcinoma = malignant neoplasm of the lung arising from the epithelium of the bronchus or bronchiole.
What are the symptoms of bronchial carcinoma?
Cough (80%)
Haemoptysis (70%) => tumour bleeding into the airway
Dyspnoea (60%) => central tumours occlude large airways => lung collapse and breathlessness on exertion
Chest pain (40%) => peripheral tumour invading into chest wall/pleura (both innervated) => sharp pleuritic chest pain
Monophonic Wheeze => partial obstruction of airway by tumour
Hoarse voice => mediastinal tumour impinging on left recurrent laryngeal nerve
Recurrent or slow-resolving pneumonia
Nerve compression => pan coast tumours in the apex of the lung
=> compression of sympathetic chain = horner’s syndrome
=> compression of brachial plexus C8/T1 palsy = muscle wasting in hand, weakness and pain radiating down the arm
Lethargy
Anorexia
Weightloss
What are the signs of bronchial carcinoma?
Cachexia
Anaemia
Clubbing
Supraclavicular or axillary nodes
Hypertrophic pulmonary osteoarthropathy
Chest signs:
Consolidation
Collapse
Pleural effusion
What are the signs of metastatic bronchial carcinoma?
Bone tenderness
Hepatomegaly
Confusion ; fits
Focal CNS signs
Cerebellar syndrome - impaired muscle coordination
Proximal myopathy
Peripheral neuropathy
Which nodes and organs does bronchial carcinoma commonly spread too?
Mediastinum, cervical and axillary nodes
Liver, Adrenal glands (Addison's) Bones (bone pain, anaemia, increased calcium) Brain, Skin
What are the complications of bronchial carcinomas?
Local:
Recurrent laryngeal nerve palsy = hoarseness
Phrenic nerve palsy
Superior vena cava obstruction
Horner’s syndrome (pancoast tumour in apex of lung)
Rib erosion
Pericarditis
Atrial fibrillation
What is the most common type of non-small cell carcinoma?
Squamous cell carcinoma - most common in europe
What tissue does squamous cell carcinoma arise from and what are its characteristic features?
Arises from epithelial cells assoc. with production of keratin
Features:
Central necrosis cavity
Causes obstructing lesions of bronchus with post-obstructive infection i.e. pneumonia
Local spread common ; metastasises late
What is the most common type of non-small cell carcinoma in non-smokers?
Adenocarcinoma
What tissue does adenocarcinoma arise from and what are its characteristic features?
Arises from mucus-secreting glandular cells
Features:
Peripheral lesions on CXR/CT
Metastases common i.e. pleura, lymph nodes, brain, bones, adrenal glands
What tissue does large cell carcinoma arise from and what are its characteristic features?
Poorly differentiated
Metastasises early
What tissue does small cell carcinoma arise from and what are its characteristic features?
Arises from neuroendocrine cells
Features:
Secretes polypeptide hormones
Arises centrally and metastasises early
Investigations are important to stage the extent of the disease, make a tissue diagnosis i.e. small cell or non-small cell carcinoma and plan treatment.
What investigations are carried out when suspecting a bronchial cancer?
Blood tests: FBC for anaemias, LFT for liver involvement, hypercalcaemia and hyponatraemia
Chest X-ray: peripheral nodules, hilar enlargement, consolidation, pleural effusion, collapse
CT: to stage the tumour => image should include adrenal glands and liver (common sites for metastases)
Cytology: sputum & pleural fluid
Fine needle aspiration or biopsy of peripheral lesions/lymph nodes
F-deocyglucose PET: helps with staging
Radionucleide bone scan: suspected metastases
Lung function test to assess suitability for lobectomy
Which test assesses suitability for lobectomy?
Lung function test ± cardiopulmonary exercise testing, stress echo
What is the staging used for non-small cell carcinoma?
TNM staging => assesses the extent of spread
What is palliative radiation treatment?
Radiation therapy => symptomatic control of lung cancer for bone and chest pain from metastases or direct invasion, haemoptysis, occluded bronchi and superior vena cave obstruction
What is the treatment for non-small cell carcinoma?
- Lobectomy (open or throacoscopic) = treatment of choice in medically fit patients => curative
- Parenchymal sparing operation => borderline fit patients and smaller tumours (T1, N0, M0)
- Radical radiation therapy for stage I, II, III
- Chemotherapy ± radiation for advanced disease
- Palliative radiotherapy => bronchial obstruction, super vena cava obstruction, haemoptysis, bone pain and cerebral metastases
What is the treatment for small cell carcinoma?
- Surgery in limited stage disease
- Chemotherapy ± radiotherapy if well enough
- Palliative radiotherapy => bronchial obstruction, superior vena cava obstruction, haemoptysis, bone pain and cerebral metastases
- Superior vena cava stent + radiotherapy and dexamethasone for superior vena cava obstruction
- Endobronchial therapy => tracheal stenting, cryotherapy, laser, brachytherapy (radioactive source placed near the tumour) => these are palliative techniques used on inoperable tumours
- Pleural drainage/pleurodesis for symptomatic pleural effusion
- Drugs: analgesia, steroids, anti-emetics, cough linctus, bronchodilators, anti-depressants
What is the prognosis for non-small cell carcinoma and small cell carcinoma?
Non-small cell carcinoma = 10 years survival without spread ; 2 years with spread
Small cell carcinoma = 3 months ; 1/1.5 years if treated
What are the differential diagnosis for a nodule found in the lung on a chest x-ray?
Primary or secondary malignancy
Abscess
Granuloma
Carcinoid tumour
Pulmonary hamargtoma
Arteriovenous malformation
Encysted effusion (fluid, blood, pus)
Cyst
Foreign body
Mesothelioma cases have increased since mid-1800’s.
What is mesothelioma and what is it’s clinical presentation?
Mesothelioma = malignant tumour arising from visceral and parietal mesothelial lining of the lung.
Common presentation = pleural effusion with persistent chest wall pain => raise suspicion even if initial pleural fluid/biopsy samples non-diagnostic.
What investigations are carried out for diagnosis in a suspected mesothelioma and how is it managed?
CT/ultrasound guided biopsy or pleural biopsy => need sufficient tissue for diagnosis
Limited management for patients
Which cancers commonly metastasise to the lungs?
Prostate Breast Bone Gastrointestinal tract Cervix Ovary Kidney
What are bronchial carcinoid tumours?
What are its related symptoms?
Slow-growing, low-grade malignant neoplasms, arising from neuro-endocrine tumours. As foregut derivates, they secrete adrenocorticotrophic hormone.
Symptoms are related to obstruction, recurrent infection or haemoptysis.
How is bronchial carcinoid tumours managed?
Which staging system is used?
Surgery = treatment of choice + long term surveillance
Staging system used is same as non-small cell carcinoma (TNM staging).
What is the most common benign lung tumour?
Pulmonary hamartoma => well defined on x-ray, extremely slow growing
What is bronchial adenoma?
Benign lung tumour arising from mucus glands and ducts of the windpipe.
