Mediicine, respiratory system, bronchial carcinoma

1. FOYEZ AHMED HASAN
BATCH : K-68

2. Global situation
 30,000 new cases of lung cancer per year in
England (6,000 in Scotland)
 Commonest cause of cancer death (33%) in men
 Commonest cause of cancer death in women in
Scotland (20%)
 90% mortality 1 year after diagnosis
 The most rapidly increasing cancer in developing
countries

3. classsification
 Primary
 Benign (rare)
 Hamartoma
 Squamous papillomatosis
 Pleomorphic adenoma
 Bronchial carcinoid
 Malignant (very common)
 Metastatic (Very common)

4. Risk factors
 Tobacco smoke- active or passive
 Asbestos
 Nickel
 Chromates
 Cadmium
 Radiation
 Atmospheric pollution
 (genetics)

5. Based on the characteristics of the disease and its
response to treatment -
 Small cell lung cancer (SCLC)
 Non-small cell lung cancer (NSCLC)

7. Squamous or epidermoid carcinoma
• The commonest type,
• Accounting for approximately 40% of all carcinomas.
• Most present as obstructive lesions of the bronchus
leading to infection.
• Occasionally cavitates (10%) at presentation.
• The cells are usually well differentiated
• Occasionally anaplastic.
• Local spread is common
• Widespread metastases occur relatively late.

8. Squamous carcinoma (keratinising)

9. Adenocarcinoma
• Arises from mucous cells in the bronchial epithelium.
• Invasion of the pleura and the mediastinal lymph nodes is
common, as are metastases to the brain and bones.
• Accounts for approximately 10% of all bronchial carcinomas.
• The most common bronchial carcinoma associ ated with
asbestos
• Proportionally more common in
•Non-smokers
•Women
•Elderly
•Far East.

10. Adenocarcinoma (gland forming)

11. Adenocarcinoma with mucin (blue stained)

12. Large cell carcinomas
 Less-differentiated forms of squamous cell and
adenocarcinomas.
 Account for about 25% of all lung cancers
 Metastasize early.

13. Large cell carcinoma

14. Small-cell carcinoma
 Often called oat-cell carcinoma,
 Accounts for 20-30% of all lung cancers.
 Arises from endocrine cells(Kulchitsky cells).
 Small-cell carcinoma spreads early and is almost
always inoperable at presentation.
 Rapidly growing and highly malignant.
 Responds to chemotherapy
 Prognosis remains poor

15. Small cell carcinoma

16. Clinical features
Lung cancer presents in many different ways, reflecting
local, metastatic or paraneoplastic tumour effects.
Cough:
 This is the most common early symptom.
 It is often dry but secondary infection may cause
purulent sputum
Haemoptysis
 Haemoptysis is common, especially with central
bronchial tumours.

17. Clinical features

18. Clinical features
Bronchial obstruction
Complete obstruction causes
 collapse of a lobe or lung
 Breathlessness
 mediastinal displacement
 dullness to percussion
 reduced breath sounds.
Partial bronchial obstruction may cause
 monophonic, unilateral wheeze that fails to clear

19. Clinical features
with coughing & impair the drainage of secretions to
cause pneumonia or lung abscess
 Pneumonia that recurs at the same site or
responds slowly to treatment, particularly in a smoker,
should always suggest an underlying bronchial
carcinoma.
 Stridor (a harsh inspiratory noise) occurs when the
larynx, trachea or a main bronchus is narrowed by the
primary tumour or by compression from malignant
enlargement of the subcarinal and paratracheal lymph
nodes.

20. Clinical features
Breathlessness.
Breathlessness may be caused by
 collapse or pneumonia
 tumour causing a large pleural effusion or compressing a
phrenic nerve and leading to diaphragmatic paralysis.
Pain and nerve entrapment.
 Pleural pain usually indicates malignant pleural invasion
 Intercostal nerve involvement causes pain in the
distribution of a thoracic dermatome.

21. Clinical features
 Carcinoma in the lung apex may cause Horner’s
syndrome (ipsilateral partial ptosis, enophthalmos,
miosis and hypohidrosis of the face) due to
involvement of the sympathetic chain at or above
the stellate ganglion.
 Pancoast’s syndrome (pain in the inner aspect of the
arm, sometimes with small muscle wasting in the
hand) indicates malignant destruction of the T1
and C8 roots in the lower part of the brachial
plexus by an apical lung tumour.

22. Clinical features
Mediastinal spread
 Dysphagia (Involvement of the oesophagus )
 Arrhythmia or pericardial effusion (If the pericardium
is invaded)
 Superior vena cava obstruction by malignant nodes causes
 suffusion and swelling of the neck and face,
 conjunctival oedema
 headache
 dilated veins on the chest wall

23. Clinical features
 Involvement of the left recurrent laryngeal nerve by
tumours at the left hilum causes vocal cord paralysis,
voice alteration and a ‘bovine’ cough (lacking the
normal explosive character).
 Supraclavicular lymph nodes may be palpably enlarged
or identified using ultrasound

24. Clinical features
Metastatic spread
 focal neurological defects
 epileptic seizures
 personality change
 Jaundice
 bone pain
 skin nodules
 Lassitude, anorexia and weight loss usually indicate
metastatic spread.

25. Clinical features
Finger clubbing
 Overgrowth of the soft tissue of the terminal phalanx
 increased nail curvature
 nail bed fluctuation
Hypertrophic pulmonary osteoarthropathy
(HPOA)
 painful periostitis of the distal tibia, fibula,radius and ulna
 local tenderness
 sometimes pitting oedema over the anterior shin.
 X-rays reveal subperiosteal new bone formation.

26. Clinical features

27. PANCOAST TUMOR

28. Pancoast syndrome

29. Physical Examination
 General Examination :
 Appearance: ill looking, may be grossly emaciated
 Nutrition: below average
 Anaemia: moderately anemic
 Clubbing: generalized clubbing involving all the fingers an toes
(HPOA present/not)
 Cyanosis,jaundice,edema: absent
 Koilonychia,leukonychia: absent
 Lymphadenopathy:Rt supraclavicular lymph node are
enlarged,hard in consistency,non tender,fixed with underlying
structure and overlying skin
 Bony tenderness:
 Skin condition:

30. Physical Examination
 Systemic Examination :
 Respiratory system examination:
 Evidence of pneumonia, pleural effusion, lung abscess.
 CVS:
 Arrythmia, pericardial effusion
 Nervous system examination:
 Higher psychic function: confusion, fits
 Cranial nerves: focal neurological signs, papilloedema
 Motor functions: hemiplegia
 Sensory functions: mono/polyneuropathy
 Cerebellar dysfunction
 Musculoskeletal system examination: Proximal myopathy,
dermatomyositis

31. Expanded Clinical Evaluation Symptoms
Elicited in History:
 Constitutional—weight loss greater than 10 lb
 Musculoskeletal—focal skeletal pain
 Neurologic-headaches, syncope, seizures, extremity weakness,
recent change in mental status
 Signs Found on Physical Examination:
 Lymphadenopathy (>1 cm)
 Hoarseness,
 superior vena cava syndrome
 Bone tenderness
 Hepatomegaly (>13-cm span)
 Focal neurologic signs, papilledema
 Soft tissue mass

32. INVESTIGATIONS

33. INVESTIGATIONS

34. INVESTIGATIONS

35. Investigations
 Routine Laboratory Tests :
 CBC with PBF: Hematocrit less than 40% in males Hematocrit
less than 35% in females
 LFT: Elevated alkaline phosphatase, GGT, AST, calcium AST,
aspartate aminotransferase ; GGT, γ- glutamyl transpeptidase.
 Imaging:
 CxR PA view: The features of bronchial carcinoma on plain X-rays are
variable:
 CT is usually performed early, as
 it may reveal mediastinal or metastatic spread, and
 helps to direct histological sampling procedures.
 also indicates whether a tumour is likely to be accessible by bronchoscopy.

36. Investigations
 USG: evidence of tumour spread to sites.
 Pleural biopsy: Pleural fluid aspiration and biopsy is the preferred investigation
 FNAC:
 lymph node biopsy: to give histology
 Bronchoscopy: to give histology and operability
 Where facilities exist, thoracoscopy increases yield by allowing
targeted biopsies under direct vision.
 bone marrow biopsy: evidence of tumour spread to sites.
 Combined CT and PET imaging is used increasingly to detect metabolically
active tumour metastases
 Radioneuclide bone scanning: if suspected metastasis
 Lung function tests:

37. Radiological Clues to Suspect
Malignancy
1. Mass lesion or coin shadow…..fig 1
2. Mediastinal widening due to enlargement of
lymph nodes ……fig 5
3. Rib erosion and rib fracture….fig 3
4. Phrenic nerve paralysis in the presence of
mediastinal mass
5. Presence of pleural effusion….fig 6
6. Cannon ball shadows….fig 4

38. Large cavitated bronchial carcinoma in left
lower lobe……..fig:1

39. Collapse of the right lung: Fig…2

40. Bronchogenic carcinoma. Left upper/zone
consolidation due to tumor and collapse. Rib erosion (arrow)
suggests malignant lesion—bronchogenic carcinoma….Fig 3

41. Pulmonary metastases. Bilateral cannon ball
shadows—common primaries thyroid, bone and
viscera..FIG :4

42. Lymphoma. Note: The bilateral paratracheal lym-
phadenopathy (arrowheads) is a common cause of mediastinal
syndrome…..Fig: 5

43. Pleural effusion right. Note: Hazy opacity occupying the right lower part, rising in
the axilla (long arrow 1). The costo-phrenic (short arrow 2) and cardiophrenic
angle (arrowhead 3) are obliterated in massive effusions, mediastinum is
displaced to the opposite side……………………………………fig 6

44. Common radiological presentations
of bronchial carcinoma
 1. Unilateral hilar enlargement: Central tumour. Hilar glandular
involvement. However, a peripheral tumour in the apical segment of a lower
lobe can look like an enlarged hilar shadow on the PA X-ray
 2. Peripheral pulmonary opacity: Usually irregular but well circumscribed,
and may contain irregular cavitation. Can be very large
 3. Lung, lobe or segmental collapse: Usually caused by tumour within the
bronchus leading to occlusion. Lung collapse may be due to compression of
the main bronchus by enlarged lymph glands
 4. Pleural effusion: Usually indicates tumour invasion of pleural space; very
rarely, a manifestation of infection in collapsed lung tissue distal to a bronchial
carcinoma

45. Common radiological presentations of
bronchial carcinoma
 Broadening of mediastinum, enlarged cardiac
shadow, elevation of a hemidiaphragm
 Paratracheal lymphadenopathy may cause widening of the
upper mediastinum.
 A malignant pericardial effusion will cause enlargement of the
cardiac shadow.
 Raised hemidiaphragm is caused by phrenic nerve palsy,
screening will show it to move paradoxically upwards when
patient sniffs
 8. Rib destruction: Direct invasion of the chest wall or
blood-borne metastatic spread can cause osteolytic
lesions of the ribs

46. Lung cancer in right lung (CT of
thorax)

47. Lung cancer in right lung( Positron
emission tomography showing increased
uptake in tumour. )

48. Lung cancer in right lung(Lung cancer
seen through a bronchoscope
(arrow))

49. Lung cancer seen through a
bronchoscope

56. Surgical treatment
Surgery is performed in early stage non-small cell
lung cancer (stage I, II and in selected IIIA)with
curative intent.
Many patients with stage III disease are treated with
chemo-radiation with a view to ‘downstaging’
disease and render it amenable to surgical resection

57. Surgical treatment
Accurate pre-operative staging, coupled with improve-
ments in surgical and post-operative care now offers 5-
year survival rates of over………
 75% in stage I disease (NO, tumour confined within
visceral pleura)
 55% in stage II disease
which includes
resection in patients with ipsilateral peribronchial or
hilar node involvement.

58. Radiotherapy
 For cure
 patients who are fit and who have a slowly growing squamous
carcinoma,
 treatment of choice if surgery is declined.
 For symptomatic relief
 Bone pain
 Haemoptysis
 Superior vena cava obstruction

59. Chemotherapy
 Mainly for SCLC, less effective for NSCLC.
 Combination chemotherapy
 i.v. Cyclophosphamide
 Doxorubicin
 Vincristine or i.v. cisplatin
 Etoposide

60. TREATMENT

61. TREATMENT

62. TREATMENT

63. TREATMENT

65. Contraindication of surgery

67. RADIOTHERAPY
Indications:

68. ROLE OF CHEMOTHERAPY

69. prognosis