Bronchogenic Carcinoma

Epidemiological The most common of malignancy worldwide

Histological type 1. Small Cell

2. Non-small cell
3. Squamous cell carcinoma
4. Adenocarcinoma
5. Large cell carcinoma
Aetiological Smoking (active and passive)
Asbestosis
Occupational exposure
Chromium, arsenic, iron oxidates, radiation

Clinical features Cough, haemoptysis, dyspnoea, chest pain, recurrent and slow
resolving pneumonia, anorexia, LOW and LOA
Cachexia, pallor, clubbing, HPOA, lymphadenopathy, Horners
syndrome
Pulmonary consolidation, collapse, or effusion
Mets: Bone tenderness, hepatomegaly, confusion, fits, local CNS
signs, cerebellar syndrome, proximal myopathy (dermatomyositis)
and peripheral neuropathy, supraclavicular lymph node (SCC)

Complication 1. Local
Recurrent laryngeal nerve and phrenic nerve, SVC
obstruction (headache, facial congestion, dilated veins),
Horners syndrome (sympathetic ganglion), rib erosion and
pericarditis, Pancoast Syndrome (invasion of lower trunks
(C8-T1) of brachial plexus (wasting of small muscles of hand)
2. Mets
Brain (spinal cord compression), bone, adrenal -> Addisons
and liver
3. Endocrine
Paraneoplastic syndrome (SIADH, high ADH and high ACTH
by SCC; high PTH by squamous cell carcinoma;
gynaecomastia by adenocarcinoma)
4. Neurological
Confusion, cerebellar syndrome, fits, neuropathy,
polymyositis/dermatomyositis, Lambert-Eaton Myasthenic
Syndrome (LEMS)

Lambert Eaton Autoimmune presynaptic disorder of neuromuscular transmission

Myasthenic where quantal of Ach release is impaired.
Syndrome (LEMS) Caused by antibody directed to calcium channels in the presynaptic
membrane. The muscle weakness predominantly affects the
proximal muscles while the extraocular muscle weakness is absent
or mild (c.f. MG)
Investigation Bedside: Sputum for cytology and spo2
Imaging:
CXR (peripheral circular opacity, hilar enlargement,
consolidation, collapse, pleural effusion, cannon ball in mets)
CT scan (to stage the tumour)
PET scan
Radionuclide bone scan
Invasive
Percutaneous fine needle aspirate and bx (peripheral lesion)
Bronchoscopy

Treatment Non small cell carcinoma

Surgical excision for peripheral lesion given no mets spread)
contraindicated in pt who have mets, mediastinal spread and
FEV1 <1.5l)
Curative radiotherapy for poor lung reserve
Chemotherapy radiotherapy for advance case
Small cell carcinoma
Always disseminated at presentation (Surgery not indicated)
May response to chemotherapy: cyclophosphamide,
doxorubicin, vincristine, etoposide/cisplatin radiotherapy
Palliation
SVC obstruction: stenting , radiotherapy and dexamethasone
Haemoptysis, bone pain and cerebral mets -> analgesia,
antiemetics, cough linctus, bronchodilator or
antidepressants
Endobronchial therapy: tracheal stenting, cryoptherapy,
brachytherapy
Pleurodesis for malignant effusion

Prognosis 1. Non-SCC: 50% 2 years survival without spread, 10% 2 years

with spread
2. SCC: Median survival 3 months if untreated; 1-1.5 years if
treated

TNM Staging for Primary Tumour (T)

non-small cell lung TX Primary tumor cannot be assessed, or
ca/small cell lung tumor is proven by the presence of
ca malignant cells in sputum or bronchial
washings but not visualized by imaging or
bronchoscopy
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor 3 cm in greatest dimension,
surrounded by lung or visceral pleura, no
bronchoscopic evidence of invasion, more
 proximal than the lobar bronchus (ie, not
in the main bronchus); or superficial
spreading of tumor in the central airways
(confined to the bronchial wall)
T1a Tumor 2 cm in greatest dimension
T1b Tumor > 2 cm but 3 cm in greatest
dimension
T2 Tumor with any of the following features
of size or extent:
Tumor > 3 cm but 7 cm
Invades visceral pleura (PL1 or PL2)
Involves the main bronchus 2 cm
distal to the carina
Associated with
atelectasis/obstructive
pneumonitis extending to hilar
region but not involving the entire
lung
T2a Tumor > 3 cm but 5 cm in greatest
dimension
T2b Tumor > 5 cm but 7 cm in greatest
dimension
T3 Tumor > 7 cm, or one that directly invades
any of the following:
Chest wall (including superior
sulcus tumors), parietal pleural
(PL3), diaphragm, phrenic nerve,
mediastinal pleura, or parietal
pericardium;
Or, tumor in the main bronchus < 2
cm distal to the carina but without
involvement of the carina; or
associated atelectasis/obstructive
pneumonitis of the entire lung; or
separate tumor nodule(s) in the
same lobe
T4 Tumor of any size that invades any of the
following: heart, mediastinum, great
vessels, trachea, recurrent laryngeal
nerve, esophagus, vertebral body, or
carina; or separate tumor nodule(s) in a
different ipsilateral lobe
Regional Lymph Node
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis to ipsilateral peribronchial
 and/or ipsilateral hilar lymph nodes and
intrapulmonary nodes, including
involvement by direct extension
N2 Metastasis in ipsilateral mediastinal
and/or subcarinal lymph node(s)
N3 Metastasis in contralateral mediastinal,
contralateral hilar, ipsilateral or
contralateral scalene, or supraclavicular
lymph node(s)
Distant Mets
MO No distant metastasis
M1 Distant metastasis
DDX of nodules on Malignancy
lung CXR Abscess
Granuloma
Carcinoid tumour
Pulmonary hamartoma
AV malformation
Encysted effusion (fluid, blood, pus)
Cyst
Foreign body
Skin tumour (seborrhoeic wart)