Bronchial Carcinoma

Question 1

How common is bronchial tumour?

Answer 1

2nd most common cancer in the UK

Most common malignant cancer worldwide

5th most common cause of death in the UK

Question 2

What is the most common cause of bronchial carcinoma?

What are the other causes of bronchial carcinoma?

Answer 2

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

Question 3

Who does bronchial tumour most commonly affect?

Answer 3

Smoker - both men and women equally

Urban > rural

Question 4

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.

Answer 4

Small cell carcinoma

Non small cell carcinoma

Question 5

What are the 3 sub-types of non-small cell carcinoma?

Answer 5

Adenocarcinoma (27%)

Squamous carcinoma (35%)

Large cell carcinoma (10%)

Question 6

Where do small cell carcinoma arise from and which syndrome do they result in?

Answer 6

Small cell carcinoma arise from endocrine cells (kulchitsky cells) => secreting polypeptide hormones => resulting in paraneoplastic syndrome.

*70% of small cell carcinoma disseminated at presentation.

Question 7

What are bronchial carcinomas?

Answer 7

Bronchial carcinoma = malignant neoplasm of the lung arising from the epithelium of the bronchus or bronchiole.

Question 8

What are the symptoms of bronchial carcinoma?

Answer 8

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

Question 9

What are the signs of bronchial carcinoma?

Answer 9

Cachexia

Anaemia

Clubbing

Supraclavicular or axillary nodes

Hypertrophic pulmonary osteoarthropathy

Chest signs:
Consolidation

Collapse

Pleural effusion

Question 10

What are the signs of metastatic bronchial carcinoma?

Answer 10

Bone tenderness

Hepatomegaly

Confusion ; fits

Focal CNS signs

Cerebellar syndrome - impaired muscle coordination

Proximal myopathy

Peripheral neuropathy

Question 11

Which nodes and organs does bronchial carcinoma commonly spread too?

Answer 11

Mediastinum, cervical and axillary nodes

Liver, 
Adrenal glands (Addison's) 
Bones (bone pain, anaemia, increased calcium) 
Brain,
Skin

Question 12

What are the complications of bronchial carcinomas?

Answer 12

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

Question 13

What is the most common type of non-small cell carcinoma?

Answer 13

Squamous cell carcinoma - most common in europe

Question 14

What tissue does squamous cell carcinoma arise from and what are its characteristic features?

Answer 14

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

Question 15

What is the most common type of non-small cell carcinoma in non-smokers?

Answer 15

Adenocarcinoma

Question 16

What tissue does adenocarcinoma arise from and what are its characteristic features?

Answer 16

Arises from mucus-secreting glandular cells

Features:
Peripheral lesions on CXR/CT

Metastases common i.e. pleura, lymph nodes, brain, bones, adrenal glands

Question 17

What tissue does large cell carcinoma arise from and what are its characteristic features?

Answer 17

Poorly differentiated

Metastasises early

Question 18

What tissue does small cell carcinoma arise from and what are its characteristic features?

Answer 18

Arises from neuroendocrine cells

Features:
Secretes polypeptide hormones

Arises centrally and metastasises early

Question 19

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?

Answer 19

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

Question 20

Which test assesses suitability for lobectomy?

Answer 20

Lung function test ± cardiopulmonary exercise testing, stress echo

Question 21

What is the staging used for non-small cell carcinoma?

Answer 21

TNM staging => assesses the extent of spread

Question 22

What is palliative radiation treatment?

Answer 22

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

Question 23

What is the treatment for non-small cell carcinoma?

Answer 23

1. Lobectomy (open or throacoscopic) = treatment of choice in medically fit patients => curative
2. Parenchymal sparing operation => borderline fit patients and smaller tumours (T1, N0, M0)
3. Radical radiation therapy for stage I, II, III
4. Chemotherapy ± radiation for advanced disease
5. Palliative radiotherapy => bronchial obstruction, super vena cava obstruction, haemoptysis, bone pain and cerebral metastases

Question 24

What is the treatment for small cell carcinoma?

Answer 24

1. Surgery in limited stage disease
2. Chemotherapy ± radiotherapy if well enough
3. Palliative radiotherapy => bronchial obstruction, superior vena cava obstruction, haemoptysis, bone pain and cerebral metastases
4. Superior vena cava stent + radiotherapy and dexamethasone for superior vena cava obstruction
5. Endobronchial therapy => tracheal stenting, cryotherapy, laser, brachytherapy (radioactive source placed near the tumour) => these are palliative techniques used on inoperable tumours
6. Pleural drainage/pleurodesis for symptomatic pleural effusion
7. Drugs: analgesia, steroids, anti-emetics, cough linctus, bronchodilators, anti-depressants

Question 25

What is the prognosis for non-small cell carcinoma and small cell carcinoma?

Answer 25

Non-small cell carcinoma = 10 years survival without spread ; 2 years with spread Small cell carcinoma = 3 months ; 1/1.5 years if treated

Question 26

What are the differential diagnosis for a nodule found in the lung on a chest x-ray?

Answer 26

Primary or secondary malignancy Abscess Granuloma Carcinoid tumour Pulmonary hamargtoma Arteriovenous malformation Encysted effusion (fluid, blood, pus) Cyst Foreign body

Question 27

Mesothelioma cases have increased since mid-1800's. What is mesothelioma and what is it's clinical presentation?

Answer 27

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.

Question 28

What investigations are carried out for diagnosis in a suspected mesothelioma and how is it managed?

Answer 28

CT/ultrasound guided biopsy or pleural biopsy => need sufficient tissue for diagnosis Limited management for patients

Question 29

Which cancers commonly metastasise to the lungs?

Answer 29

``` Prostate Breast Bone Gastrointestinal tract Cervix Ovary Kidney ```

Question 30

What are bronchial carcinoid tumours? What are its related symptoms?

Answer 30

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.

Question 31

How is bronchial carcinoid tumours managed? Which staging system is used?

Answer 31

Surgery = treatment of choice + long term surveillance Staging system used is same as non-small cell carcinoma (TNM staging).

Question 32

What is the most common benign lung tumour?

Answer 32

Pulmonary hamartoma => well defined on x-ray, extremely slow growing

Question 33

What is bronchial adenoma?

Answer 33

Benign lung tumour arising from mucus glands and ducts of the windpipe.