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Bronchogenic Carcinoma Shaher Samra Anas Wardat

25 / 10 / 2009

Bronchogenic Carcinoma
Lung cancer : 2nd most common cancer; after prostate in males and breast in female. For both males and females, it is the most common cause of cancer death. Etiology :

Smoking active ( being the smoker )

Passive (being exposed to smoke e.g.in restaurants, bars or at house if the father or/and the mother are smokers) Causes 80-90% of all lung cancer

Occupational: Asbestos (used in insulation), Radon, polycyclic

hydrocarbons, inorganic arsenic, Nickel (used in polishing diamonds and gold).

Genetic: ras-family, Chromosome region 3p.

Types of lung cancer: Small cell carcinoma (SCLC): 18% originate from APUD (amine precursor uptake and decarboxylation) cell, which is of neuro-endocrine origin. SCLC associated with para-neoplastic syndrome more than NSCC, due the APUD cells. Non-small cell carcinoma (NSCLC): More common. Types: Squamous cell most common. Adenocarcinoma carcinoma Bronchioalveolar cell carcinoma (not mentioned by the doc). Large cell undifferentiated carcinoma (not mentioned by the doc). Others (Rare): Carcinoid, Mucoepidermoid carcinoma Adenoid cystic carcinoma.
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Symptoms:

Asymptomatic (5%) General symptoms: weight loss, anorexia and generalized weakness. Specific symptoms; due to the tumors location:
i. cough hemoptysis: Lung CA causes mild hemoptysis (not massive). Hemoptysis occurs if the cancer is localized in the airway originated from (e.g. bronchial CA) or extended into it. ii. S.O.B. (shortness of breath) Due to: atelectasis (obstruction to the airways). Segmental emphysema which may progress to global emphysema. iii. CP (chest pain).

Malignant pleural effusion. Post-Obstructive Pneumonia:

Post-obstructive pneumonia differs from community acquired pneumonia; the post obstructive contains anaerobic infection and treated by penicillin.

Regional symptoms:
i. Hoarseness lung CA in the left side affects the left recurrent laryngeal nerve. ii. Heart involvement leads to malignant pericardial effusion and arrhythmias. iii. SVC (superior vena caval) syndrome: Seen in: a) Right side lung tumor, usually in squamous cell CA. b) NHL (non-Hodgkins lymphoma).

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 SVC blockage causes: facial swelling, plethoric changes, dilated neck and anterior chest veins, fullness of the head, headache and dysphagia (due to esophageal invasion). iv. Pancoasts Tumor: Apical lung tumor, mainly at the right side, more in NSCLC. C/O: 1. Shoulder pain (aching). 2. Arm pain due to invasion of the nerves C8, T1 and T2, which are the roots of the ulnar nerve. 3. Weakness & Atrophy of the hand. 4. Horners syndrome. v. Horners Syndrome: Due to involvement of the sympathetic chain, by invasion of the paravertebral and inferior cervical ganglion. C/O: 1. Myosisconstricted pupil) 2. Ipsilateral anhydrosis absence of sweat at the same side of the tumor. 3. Ptosis 4. Uni-lateral enophthalmussunken eyes. ptosis makes the eyes looks like they are sunken.

Paraneoplastic hormonal syndromes:

I. Parathyroid like hormone (PTHi) secretion, which causes hypercalcemia, associated with squamous cell CA. II. Hypertrophic pulmonary osteoarthropathy (HPOA): Bilateral sever joint tenderness, mainly in the wrists and ankles.

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 On X-ray we can see periosteal new bone formation at the distal ends of long bones. Associated with adenocarcinoma and large cell CA. III. Syndrome of inappropriate antidiuretic hormone secretion (SIADH): Associated with SCLC (small cell lung CA). Leads to hyponatremia, due to Na loss in urine. IV. Cushings syndrome: Associated with SCLC. Due to increased ACTH (adrenocorticotrophic hormone) production from ACTH-producing tumor. C/O: 1. Hyperpigmentation. 2. Hypokalemia. 3. Hypertension. 4. Edema. V. VI. Carcinoid Syndrome caused by SCLC. Calcitonin Caused by SCLC. Leads to calciuresis; Ca2+ loss in urine VII. VIII. IX. X. Gynecomastia caused by large cell, due to gonadotropin secretion. Hypoglycemia due to insulin like activity. Or, Hyperglycemia e.g. ACTH effect in Cushings syndrome Hyperpigmentation caused by MSH (melanocyte-stimulating hormone) production or in Cushings syndrome.

Paraneoplastic Neurologic Syndromes:

Lambert-Eaton Syndrome: The opposite of Myasthenia gravis. Limb muscle weakness which improve with time after muscle contraction, due to acetylcholine accumulation. Improves with lung CA treatment.
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Dementia Encephalopathyassociated with SCLC. Peripheral Neuropathy associated with SCLC. Subacute cerebellar degeneration: Bilateral ataxia. Not related to ischemic effect, it is lung CA manifestation. Metastases: Most Small Cell (SCLC) spread early and rapidly; so that surgery is not considered in SCLC patients, even if the tumor is few centimeters in diameter. We treat the SCLC with chemotherapy (very effective in SCLC) and radiotherapy. Sites of metastases : i. ii. iii. iv. Bone marrow. Liver Adrenal glands CNS: In 10% of SCLC will have CNS metastases without symptoms at the presentation. 30-50% of SCLC will have brain lesion seen by head CT-Scan. Associated symptoms: i. Seizure. ii. Syncope. iii. Headache. iv. Nausea. v. Vomiting. vi. Increase intra cranial pressure Common in adenocarcinoma and large cell lung CA. v. Skin: Skin metastases findings: erythema multiforme, acanthosis nigricans, dermatomyositis, scleroderma, thrombophlebitis, tylosis (hyperkeratosis of palms and soles).

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Constitutional symptoms of lung CA metastases: weight loss, anorexia, fatigue, weakness. Clubbing result from metastatic lung CA. Lung CA diagnosis by: History and symptoms. Lymph node examination, especially supraclavicular and the scalene LNs. Screening people who are at high risk. Chest X-ray and chest CT-scan, to detect lung masses: We need to follow the mass for 2 years to determine its type (malignant or benign). If a patient came complaining of a mass for 2 years ago, we compare a new CXR with an old one, if the masss size and location didnt change, then it is a benign lesion. Central masses are usually small cell or squamous cell CA. Peripheral masses are usually adenocarcinoma or large undifferentiated cell CA. Calcification: Indicates a higher chance for benign lesion, but crescent calcification more likely indicates malignancy. On CXR, central, diffuse, laminated or popcorn mass: usually indicates benign tumor. Lung tissue examination: Sputum cytology if there is sputum production. ThoracentesisCytological analysis of pleural liquid. Sample of pleural liquid is obtained by needle aspiration. Pleural biopsy to detect mesothelioma.
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Bronchoscopy: BAL (bronchoalveolar lavage). Brush. TBNA (trans-bronchial needle aspiration). EBB (endo-bronchial biopsy), for bronchial lesion. TBB (Trans-bronchial biopsy). Thoracoscopy or open lung biopsy mediastinoscopy CT chest-guided transcutaneous needle biopsy.

Bone Scan: For the detection of bone metastases. PET (Positron emission tomography) Scan: Identification of malignant lesions in the lung is based on their increased uptake and metabolism of glucose. The technique involves injection of a radiolabeled glucose analogue. Applicable only on masses > 1 cm in diameter. Less specific in DM and infection. Cost: it is an expensive study. Not good for metastases evaluation and staging.
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Tumor markers (CEA, PTH, ACTH), not useful not used. PFT (pulmonary function test): To decide if candidate for surgery. Predicted post-op FEV1 (= post-operative forced expiratory volume in the 1st second) > 0.8 L is required. FEV1 normally 3-5 L, in a smoker or COPD it is less due to lung volume loss. Lung cancer staging: SCLC: limited to hemithorax vs. extensive disease NSCLC: TNM system Classification T: Primary tumor (size & location) N: Regional LN involvement M: Presence or absence of Metastases Used for prognosis & to guide treatment plan.

The doctor said, regarding the table above, we only need to know that there is a system for staging.
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Lung cancer prognosis: SCLC: Median survival = 1-2 yrs, as it is sensitive to chemotherapy. 30% die from local complications, 70% from carcinomatosis 50% has brain lesion at autopsy. NSCLC: Median survival with metastases = 6 wks 1 yr less responsive to chemotherapy. Depends on performance status (patients activity, severity of COPD, etc), disease extent, and weight loss. Lung cancer treatment: SCLC: Chemotherapy: Cisplatin, Etoposide Radiation: Palliative For Head lesion NSCLC: Surgery: (Lobectomy to Pneumonectomy) Stage I-IIIA. Needs Post-Op FEV1 > 0.8 L Chemotherapy: Stage II-IV Radiotherapy: for Stage IIIB + Palliative Adjuvant therapy (combination).

The End

Done by:

Anas Wardat
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Special thanks to:

H. Haddad

M. Klaib, A. Bataineh and R. Tahat

Zaid Zraigat, Odai abu Dagar, Rasheed Janaydeh, Ibraheem Saif and Majd Eghbareyeh.

Borini, Ra2ed, Abd Allah bani Fares,Feras T3ani and Ibraheem Hmaisat.
Special thanks to my colleagues in Group A2.. Last, but by no means least, I wanna thank SAWA summarizing

group, for their real hard working , honesty and dedication to help us
(2009, 4th year medical students) and make our study much more easier; more than any group else.

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