Bronchogenic Carcinoma

• Lung cancer is the leading cause of cancer

deaths in both men and women

• The causal connection between cigarettes and

lung cancer is now established not only
epidemiologically but also through identification
of carcinogens in tobacco smoke and analysis of
the effect of these carcinogens on specific
oncogenes expressed in lung cancer
Grey tumor arising in the main bronchus at a point
of bifurcation. These tumors usually arise in the
hilus or near the hilus of the lung
Bronchogenic squamous cell carcinoma arising in a
left mainstem bronchus. Notice that the lung distal

to this is atelectatic
 Aetiology
Cigarette smoking
• Cigarette smoking causes more than
80% of cases of lung cancer

• Through the 1990s, mortality from lung

cancer fell among men while it
increased among women, reflecting
changing patterns of tobacco use over
the past 30 years
 Environmental risk factors
• Exposure to environmental tobacco smoke

• Radon gas (among uranium miners and in areas where

radium in the soil causes significant indoor air
contamination)

• Asbestos (60- to 100-fold increased risk in smokers with

asbestos exposure)

• Metals (arsenic, chromium, nickel, iron oxide)

• Industrial carcinogens (bis-chloromethyl ether)

• Familial predisposition to lung cancer is recognized

• Diseases associated with an increased risk of lung cancer,

including pulmonary fibrosis, COPD, and sarcoidosis
 Prognosis
• The mean age at diagnosis of lung cancer is 60

• It is unusual under the age of 40

• After the diagnosis of lung cancer is made,

approximately 40% of patients survive 1 year

• The combined 5-year survival rate for all stages

of lung cancer is now approximately 15%,
improved from 12% in 1974–1976
Bronchogenic Carcinoma
 Histologic types of bronchogenic
carcinoma
Squamous cell carcinoma (25–
35% of cases)
• Arises from the bronchial epithelium, typically
as a centrally located, intraluminal sessile or
polypoid mass

• Squamous cell tumors are more likely to

present with hemoptysis and more frequently
are diagnosed by sputum cytology

• They spread locally and may be associated with

hilar adenopathy and mediastinal widening on
chest radiography
Squamous cell
carcinoma
Squamous cell
carcinoma
Adenocarcinoma (35–40% of cases)

• Arises from mucus glands or, in the case of the

bronchioloalveolar cell carcinoma (2% of
cases), from any epithelial cell within or distal to
the terminal bronchioles

• Adenocarcinomas usually present as peripheral

nodules or masses

• Bronchioloalveolar cell carcinoma spreads intra-

alveolarly and may present as an infiltrate or as
single or multiple pulmonary nodules.
Adenocarcinoma
Adenocarcinoma
Large cell carcinoma (5–10% of cases)

• It is a heterogeneous group of relatively

undifferentiated tumors that share large cells
and do not fit into other categories

• Large cell carcinomas typically have rapid

doubling times and an aggressive clinical course

• They present as central or peripheral masses.

Large cell carcinoma
 Small cell carcinoma (15–20% of
cases)

• It is a tumor of bronchial origin that typically

begins centrally, infiltrating submucosally to
cause narrowing or obstruction of the
bronchus without a discrete luminal mass

• Hilar and mediastinal abnormalities are

common on chest radiography
Small cell carcinoma
Small cell lung cancer
• For purposes of staging and treatment, bronchogenic
carcinoma is divided into small cell lung cancer (SCLC)
and the other three types, conveniently labeled non–
small cell lung cancer (NSCLC)
• This practical classification reflects different natural
histories and different treatment

SCLC
• SCLC is prone to early hematogenous spread
• It is rarely amenable to surgical resection and has a
very aggressive course with a median survival
(untreated) of 6–18 weeks

NSCLC
• The three histologic categories comprising NSCLC
spread more slowly
• They may be cured in the early stages following
resection, and they respond similarly to chemotherapy
 Clinical Findings
Lung cancer is symptomatic at
diagnosis in 75–90% of patients

The clinical presentation depends on

the type and location of the primary
tumor, the extent of local spread,
and the presence of distant
metastases and any paraneoplastic
syndromes
 Symptoms
• Anorexia, weight loss, or asthenia occurs in 55–
90% of patients presenting with a new diagnosis
of lung cancer

Cough:
• Up to 60% of patients have a new cough or a
change in a chronic cough. It may be dry or
purulent sputum is present if secondary infection

Hemoptysis:
• Common if tumour is in central bonchus
• Repeated scanty hemoptysis or blood streaked
sputum in a smoker is highly suggestive
 Pancoast’s syndrome:
• Featured by pain in shoulder and inner aspect of the arm
• Caused by involvement of lower part of brachial plexus

Dysphagia:
• Mediatinal spread may lead to dysphagia

Symptoms due to blood borne

metastasis:
• Focal neurologocal defecits
• Epileptic seizures
• Personality change
• Jaundice
• Bone pain
• Skin nodules

Hoarsness:
Compromise of the recurrent laryngeal nerve

Superior vena cava syndrome

obstruction of the superior vena cava with supraclavicular venous
engorgement
57 yr old male who presented with hemoptysis and
radicular left arm pain. Note typical Horner’s
syndrome.  Bronchogenic carcinoma or Pancoast
tumour was etiology
 Paraneoplastic
Syndrome
• They are incompletely understood patterns of organ
dysfunction related to immune-mediated or secretory effects
of neoplasms

• Patients with small cell carcinoma can develop syndrome of

inappropriate antidiuretic hormone (SIADH)

• Squamous cell carcinoma can develop hypercalcemia due to

secretion of PTH-like peptide

• Digital clubbing is seen in up to 20% of patients at diagnosis

• Other common paraneoplastic syndromes include increased

ACTH production, anemia, hypercoagulability, peripheral
neuropathy, and the Eaton-Lambert myasthenia syndrome

• Their recognition is important because treatment of the

primary tumor may improve or resolve symptoms even when
the cancer is not curable
 Signs
Examination is normal unless the disease is far
advanced

Bronchial obstruction:
• Signs of collapse
• Signs of obstructive emphysema
• Signs of pneumonia
• Wheeze which fails to clear after coughing

Phrenic nerve paralysis:

• Signs of unilateral diaphragmatic palsy

Pleural involvement
• Pleural rub and signs of pleural effusion

Digital Clubbing:
• Associated with Hypertrophic pulmonary oteoarthropathy
(HPOA), giving rise to pain and tenderness due to periostitis of
long bones
 Investigations
Laboratory Findings
• The diagnosis of lung cancer rests on examination of a tissue or
cytology specimen

Sputum cytology
• It is highly specific but insensitive; the yield is highest when there
are lesions in the central airways

Thoracentesis
• Used to establish a diagnosis of lung cancer in patients with
malignant pleural effusions
• If cytologic examination of an adequate sample (50–100 mL) of
pleural fluid is nondiagnostic, the procedure should be repeated
once. If results remain negative, thoracoscopy is preferred to
blind pleural biopsy

Fine-needle aspiration
• FNA of palpable supraclavicular or cervical lymph nodes is frequently
diagnostic
 Fiberoptic bronchoscopy:
• It allows visualization of the major airways
• Cytology brushing of visible lesions and
lavage of lung segments with cytologic
evaluation of specimens
• Direct biopsy of endobronchial abnormalities
• Blind transbronchial biopsy of the pulmonary
parenchyma or peripheral nodules
• Fine-needle aspiration biopsy of mediastinal
lymph nodes
 Imaging
• Nearly all patients with lung cancer have
abnormal findings on chest radiography or CT
scan

• Following are some of the finding but they are

rarely specific for a particular diagnosis

• Unilateral Hilar enlargement

• Peripheral pulmonary opacity
• Lung lobe or segmental collapse
• Pleural effusion
• Broadening of mediastinum, enlarged
cardiac shadow, elevation of
hemidiaphragm
• Rib destruction
 The patient's PA chest x-ray showing
the tumor in the posterior mediasinum
 PA chest X-ray reveals a large suprahilar
density. There is bilateral pleural thickening,
with calcification
Small Cell Carcinoma
A large central lesion was diagnosed as non–
small cell carcinoma
Left pleural effusion and volume loss secondary to
non–small cell carcinoma of the left lower lobe. The
pleural effusion was found to be malignant;
therefore, the lesion is inoperable
Complete left lung collapse secondary to
bronchogenic carcinoma of left mainstem
bronchus
Peripheral pulmonary
carcinoma
 Staging
• Accurate staging is crucial:

• (1) to provide the clinician with

information to guide treatment
• (2) to provide the patient with
accurate information regarding
prognosis
• (3) to standardize entry criteria for
clinical trials to allow interpretation of
results
 Staging of NSCLC
• The TNM international staging system attempts a
physical description of the neoplasm

• Primary Tumor (T):

T describes the size and location of the primary tumor

• Regional Lymph Nodes (N)

N describes the presence and location of nodal metastases

• Distant Metastases (M) 

M refers to the presence or absence of distant metastases
• This classification is used to guide therapy

• Many patients with stage I and stage II disease are

cured through surgery

• Patients with stage IIIB and stage IV disease do not

benefit from surgery

• Patients with stage IIIA disease have locally invasive

disease that may benefit from surgery in certain
circumstances.
 Staging of SCLC
• SCLC is not staged using the TNM system because
micrometastases are assumed to be present on
diagnosis

• SCLC is divided into two categories:

• Limited disease (30%), when the tumor is limited to

the unilateral hemithorax (including contralateral
mediastinal nodes);

• Extensive disease (70%), when the tumor extends

beyond the hemithorax (including pleural effusion)

• This scheme also guides therapy

• Patients with limited SCLC benefit from thoracic
radiation therapy in addition to chemotherapy and may
benefit from prophylactic cranial radiation therapy
 Treatment
Non–Small Cell Carcinoma
Surgical Resection:
• Cure of NSCLC is unlikely without resection

• Initial approach to the patient is determined by the

answers to two questions:
• (1) Is complete surgical resection technically feasible?
• (2) If yes, is the patient able to tolerate the surgery with
acceptable morbidity and mortality?

• Radiation therapy following surgery improves local control

but does not improve survival.
 Contraindications to surgical
resection
• Extrathoracic metastases
• Malignant pleural effusion
• Tumor involving the heart, pericardium,
great vessels, esophagus, recurrent
laryngeal or phrenic nerves, trachea,
main carina, or contralateral
mediastinal lymph nodes
 Neoadjuvant chemotherapy
• It consists of giving antineoplastic
drugs in advance of surgery or
radiation therapy

• There is no consensus on the impact

of neoadjuvant therapy on survival

• Neoadjuvant therapy is more widely

used in selected patients
 Adjuvant chemotherapy
• It consists of administering antineoplastic
drugs following surgery or radiation therapy

• Adjuvant chemotherapy with alkylating

agents such as cyclophosphamide increases
mortality so it is not recommended. Newer
antineoplastic agents with less toxicity are in
clinical trials in these patients

• Chemotherapy in NSCLC is not very effective

• Multidrug platinum-based chemotherapy is

associated with an increase in survival in
patients with advanced disease There is no
evidence of a survival benefit in patients with
poor performance status
 Treatment
Small Cell Carcinoma
Chemotherapy

Response rates of SCLC to cisplatin and etoposide

are excellent:

• 80–100% response in limited-stage disease

• 60–80% response in extensive stage disease
• However, remissions tend to be short-lived with a
median duration of 6–8 months
• Once the disease has recurred, median survival is
3–4 months
• Overall 2-year survival is 20% in limited-stage
disease and 5% in extensive-stage disease
 Radiation therapy
Thoracic radiation therapy improves
survival in patients with limited SCLC
but not those with extensive disease

Whole brain radiation therapy

decreases the incidence of central
nervous system disease but does not
affect survival
 Palliative therapy
Radiotherapy:
• External beam radiation therapy is used to control dyspnea
and hemoptysis, pain from bony metastases, obstruction
from superior vena cava syndrome, and symptomatic brain
metastases
• Intraluminal radiation (brachytherapy) is an alternative
approach to endobronchial disease.
• Photoresection with the Nd:YAG laser
• It is sometimes performed on central tumors to relieve
endobronchial obstruction, improve dyspnea, and control
hemoptysis
Resection
• Resection of solitary brain metastases does not affect
survival but may improve quality of life when combined
with radiation therapy
• Pain control
• As patients approach the end of life, meticulous efforts at
pain control are essential
• Consultation with a palliative care specialist
 Prognosis
• The overall 5-year survival rate for lung cancer is
15%

• Predictors of survival are the type of tumor (SCLC

versus NSCLC), the stage of the tumor, and the
patient's performance status, including weight
loss in the past 6 months

• Best prognosis is with well-differentiated

Squamous cell tumors which have not
metastasized and are amenable to surgical
resection
Rarer Types of Lung Tumors
• Adeno-squamous carcinoma
• Carcinoid tumor
• Bronchial gland adenoma
• Bronchial gland carcinoma
• Hamartoma
• Bronchioalveolar Carcinoma