Download 6._Bronchial_Tumors

BRONCHIAL TUMOURS
Bronchial tumours , widely divided in to primary lung
tumours and secondary or metastatic cancer.
The majority of primary lung tumour is bronchial carcinoma,
and It is one of the most common cancer world – wide,
It causes 18% of all cancer death.
Cigarette smoking is by far the most important single factor
in the causation of the lung cancer. It is thought to be
directly responsible for at least 90% of lung carcinomas,
and the risk is directly proportional to the amount smoked
and to the tar content of the cigarettes.
Risk falls slowly after smoking cessation , but remain above
the risk of non- smokers.
• Bronchial Carcinoma
Is the commonest cause of cancer death in men or women
in the UK. More women now die from lung cancer than
breast cancer in the UK and USA.
In practical term we can divide bronchial cancer in to two
groups.
1- Non- small cell lung cancers ( NSCLC), that accounts for
75%-80% of all lung cancers, these include ( squamous ,
adenocarcinoma and alveolar cell cancer)
2- Small cell lung cancer (SCLC), that account for 20% 25%of all lung cancers.
Clinical features
Lung cancer presents in many different ways. Most
Commonly, symptoms reflect local involvement of the
bronchus, but may also arise from spread to the chest wall
or mediastinum ,from distant blood borne spread or, less
commonly , as a result of a variety of non-metastatic
paraneplastic syndrome.
A- Local tumour effect
- Persistent cough , is often dry but it might associate with
purulent sputum if there is secondary infection or change in
usual cough.
- Haemoptysis, is a common symptoms especially in
tumour arising from central bronchi, occasionally large
tumours invade large blood vessels, that can cause
massive haemoptysis .
- Chest pain , that could indicate chest wall involvement
with the tumour .
- Unexplained SOB, due to narrowing of bronchial tree or
bronchial obstruction.
- Hoarseness of voice, indicate involvement of Lt recurrent
laryngeal nerve.
- Dysphagia , could be due to large tumour invading or
narrowing oesophagus.
- Shoulder pain due to apical tumours that invades
brachial plexus and cause wasting or weakness of small
muscles of the hands.
B- Metastatic tumour effects.
- Cervical /supraclavicular LN enlargement.
- Palpable live edge.
- Bone pain or pathological fracture due to bone
metastasis
- Neurological manifestation due to cerebral metastasis.
- Hypercalcaemia due to bone metastasis ( the patient
may present with polyuria and poly dypsia with
abdominal pain) .
C-Non –metastatic extra pulmonary manifestation of lung
cancer.
1- Endocrine
-Inappropriate ADH secretion that cause hyponatremia.
- Ectopic ACTH( adrenocorticotrophic ) hormone secretion
,that cause Cushing's syndrome.
- Hypercalcaemia due to secretion of parathyroid hormone
- Carcinoid syndrome.
- Gynaecomastia
2- Neurological
- Polyneuropathy
- Myelopathy
- Cerebellar degeneration
- Myasthenia like syndrome( Lambert- Eaton Syndrome)
3- Others
- Clubbing of fingers
- Hypertrophic pulmonary osteoarthropathy
- Nephrotic syndrome
- Polymyositis and dermatomyositis.
Physical signs
Examination is usually normal unless there is significant
bronchial obstruction, or the tumour has spread to pleura ,
mediastinum or supraclavicular LNs.
A tumour obstructing a large bronchus produce a physical
sign of collapse.
A monophonic or unilateral wheeze , suggests the
presence of fixed bronchial obstruction, and the presence
of strider indicates obstruction at or above the level of
Carina.
Phrenic nerve paralysis , cause unilateral diaphragmatic
paralysis , that will give dull percussion with absent
breath sound in lung base.
Involvement of the pleura may produce plural rub or
Effusion. Bronchial cancer is the common cause of
Superior vena cava syndrome, that initially presents as
bilateral jugular vein engorgement and later as oedema
affecting face , neck arm and conjunctivae
Horner syndrome;
It represents unilateral (meiosis, ptosis, enophthalmos and
Anhidrosis), this is due to direct involvement of the
sympathetic chain by the tumour.
Investigations:
The main aims of investigations are to confirm the
diagnosis , establish the histological cell type and define
the extend ( stage) of the disease.
1- Blood tests including sodium , calcium , liver function test
2- CXR, is important investigation , the common radiological
features of bronchial cancer are;
-
Unilateral hilar enlargement
peripheral pulmonary opacity
Lung, lobe or segmental collapse
Plural effusion
Broadening of mediastinum
Enlarged cardiac shadow
Elevation of hemidiaphragm
Rib or bone distruction
3- CT chest (Staging CT), to determine the site and the
extend of the tumour, and some time helps to determine
the site for the biopsy through bronchoscopy.
4- Flexible Bronchoscope, around three quarters of primary
lung tumours can be visualised using a flexible
bronchscope. Bronchial biopsies and brush samples can
be taken for pathological examination, and a direct
assessment can be made of operability as judged by
proximity of central tumour to carina.
If the tumour is not visible at bronchoscopy, washing and
brushing can be taken from radiologically affected lung
Segments.
5-CT or USS guided biopsy, is important method for
diagnosis especially for peripheral lesions that is not
accessible through bronchscopy. This method carries a
small risk of Pneumothrax.
6- Sputum cytology, can be valuable diagnostic aid in
patients not fit for bronchoscopy.
7- Plural biopsy , is indicated when there is plural effusion.
8- Mediastinoscopy, especially in patients with mediastinal
mass or Mediastinal LN enlargement.
9- some times thorachoscopy or thoracotomy are required
to obtain diagnosis.
10- In patients with metastatic disease the diagnosis can
often be confirmed by needle aspiration or biopsy of
affected LNs, skin lesions, liver or bone marrow.
11- others like Bone scan, MRI or CT head
12- new investigation is PET scan ( Positron Emission
Tomography ) .