Download Bronchogenic Carcinoma

Bronchogenic Carcinoma
Abstract
• Brochogenic carcinoma is also called Lung cancer.
• It is a frequent and important neoplasm in both
developed country and developing country.
• In recent years, It is reported that lung cancer is the
leading fatal neoplasm of men and women.
• It is strongly associated with the use of tobacco
products, particularly with cigarettes.
Incidence and prevalence
• Lung cancer is the leading cause of cancerrelated death of men in 28developed countries
of the world
• Squamous cell carcinoma is thought to be the
most frequent form of the tumor(30-50 percent
of all cases),followed by adenocarcinoma, large
cell carcinoma, and small cell carcinoma.
• Nowadays an increase has occurred in the
incidence of adenocarcinoma, which is the most
common histologic subtype.
Etiology and pathogenesis
• Cigarette smoking
• Occupational associations: asbestos,
uranium( in miners), arsenical fumes,
nickel,radon gas ects.
• Other factors include air pollutions ,
ionizing radiation .
• Nowadays It is reported that tuberculosis
is associated with the incidence of lung
cancer.
Pathogenesis
• Many factors influence the formation of
lung cancer. The development of lung
cancer is multistep process. The transformation of normal bronchial epithelial
cells to malignant cells is unknown.
• Perhaps It is related to: damage to
cellular DNA; alteration in cellular
oncogene expression; tumor-derived
factors that stimulate cellular division.
Etiology and pathogenesis
• Chronic inflammation of the lung, such
as from interstitial fibrosis and areas of
scarring is associated with the occurrence
of adenocarcinoma.
• Genetic factors also involve the formation
of lung cancer.
Major categories of genes that potentially
determine susceptibility to lung cancer,
include proto-oncogenes, tumor suppressor
genes, ects.
Oncogene abnormalities
Oncogene SCLC
NSCLC
Ki-ras
H-ras
N-ras
Myc
0
0
0
Majority
30-50% of adenocarcinomas
Rare mutation, over expression
Rare mutation, over expression
Gene amplification and
overexpression
Classifications
• According to anatomy:
(1)Central lung cancer,mostly is squamous cell
carcinoma and small cell carcinoma.
(2) peripheral lung cancer, mostly is
adenocarcinoma.
• According to histologic classification:
Small cell lung cancer(SCLC) and Nonsmall cell lung cancer(NSCLC).
NSCLC includes Squamous cell carcinoma,
large cell carcinoma, adenocarcinoma,
adenosquamous carcinoma.
Classifications
• Squamous cell carcinoma:It is the most
common subtype.It arises from altered
bronchial epithelium and growth in situ.It is
related to cigarette smoking.Cavitation can
occure in the distal to the obstructing mass.
• Adenocarcinoma: It arises from the
submucosal glands,located in peripheral
airways and alveoli.Peripheral
adenocarcinomas are usually wellcircumscribed, grey-white masses that rarely
cavitate.
Classification
• Large-cell carcinoma, are usually located
peripherally.They can be quite large and not
infrequently cavitate. They have large
nuclei,prominent nucleoli,abundant
cytoplsma.There are two types , Giant-cell
carcinoma and clear-cell carcinoma.
• Adenosquamous : There are definite features
of adenocarcinoma and squamous ce
carcinoma.
Classification
• Small cell carcinoma has three subtypes ,
oat-cell carcinoma, intermediate cell type
and combined oat- cell carcinoma.SCLC
belongs in a group of tumors derived
from neuroendocrine cells that are
responsible for the production and
secretion of specific peptide product.they
may related to paraneoplastic syndrome.
Clinical Manifestations
• Due to primary lesions:
cough, dyspnea, hemoptysis, sputum, wheezing,
weight loss, fever, pneumonia
• Due to local extension:
chest pain,hoarseness,superior vena cava
syndrome, horner’s syndrome, dysphagia,
pericardial effusion,pleural effusion,
diaphragm paralysis
• Only 5-15 percent of patients are asymptomatic
when discovered to have bronchogenic carcinoma.
Clinical manifestations
Regionnal spread to hilar and mediastinal nodes
may cause dysphagia due to esophageal
compression, horseness due to recurrent
laryngeal nerve compression, horner’s
syndrome due to sympathetic nerve
involvement, and elevation of the
hemidiaphragm from phrenic nerve
compression.
Clinical manifestations
• Superior sulcus, or pancoast’s tumor
may involve the brachial plexus, resulting
in a c7-t2 neuropathy with pain,
numbness, and weakness of the arm.
• Cardiac involvement is seen in About 2025 percent of patients
Clinical manifestations
• Extrapulmonary manifestations. Including
metastasis to other organs, such as brain,
central nervous system, skeleton system,
liver,adrenal glands and lymph nodes ects.
• Paraneoplastic syndromes are remote effects
of tumor. They lead to metabolic and
neuromuscular disturbances unrelated to the
primary tumor, metastases, or treatment. They
may be the first sign of the tumor.They do not
indicate that a tumor has spread.
Clinical manifestations
Paraneoplastic syndromes include:
hypertrophic pulmonary osteoarthropathy,
hypercalcemia,inappropriate antidiuretic
hormone secretion syndrome,polymyositis,
subacute cerebellar degeneration,peripheral
neuropathies and cushing’s syndrome ects.
Physical examinations
• Usually in early stage, most of the patients with
lung cancer have no positive physical findings.
• General findings include abnormal percussion,
breath sounds changes, moist rales (when
pneumonia happens)
• Digital clubbing, superior vena cava syndrome,
horner’s syndrome(unilaterally constricted
pupil, enophthalmos,narrowed palpebral
fissure and loss of sweating on the same side of
the face.
Physical examinations
• Endobronchial obstruction may result in
a localized wheeze
• Lobar collapse may result in an area of
decreased breath sounds and dullness to
percussion.
Chest X-ray
• The examination is the most important
method. It can detect the presence of lung
cancer. The most frequent finding is a mass
in the lung field.
Secondary manifestations seen on the chest
radiograph include lober collapse,pneumonitis
because of endobronchial obstruction,elevation
of the hemidiaphragm, pleural effusion, hilar
and mediastinal adenopathy and erosion of
ribs or vertebrae due to metastases.
• Alveolar cell cancer can manifest as a localized
infiltrate mimicking pneumonia.
阻塞性肺不张 Obstructive atelectasis)
支气管腔内阻塞或腔
外压迫
• 一侧性肺不张
患侧均匀致密影
纵隔向患侧移位
肋间隙变窄
健侧代偿性肺气肿
中央型肺癌
（Central bronchogenic carcinoma)
• 直接征象
肺门肿块
• 间接征象
阻塞性肺炎
阻塞性肺气肿
阻塞性肺不张
Diagnosis of Bronchogenic
carcinoma
Abstract
Diagnosis of lung cancer requires:
A: detecting the tumor
B: establish the cell type
C: define the stage of the tumor among
these, Determing cell type is the most
important because it influences the
treatment.
Many methods we used to detect the tumor,
including chest X-ray, computer Tomo
graphy(CT),Magnetic resounce imaging (MRI),
PET, histologic examination (mainly sputum
examination, bronchoscopy biopsy,bronchial
brushing , bronchial washings, transbronchial
needle aspiration and transthoracic needle).
If a diagnosis is not established by these
imaging examination and cytologic study ,
we can use thoracotomy.
Before we make the decision , we must
weigh some foctors,for example , the
importance, age of the patient and other
complicating illness.
Chest X-ray
It is the most important method to find lung
cancer. If a patient with chronic cough,
sputum with few blood, and dyspnea, lower
fever he should adopt a chest X-ray. The
most frequent finding is a mass in the lung
field.
On chest X-ray, secondary
manifestations include lobar collapse,
pleural effusion, pneumonitis,
elevation of the hemidiaphragm, hilar
and mediastinal adenopathy, and
erosion of ribs or vertebrae due to
metastases.
Central lung cancer manifestations
on chest radiography
Secondary manifestations we mentioned
above may be exist if metastases
happen,including lobar collaps, obstuctive
pneumonitis, pleural effusion.
Mainly shows a mass locate in the one side
of hilar,some times it makes the
mediastinum widen.
Peripheral lung cancer on chest
radiography
The most frequent finding is a mass in the
lung field. Sometimes the mass is not smooth,
and with a cavity. Secondary manifestations
can be also seen on the chest X-ray, such as
pleural effusion.
Alveolar cancer on chest
radiography
The chest X-ray usually shows
dissiminated small nodules in
the lung field.
细支气管肺泡癌
（Bronchiolalveolar carcinoma)
• 早期：孤立结节状或肺炎
样浸润
• 晚期：弥漫性结节状、斑
片影，腺泡结节状占位病
变
Lung cancer on CT
CT is the most useful in evaluating patients
with pulmonary and mediastinal masses.
It is also useful for detecting multiple
metastases.
CT can show a mass to be located in which
lobe of lung field and the size of the mass. It
also shows the nodule in the mediastinum.
Sometimes,when a mass locate behind the
heart, chest X-ray can`t detect it .CT can
detect some secret sites of lung cancer.
周围性肺癌（Peripheral carcinoma)
Bronchoscopy
It is important both for determining if a
tumor is present and for obtaining tissue for
histologic diagnosis.
Usually, the combination of bronchial
brushing and forceps biopsy is positive 90 to
93 percent of the tumors located in proximal
airway.
Transbronchial lung biopsy
• It may be utilized when tumor located
in peripheral airway.
• Transthoracic needle with guidance
by CT can be used to detect lesions
located near the chest wall
Thoracotomy
If the methods mentioned above are not useful
for detecting the cell type of lung
cancer,thoracotomy may be used.
But we should analyse some other factors before
we adopt the method, for example the age of the
patient,the pulmonary function,
and complicating illness.
In some circumstances,a histologic
diagnosis can be made by biopsy of
metastatic sites,such as lymphy nodes,
liver, bone or bone marrow.
Other laboratory examinations
some tumor markers
(CEA .CA199. CA211. NSE)
Some gene examination, p53gene, ras
gene.
According to the history, clinical
manifestations, physical examination,
laboratory examination espically chest Xray, CT scanning histologic examination of
sputum,biopsy tissue,obtained by
bronchoscopy, bronchial brushing ,
transbronchial and transthoracic, we can
make a diagnosis.
Staging of lung cancer
Non-small cell lung cancer.
TNM classification of Non-small cell
lung cancer.
Small cell lung cancer has often
metastasized at the time of diagnosis.
TNM staging is not suited to small cell
lung cancer.Small cell lung cancer is
divided into limited and extensive stage
disease.
TNM classification of lung cancer
– Primary Tumor(T)
• TX:primary tumor can not be assessed. tumor present as
determined by presence of malignant cells in
bronchopulmonary secretions, but not radiographically
visible; no evidence of primary tumor
• T0:No evidence of primary tumor
• Tis:carcinoma in situ
• T1:Tumor 3 cm or less surrounded by lung or visceral
pleura, but without evidence of invasion proximal to lobar
bronchus at bronchoscopy
• T2:Tumor more than 3 cm or tumor invading visceral
pleura or associated with obstructive pneumonitis or
atelectasis; involving less than entire lung; at bronchoscopy,
proximal extent of visible tumor must be within a lobar
bronchus or at least 2 cm distal to carina
• T3:Tumor of any size with direct extension into
chest wall, diaphragm, or mediastinal pleuraor
pericardium without involving heart, great vessels,
trachea, esophagus, or vertebral body; also
includes superior sulcus tumors and
• T4:Tumor of any size invading mediastinum or
involving heart ,great vessels, trachea,esophagus,
vertebral body,or carina or presence of malignant
pleural effusion
•
•
•
•
Nodal Involvement(N)
Nx: can not assess regional lymph node
N0:No demonstrable metastasis to regional lymph
nodes
N1:metastasis to peribronchial or the ipsilateral, or
both,hilar lymph nodes,including direct extension
N2:metastasis to ipsilateral mediastinal lymph
nodes and subcarinal lymph nodes
N3:metastasis to contralteral mediastinal lymph
nodes,contralateral hilar lymph nodes,ipsilateral or
contralateral scalene or supraclavicular lymph
nodes
Distant metastasis(M)
• Mx: distant metastasis can not be assessed
• M0:No distant metastasis
• M1:Distant metastasis present
Stage grouping
0 stage TisNoMo
Ⅰ stage ⅠA T1N0M0
ⅠB
T2N0M0
Ⅱ stage ⅡA
ⅡB
T1N1M0
T2N1M0, T2N0M0, T3N0M0
Ⅲ stage ⅢA
ⅢB
T3N1M0, T1N2M0, T2N2M0, T3N2M0
T4N0M0, T4N1M0, T4N2M0, T1N3M0,
T2N3M0 , T3N3M0, T4N3M0
Ⅳstage any T and any N, M1
Small cell lung cancer has often metastasized
at the time of diagnosis.
TNM staging is not suited to small cell lung
cancer.
Treatment
Including:
A:Surgery
B:Chemotherapy
C:Radiation therapy
D:Some other therapy
immunologic therapy,
Chinese traditional therapy
Surgery
Non-small cell lung cancer: patients with
stage I and II are considered candidates for
surgical resection, with stage III cancer may
be candidates for surgery with postoperative
radiation of the mediastinum.
Surgery
More than 90 percent of small cell lung
cancer has often metastasized at the time of
diagnosis.
So these patients usually adopt radiation
therapy or chemotherapy before surgery.
Surgery
We must measure pulmonary function before
surgical therapy.
Forced vital capacity greater than 2 liters and a
forced expiratory volume in the first second
(FEV1)of greater than 50 percent of the forced
vital capacity predict that a patient can tolerate
the consequences of pneumonectomy.
Chemotherapy
Non-small cell lung cancer
MVP:MMC 6-8mg/m2 (1), VDS 3mg/m2
NP:VP-16 (d1,d8). DDP 100mg/m2 (d1)
GP
Small-cell lung cancer it is highly responsive to
chemotherapy.
EP regimen VP-16 100mg/m2 d1~d3.
DDP 100mg/m2 d1. GP
Chemotherapy
Aggressive chemotherapy produces
complications and symptoms in all patients. All
experience anemia,leukepenia and opportunistic
infection other complications include
nausea,vomiting possible cadiotoxicity,
hemorrhagic cystitis and peripheral neuropathy.
Radiation therapy
It is of proven benefit in controlling
bone pain,spinal cord compression,
superior vena cava syndrome and
bronchial obstruction.