Bronchogenic Ca

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Bronchogenic carcinoma

Lung cancer is a leading cause of preventable death attributed to smoking and


environmental exposure. Its highest incidence is in men but recent trends have
shown a significant increase in women paralleling the trend of smoking prevalence
in different genders. Bronchogenic carcinoma is mainly divided into non-small cell
carcinoma (NSCC) and small cell carcinoma (SCC). Non-small cell carcinoma makes
up 80% of all bronchogenic carcinomas.

NSCC has three main histological types


1. Squamous cell carcinoma (mainly central)
Has a strong association with smoking as compared to adenocarcinoma.
Macroscopically it appears as a white or grey tumor growing from bronchial
epithelium
Histology shows keretinazation and pearl formation
Immunohistochemistry shows cytokeratin 5 and 6 (CK5 and CK6) carcinoembryonic
antigen and keratin

2. Adenocarcinoma (mainly peripheral)


Is the common histological type found in non-smokers. Also arises in areas of
previous scarring/fibrosis it has an association with tuberculosis scarring and
bronchiectasis and is also common histological type in women. Macroscopically it
appears as a white fleshy solid tumor. Immunohistochemistry reveals TTF-1
(Thyroid transcription factor 1) Cytokeratin 7 (CK7)

3. Large cell carcinoma


is a poorly differentiated epithelial tumor consisting of sheets or nests of large
polygonal cells with vesicular nuclei and prominent nucleoli. Large cell carcinoma is
usually diagnosed by excluding other tumor types during histopathologic
examination. Most large cell carcinomas are located in the peripheral lung and
invade the visceral pleura, chest wall, or adjacent structures.

Other histological types like adenosquamous carcinoma, adenoid cystic carcinoma,


epithelial- myoepithelial carcinoma and epidermoid cystic carcinoma make up 2%
of NSCC.

Adenocarcinoma is also further divided into


a. bronchoalveolar carcinoma ( usually presents as a solitary pulmonary nodule
with a diffuse intestinal infiltrative pattern resembling a pneumonia)
b. papillary
c. Acinar
d. Mucinous

SCC
Small cell carcinoma previously known as oat cell carcinoma has the greatest
association with paraneoplastic syndromes. It is very aggressive with a fast
progression. However it is very much chemo sensitive but has a high recurrence
DR R Kanyongo Dept of Cardiothoracic and Vascular Surgery 2015 Page 1
rate. Because of its aggressive nature SCC is usually staged into stages; extensive
disease and limited disease.

Neuroendocrine cells

1. Atypical carcinoid
2. Typical carcinoid
3. Neuroendocrine large cell carcinoma
4. Neuroendocrine small cell carcinoma

Risk factors
Smoking
Asbestos
Occupational exposure to radon, polycyclic aromatic hydrocarbons in dyes
Arsenic
Radiation
Nickel
Chromates
TB scarring

Pathophysiology

Development of lung cancer is considered as a series of genetic changes induced by


environmental factors, which leads a normal cell to develop into a cancer. These
genetic changes are mutations of the tumor oncogenes and tumor suppressors as
well as the change in the tumor microenvironment that allows the tumor to grow
and metastasize into other organs. Known mutations in adenocarcinoma are of the
K-RAS oncogene EGFR and the tumor suppress genes p53 and p16. Similar
multistage mutations also occur in invasive squamous cell carcinoma but less than
2% mutations of K-RAS and EGFR mutations but with about 60% in p53 mutations.
Small cell carcinoma has ~ 90 p16/RB gene mutations and 30% mutations in Myc
oncogene.

Clinical presentation
Cough
Hemoptysis
Chest pain
Dyspnea
Weight loss

Metastatic effects
1. Pancoast tumor; apical lung tumour invading the cervical sympathetic
ganglia causing Horner’s syndrome. Pancoast syndrome occurs when there is
Horner’s syndrome plus invasion of the lower roots of the brachial plexus

DR R Kanyongo Dept of Cardiothoracic and Vascular Surgery 2015 Page 2


causing pain in the medial aspect of the arm and wasting of the thena
muscles of the hand.

2. Horner’s syndrome: ptosis, miosis, enopthalmous and anhidrios


3. Pathological bone fractures
4. Paraplegia ( mets to the spine
5. Stroke/ neurological deficits ( mets to the brain)

Non metastatic effects/ Para neoplastic syndromes


1. Clubbing
2. Hypertrophic osteoathropathy
3. Acanthosis Nigrans
4. Dermatomyositis
5. Lambert Eaton syndrome

Neuroendrocrine symptoms
1. Cushing syndrome
2. Syndrome of inappropriate ADH secretion
3. Hypercalcaemia (secretion of Parathormone like hormone)
4. Hyperglycaemia
5. Hypercalcinotanaemia
6. Hyperthyroidism
7. Carcinoid syndrome

Investigations.
1.CXR ( after FBC and U+E)
2. Bronchoscopy and biopsy/ bronchoalveolar lavage with bronchial Washings for
cytology
3. CT scan chest Abdomen and pelvis ( brain in suspected mets)

Staging
Tx Malignant cells in bronchial secretions, no other evidence of tumour
Tis carcinoma in situ
T0 None evident
T1 <3cm
T2 3cm -7cm tumor or any tumor which is >2cm distal from carina/ any tumor
size with visceral pleural involvement , partial atelectasis from tumor
T3 tumor >7cm tumor involving the chest wall. Tumor less than 2cm from carina
T4 tumor invading heart, aorta and esophagus and other mediastinal structures
presence of malignant pleural effusion

No no nodal involvement
N1 peribrochial nodes ipsilateral hilar nodes
N2 contralateral hila ipsilateral mediastinal and subcarinal lymph nodes
N3 contralateral mediastinal nodes, scalene and supraclavicular nodes

DR R Kanyongo Dept of Cardiothoracic and Vascular Surgery 2015 Page 3


Mo no metastasis
M1 distant metastasis
M1a separate tumor nodule(s) in contralateral lobe, pleural nodules malignant
pleural and pericardial effusion
M1b distant metastasis

From the TNM classification Bronchogenic cancer can be staged from Stage I -IV
Management will thus depend on the stage of the tumor
* read on the various stages for interest *

In general there is good outcome for surgery for stage I upto stage II b. however
surgery can be performed for tumors upto stage IIIb. Surgery is either a lobectomy
or a pneumectomy. However the cardiopulmonary reserve has to be assessed before
undertaking these operations to assess whether or not a patient will be able to
withstand surgery. Surgery remains the mainstay in treatment of lung cancers.
Radiotherapy can be offered to patients who can not withstand surgery. For
advanced disease chemotherapy is offered.

Prognosis
Overall, the prognosis for lung cancer is poor. The estimated overall 5-year survival
rate for all of the patients with lung cancer is about 16 percent; however, patients
with resected pathologic early stage lung cancer can achieve a 5-year survival rate
of 70 to 80 percent. The type and pathologic stage of lung cancer is the best
predictor for prognosis

DR R Kanyongo Dept of Cardiothoracic and Vascular Surgery 2015 Page 4

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