BRONCHIAL TUMOURS

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BRONCHIAL TUMOURS
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• 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.

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• 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 -
• 25of all lung cancers.

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• 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.

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• 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.

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• 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) .

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• 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)

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• 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.

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• 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

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• 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

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• 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

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• 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.

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• 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.

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• 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 ) .