BRONCHOGENIC

CARCINOMA

Dr. Vineet Chauhan

 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

 Commonest cancer in males and 2nd most common in

females
 Occurs in 5th to 6th decade of life, uncommon before 40
 Squamous cell carcinoma is thought to be the most
frequent form of the tumor(50 -70%) percent of all
cases),followed by adenocarcinoma (15%), anaplastic
( large cell carcinoma, oat cell) 20-30%, and small cell
carcinoma (1-10%).
 Nowadays an increase has occurred in the incidence of
adenocarcinoma
Etiology and pathogenesis
 Cigarette smoking- smoke contains polycyclic
hydrocarbons and unburned tobbacco
contains N- nitroso-nornicotine--carcinogenic
 Occupational associations: asbestos,
uranium( in miners), arsenical fumes, nickel ,
radon gas etc.
 Other factors include air pollutions-
sulphurous smoke , ionizing radiation
 Dust laden tar
 Respiratory viruses
 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.

 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.
Classifications
 According to macroscopic variety:
(1)Main bronchus tumors
Most common variety
Arises from 1st or 2nd division of bronchus
Frequently cause bronchial obstruction
Mostly squamous cell carcinoma
(2) Peripheral tumors
Arise from small bronchi
Late in producing symptoms, detected
accidently
Mostly is adenocarcinoma.
 (3) Pancoast tumors )
 Peripheral tumors found in apex of lungs
 Early symptoms because of invasion of
brachial plexus and sympathetic chain
 Slow growing variety
 Scar carcinoma
 Arises from previous pulmonary disease
 Tuberculosis, infarct, inflammatory lesions
 Adenocarcinoma variety
Pancoast tumors
Microscopic Classification
 Squamous cell carcinoma (50-70%)
 Most common type.
 It arises from altered bronchial epithelium
(squamous metaplasia)
 It is related to cigarette smoking.
 Arises from main bronchi, yet peripheral
tumors and pancoast tumors of this variety
 Slow growing, bulky tumors
 Involves quickly hilar, paratracheal,
subcarinal LN
Microscopic Classifications
 Adenocarcinoma (15%)
 It arises from the submucosal

glands,located in peripheral airways and

alveoli.
 Non smokers, females

 Growth rapid

 Metastasize –vascular-liver, brain ,bone,

adrenals
 Cannon ball tumors
Adenoca. –cannon ball
tumors
Microscopic Classifications
 Undifferentiated/ anaplastic carcinoma (20-30%)
 Highly aggressive type
1)Oat cell variety is most aggressive amongst these
 Central location
 Spread-lymphatic, disseminates to surrounding tissue
and vascular spread
2)Large cell (giant cell tumors) (1-10%)
 Variant of adenocarcinoma
 Aggressive tumor - peripherally located
 Lymphatic spread not seen
Classification
3) Small cell carcinoma
 Located peripheraly

 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.
Microscopic Classifications
 Bronchoalveolar/ alveolar cell carcinoma
 Arises from alveolar cells or typical clara
cells in the bronchioles
 Favorable prognosis compared to other
tumors
Spread
 Direct extension- mediastinum, pleura,
pericardium,chest wall
 Intrabronchial spread-main bronchus tumors
 Lymphatic spread-
 hilar- subcarinal-paratracheal-supraclavicular-
inferior deep cervical LN
 In lungs-peri bronchial and perivascular
spread
 Blood spread- adenocarcinomas, oat cell
,giant cell
 Clinical Manifestations

 Due to primary lesions:

Cough

Dyspnea

Hemoptysis

Chest pain
Clinical manifestations
Regional spread to hilar and
mediastinal nodes may cause
 Invasion of mediastinum-SVC-congestion

of veins of face
 Dysphagia due to esophageal compression,

 Hoarseness due to recurrent laryngeal

nerve compression,
 Horner’s syndrome due to sympathetic

nerve involvement
 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 20-
25 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 etc.
 Paraneoplastic syndromes are remote effects
of tumor.
 Release of hormone like substance
 They lead to metabolic and neuromuscular
disturbances unrelated to the primary tumor,
metastases, or treatment.
 They may be the first sign of the tumor.
 Regression of symptoms after removal of tumor
 They do not indicate that a tumor has spread.
Paraneoplastic syndrome
 Cushing syndrome- oat cell ca, older males
 ADH produced by poorly differentiated tumors-
water retention, hyponateremia, cerebral
sysmptoms(confusion)
 Carcinoid syndrome production of 5
hydroxytraptophan by oat cell ca
 Parathormone- Squamous cell Ca-
hypercalcemia and mental confusion
 Ectopic gonadotrophin secretion-
gynaecomastia
 Hypoglycemia
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.
（ Central bronchogenic carcinoma)
Diagnosis of Bronchogenic
carcinoma
 Abstract
Diagnosis of lung cancer requires:
A: Detecting the tumor
B: Establish the cell type - histology
C: Define the stage of the tumor

Determining the cell type is most important

because it influences the treatment.
Many methods we used to detect the tumor, including
Chest X-ray,
Computer Tomo graphy(CT),
Magnetic resonace imaging (MRI),
PET (Positron emmision tomography)
Histologic examination
sputum examination
bronchoscopy -biopsy,bronchial brushing , bronchial
washings, transbronchial needle aspiration
transthoracic needle aspiration
If a diagnosis is not established by these
imaging examination and cytologic study , we
can use thoracoscopy/ thoracotomy.
 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.
 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 .
（ 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.
 CT guided lung biopsy

• Transthoracic needle with guidance

by CT can be used to detect lesions
located near the chest wall
 Thoracoscopy /Thoracotomy

If the methods mentioned above are not useful for

detecting the cell type of lung cancer,
thoracoscopy/thoracotomy may be used.
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. )

Blood IX- eosinophilia

Staging of lung carcinoma
AJCCS (American joint committee for cancer
staging)
 Occult carcinoma-no evidence of primary tumor or

metastasis but brochopulmonary secretions

contain malignant cells
 Invasive carcinoma-

 Stage1-primary tumor w/o metastasis to LN or

distant sites
 Stage 2-tumor metastasis to ipsilateral hilar LN

 Stage 3- tumor metastasis to contralateral hilar

region, mediastinum, or with distant metastasis

 Treatment
Includes
A:Surgery

B:Chemotherapy

C:Radiation therapy

D:Other therapy
Immunologic therapy,
Laser
Surgery
 Surgical removal of primary tumor is the
treatment of choice
 Contraindications of operability
 Involvement of main bronchus within 1.5 cm of
carina
 Invovement of oesophagus, RLN, SVC, phrenic nerve
 Trachea compression
 Vocal cord involvement
 Distant meatstasis
 Unfit for operation, poor respiratory reserve, cardiac
disease
Surgery
 Radical resections depending on location
of tumor
 Radical lobectomy- confined to one lobe
 Radical pneumonectomy- involvement of
main bronchus
 Other operations include
 Local wedge resection and sleeve
resection in cases of poor respiratory
reserve
 Surgery

Non-small cell lung cancer:

 Stage I and II are considered candidates for
surgical resection
 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.
Radiation therapy or chemotherapy to be
considered before surgery.
Chemotherapy
 Role to play in small cell Ca(oat cell)
 Aggressive chemo is treatment of choice
 Cyclophophamide, doxorubucin, and
vincristin Adriamycin
 Chemo given in conjugation with
radiotherapy
 Non small cell Ca
 Role of chemo variable
 More effective in Adeno Ca than Sq. Ca
Radiotherapy
 Given to those in whom surgery is
contraindicated
 Refuse surgery
 Recurrence after surgery
 As an adjuvant to surgery
 5000-6000rads 5times weekly for 5 weeks
 Preoperative RT- Pancoast tumors
 Post-operative- tumor left in surgery
 Palliative RT- severe chest pain, bony
metastasis
Others
 Immunological therapy
 BCG injected intra tumoral can be given
bronchoscopically, CT guided
 Laser therapy
 YAG laser (yttrium aluminium garnet)
can be used for inoperable lesions/
massive haemoptysis
Secondary Carcinoma
 Metastasis from
 Carcinomas- breast, kidney , thyroid,
colon ,prostate testis, uterus
 Sarcomas-osteosarcoma
 Choriocarcinoma
 Malignant melanoma
Secondary Carcinoma
 Spread
 Blood borne
 Lymphatic
 Types
 Solitary central deposit
 Multiple deposits- unilateral /bilateral (cannon
ball)
 Treatment
 Solitary deposit- surgery
 Chemotherapy and radiotherapy