Bronchogenic Carcinoma

Its the second most common cancer, after prostate cancer in males and breast
cancer in females, but its the leading cause of cancer death for both genders.

Causes:
1) Smoking: both active and passive smoking cause about 80-90% of all lung
cancers.
2) Occupational: Asbestos (used to be used in heat insulation, now its used in
breaks in cars, it causes both lung cancer and mesothelioma maybe even after
20 years of exposure), radon, polycyclic hydrocarbons, inorganic arsenic, nickel
(used in the gold industry).
3) Genetic predisposition: ras-family and chromosome region 3p.

Pathology:
Small cell carcinoma (SCLC): (18%), its well known to cause paraneoplastic
syndromes because it originates from APUD (amine precursor uptake and
decarboxylation) cells which are of neuro-endocrine origin so they produce
different hormones and enzymes causing such syndromes.
Non-small cell carcinoma (NSCLC), of many subtypes:
1) Squamous cell (30%).
2) Adenocarcinoma (most common) and bronchioalveolar cell carcinoma (30.7%).
3) Large cell undifferentiated carcinoma (9.4%).
4) Carcinoid (very rare).

Symptoms:
5% are asymptomatic.
Cough, hemoptysis, shortness of breath, post-obstructive pneumonia,
malignant pleural effusion, chest pain (maybe on respiration due to metastasis
to the ribs), even shoulder pain, generalized weakness, weight loss
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 Post-obstructive pneumonia is due to the

tumor obstructing the air ways resulting in
recurrent anaerobic infections in the same
lobe. So remember, pneumonia might not
be merely pneumonia!
Regional effects:
1) Hoarseness, due to metastasis to the recurrent laryngeal nerve. Its more
common in tumors on the left side, but why!? Because the left recurrent
laryngeal nerve is pulled down by the aortic arch, making it more proximal
to the lung and the tumor in it.
2) In the heart we could see malignant pericardial effusion and arrhythmias.
3) SVC syndrome:
Logically its more common in tumors
that are on the right side especially
squamous cell tumors. And what
actually happens is that the tumor gets
on/into the superior vena cava
obstructing it, resulting in plethora and
swelling of the face, dilated neck and anterior chest veins, fullness of the
head, severe headache and dysphagia because the dilated SVC puts
pressure on the esophagus obstructing it.
4) Pancoasts tumor: an apical lung tumor, its more common in NSCLC
resulting in shoulder and arm (ulnar nerve involvement) pain with atrophy and
weakness in the hand due to involvement of the brachial plexus (C2-T1-T2),
as well as Horners syndrome.
5) Horners syndrome, which is caused by invasion of the paravertebral and
inferior cervical ganglia, resulting in sympathetic changes: myosis, ptosis,
unilateral enophthalmus, and ipsilateral anhydrosis.
If this tumor was on the left side it might be thought of as cardiac chest pain,
but a chest x-ray should show the apical tumor and clear the confusion out. So
thats one more important reason why we should do chest x-ray in such cases,
and one of the others is that it might be aortic dissection (seen as wide
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mediastinum) because if it was thought of as MI, and by giving anticoagulants,

you would kill the patient.
Paraneoplastic hormonal syndromes:
Parathyroid like hormone (PTHi) secretion, its more common in squamous
cell carcinoma were the malignant cells themselves secrete this hormone.
Parathormone is subsequently decreased due to the hypercalcemia which
was caused by the parathyroid like hormone secretion.
Hypertrophic pulmonary osteoarthropathy, which is characterized by a
severe fracture-like pain in the tarsals and other joints and bones in the
extremities due to new periosteal (bone) formation.
The worst pain ever is bone pain xD
SIADH (syndrome of inappropriate anti diuretic hormone), which means
excess ADH which results in Hyponatremia due to Na loss in urine. The
opposite of what happens in diabetes inspidus. They develop in small cell
lung carcinoma "SCLC".
ACTH, Cushings syndrome: there's hypertension, hypokalemia, edema,
hyperpigmentation. Those develop in small cell lung carcinoma "SCLC".
Carcinoid Syndrome: (in SCLC and Adenocarcinoma).
Calcitonin (in SCLC): Calciuresis.
Gynecomastia (Gonadotropin): in Large cell carcinoma.
Hypoglycemia (insulin like activity).
Hyperpigmentation (MSH).
Paraneoplastic Neurologic Syndromes:
Peripheral Neuropathy: (SCLC).
Dementia Encephalopathy: (SCLC).
Meningitis like symptoms.
Subacute Cerebellar Degeneration causing ataxia and such and such.
Eaton-Lambert Syndrome, an autoimmune disease where antibodies are
formed against voltage-gated calcium channels in the neuromuscular
junction, very characteristic of lung cancer (esp. SCLC), it is manifested by
muscle weakness; the patient wakes up weak and gets better on exertion
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throughout the day, opposite to another autoimmune disease (myasthenia

gravis). It responds to treatment.

Metastases:
Most Small Cell carcinomas spread very early to the bone marrow, liver,
adrenal glands and the CNS that by the time of diagnosis its already spread.
We see CNS involvement in adeno, large and small cell carcinoma, but
especially in SCLC; 10% at presentation (50% will have a brain lesion later on).
Head CT- Scan is therefore being done to people diagnosed with SCLC.
Signs of metastasis include: Constitutional symptoms (such as weight loss,
Anorexia, fatigue, weakness), clubbing, skin involvement including metastases,
Erythema Multiforme, Acanthosis Nigricans, Dermatomyositis, scleroderma,
Thrombophlebitis, Tylosis (Hyperkeratosis of palms and soles).

Diagnosis of lung cancer:

History and Physical examination.
Screening, but only high risk patients.
Chest X-ray (and comparing it with an old one) and Chest CT-Scan looking for
lesions;
Central: Small and Squamous cell carcinoma.
Peripheral: Adeno and large undifferentiated cell carcinoma.
Calcification: which indicates a higher chance for the lesion to be benign but
you still cant rule out malignancy (crescent calcification).
Central, diffuse, laminated or Popcorn lesions are usually benign as well.
Needs follow up for about 2 years.

Here's a central mass, so think of small/squamous cell carcinoma,

bet-hoon abu rya9, bet-hoon.

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 Tissue diagnosis: in order to have cancer, you have to have cancer cells."
Presence of a mass and/or malignant cells in any of the following is enough to
diagnose lung cancer:
Sputum cytology.
Thoracentesis cytology (pleural tap).
Pleural Biopsy: (Mesothelioma)
Bronchoscopy: BAL, Brush, TBNA, EBBx, TBBx
Thoracoscopy or Open Lung Bx Mediastinoscopy.
CT Chest-Guided Transcutaneous needle Bx.

Flexible bronchoscopy performed via oral insertion. Most

flexible bronchoscopy procedures can be performed with
topical anesthesia applied to the airways.

Bronchoscopic appearance of squamous cell carcinoma

of the right bronchus intermedius, meen rasheed?

Bone Scan, when there is severe pain suggesting metastasis to the ribs.
PET (Positron emission tomography) Scan:
For >1 cm lesions.
Less specific in DM and infection.
Not good for Mets. evaluation.
It is rather costy.
Tumor Markers (CEA, PTH, ACTH): theyre not useful.
PFT: to decide if the patient is a candidate for surgery.
Predicted Post-op FEV1 (forced expiratory volume) must be more than
0.8L. This means that if the FEV1 for both lungs is to say 2 L and we have to
remove a mass that's obstructing one of the lungs, we'll end with a FEV1 of
1L at least and that is enough!

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 Staging:
SCLC: it has 2 stages, limited to hemithorax Vs Extensive disease going
outside the chest.
NSCLC: TNM system Classification:
T: Primary tumor (size & location).
N: Regional LN involvement.
M: Presence or absence of Metastases. When metastasis is there, the
stage is 4.
Used for prognosis and to guide the treatment plan. There's a table for the real
thing. The doctor went over some of it and very quickly.

,,, ,,,,

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 Prognosis:
SCLC:
Median survival is 1-2 years because they somehow respond to
chemotherapy.
30% die from local complications, 70% from carcinomatosis.
50% have a some sort of brain lesion at autopsy.
NSCLC:
Median survival with mets is 6 weeks to 1 year.
Less responsive to Chemo in an advanced stage compared to SCLC.
Depends on Performance status, disease extent, Weight loss
So as a conclusion, if it's an advanced stage (mets) it's better to be SCLC
because it responds to chemotherapy and if it was limited its better to be NSCLC
so we could do surgery and cure it.

Treatment:
SCLC:
Chemotherapy: cisplatin, etoposide.
Radiation: palliative for head lesions.
We cant do surgery because the cancer has already spread on diagnosis.
NSCLC:
Surgery: (lobectomy to pneumonectomy) from stage I to IIIA, needs postop FEV1 > 0.8 L. All stages after IIIA are beyond surgery.
Chemotherapy: stages II to IV.
Radiotherapy: for stage IIIB + palliative.
Adjuvant therapy (combination).

This lecture was edited by the splinderest

of all them beams, beam this, twice!
You only stumble upon difference once in your life, just saying.

Joe Biden,

Laith Al-Momani
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