CARCINOMA LUNG

Introduction: Bronchial carcinoma is by far the most common lung tumour (>90%). This is responsible for 25% of all cancer deaths and is the most common cause of death in male. Etiology: 1. Cigarette smoking- Most common cause. Directly proportional to the amount of number of cigarette smoked. 2. Passive smoking 3. Atmospheric pollution. Pathology: It arises from bronchial epithelium or mucous glands. Common cell types are Squamous 35% Small cell 20% Adenocarcinoma 30% Large cell 15%

Bronchial carcinoma may involve the pleura, chest wall, brachial plexus or may spread to mediastinum and compress oesophagus, SVC, trachea, phrenic/left recurrent laryngeal nerve. Lymphatic spread to supra clavicular and mediastinal LN and blood borne metastasis most commonly in liver, bone and brain is frequently observed.

Clinical features:
1. Cough Most common early symptom.

Pneumonia /lung abcess secondary to bronchial obstruction may develop leading to productive cough with purulent sputum.
2. Hemoptysis Repeated scanty

hemoptysis/ massive hemoptysis.

3. Breathlessness Due to collapse of

lung or development of pleural effusion.

4. Pleural pain Reflects invasion of

pleura. Intercostal nerve/brachial plexus involvement may cause pain in the chest and upper limb. 5. Apical carcinoma may cause Horners syndrome (ipsilateral ptosis, enophthalmos, small pupil, hypohydrosis of face) or may result into Pancost syndrome (pain in shoulder and inner arm). 6. It can also present with symptoms of metastasis like seizures, jaundice, bone pain etc. 7. Non-metastatic extrapulmonary manifestations of bronchial carcinoma include SIADH Hypercalcemia Ectopic ACTH secretion Neuropathy Myasthenia Cerebellar degeneration etc.

Physical signs: Patients are usually cachectic and anemic.

Physical signs may be normal unless there is significant bronchial obstruction or spread to pleura and mediastinum. Thus symptoms could be because of collapse, pneumonia or effusion. Unilateral wheezing is due to fixed bronchial obstruction. A hoarse voice and stridor may be occasionally seen. Cervical and supraclavicular lymphadenopathy is common. Ca bronchus may also cause SVC syndrome, clubbing and hypertrophic pulmonary osteoarthropathy (HPOA). There could be signs of metastasis like bone tenderness, hepatomegaly and focal CNS signs.

Investigations:

CXR findings includea) Unilateral hilar enlargement b) Peripheral pulmonary opacity c) Lung, lobe or segmental collapse d) Pleural effusion e) Broadening of mediastinum, enlarged cardiac shadow, elevation of hemidiaphragm. f) Rib destruction.

Bronchoscopy with bronchial biopsy and brushings most

useful as it provides histological cell type diagnosis and thus determine the management. CT scan with CT guided biopsy Thoracoscopy/ Thoracotomy FNAC of LN/ skin lesions Sputum cytology.

Management: Cure can be achieved only through surgical

excision. In majority, surgery is not possible and can be offered only palliative therapy.
a) Treatment of non small cell tumours excision is

the treatment of choice for peripheral tumours with no metastatic spread. Curative radiotherapy is an alternative. b) Treatment of small cell tumours they are nearly always dessiminated at presentation. Hence surgery is not possible. It may responed to chemotherapy (Cyclophosphamide, Doxorubicin and Vincristine) or (IV Cisplatin and Etoposide). Palliation Radiotherapy is commonly used for bronchial obstruction, SVC obstruction, hemoptysis and bone pain. Laser therapy this is essentially palliative. Best result are obtained in tumours of main bronchi. Pleural effusion may require drainage and pleurodesis. General management Analgesia, treatment of hypercalcemia and SIADH are important.

Prognosis: Overall prognosis is poor with 80% dying within 1

year of diagnosis. Best prognosis is with well differentiated squamous cell tumours which have no metastasis.

Prevention: Quit smoking.

Other lung tumours : These are rare and include 1. 2. 3. 4. 5. 6. Adenosquamous Ca Carcinoid tumour Bronchial gland adenoma Bronchial gland Ca Hemartoma Bronchoalveolar Ca.

NEOPLASMS OF PLEURA
Mesothelioma of pleura: This is a malignant tumour of pleura
most commonly due to exposure to blue asbestos. A lag time of 20 yrs. or more is typical between asbestos exposure and development of mesothelioma. Exposure of asbestos by inhalation can lead on to asymptomatic pleural thickening, pleural effusion (self limiting) or diffuse pulmonary fibrosis leading on to restrictive lung disease with progressive dyspnoea, clubbing and fine crackles.

Clinical features: Chest pain, pleural effusion and

breathlessness.

Investigations: CXR / CT scan Pleural thickening/ effusion. Treatment: These are chemo resistant and radiotherapy is
effective in preventing tumour growth through biopsy site. Treatment is largely symptomatic.