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Investigations-and-Diagnosis-of-Bronchogenic-
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Bronchiogenic carcinoma should be considered in the diagnosis of all respiratory

disorders. Malignancy can mimic virtually all common pulmonary diseases such as
tuberculosis, Pneumonia, Lung abscess, atelectasis, localized emphysema, Pleural
effusion etc. So how can we give a detailed or differential diagnosis to single it out?

Investigations
Radiological findings: Radiological findings may be protean. The presence of a circular
or irregular shadow in an symptomatic patient may be the only finding. The classical
circular shadow is called lesion. In more advanced cases, the lesion may be more
extensive. Hilar glands are enlarged. The growth may undergo central cavitation and the
resulting abscess shows thick and ragged walls. The presence of hilar adenopathy should
suggest the malignant nature of the lesion. Presence of diaphragmatic paralysis along
with a hilar mass should strongly suggest the possibility of bronchogenic carcinoma.
Other features like collapse, consolidation, localized emphysema, and pleural and
pericardial effusion may also be present. Special procedures such as tomography,
selective pulmonary angiography, isotope scan may help further. A single peripherally
placed "coin shadow" in the lung may be caused by primary or secondary neoplasms,
tuberculosis, fungal infections or old scars.

Sputum examination: Hemoptysis is present in many cases and the sputum is typically
described as "currant jelly". Malignant cells may be detected in the sputum by examining
after methylene blue staining and this can be confirmed by Papanicolaou's method. Other
diagnositc procedures include bronchoscopy, needle biopsy of palpable lymph nodes in
the neck and axilla and scalene fat pad biopsy. The right scalene node should be biosied
in cases of lesions of the right lung and the left lower lobe. The left scalene node should
be biopsied for left upper lobe neoplasms. Mediastinoscopy and biopsy of abnormal
nodes is a more rewarding procedure. When a solitary pulmonary nodule (coin shadow)
is detected and diagnosis is not evident, the patient should be followed up to see the
progress of the lesion. In general, malignant lesions have a doubling time of 5 weeks to
18 months. More rapid growth is suggestive of inflammatory lesions. Calcification is in
favor of non-malignant lesions though this is not always true. When there is strong
suspicion of malignancy, diagnostic thoracotomy is indicated.

Treatment
Management depends on the stage of the tumor on diagnosis, histological type and
presence of complications. Treatment may consist of surgery, irradiation and
chemotherapy.

Surgery
When the primary is small and is detected before clinical manifestations develop and
there are no metastases, surgical treatment is ideal. Contraindications to surgery include
infiltration of the trachea, carina, superior vena cava, recurrent laryngeal nerve paralysis
and pleural effusion. Presence of mediastinal nodes and distant metastases are
contraindications to surgery. Surgical results are less satisfactory in those cases who have
developed symptoms.

Radiotherapy
Radical radiotherapy is preferred in selected cases. In practices, in the majority of cases
radiotherapy is given as a palliative measure in inoperable cases with local spread or
distant metastases. Several recent advances in radiotherapy techniques such as split dose
radiotherapy, use of radio-sensitizers, and the availability of modern radiation equipment
like linear accelerator, betatron, neutron beams and meson beams have made
radiotherapy more effective with less hazards. In some centers, radiotherapy is also used
prophylactically to the brain to prevent the development of metastases.

Chemotherapy
It is indicated in 90% of patients with bronchogenic carcinoma. The choice of drugs is
based on the tumour histology, facilities for supportive therapy, and tolerance by the
patient. Chemotherapy may be used as the sole modality of treatment in advanced cases
or as an adjunct to surgery and radiotherapy. Commonly used chemotherapeutic agents
are methotrexate, cyclophosphamide, vincristine, CCNU, adriamycin and cisplatin.

Prognosis
Since most of the cases are diagnosed late in the disease, overall prognosis in
bronchogenic carcinoma is poor. Asymptomatic subjects detected by investigations have
the best prognosis. Next in line are subjects with symptoms referable to the primary
tumour with a duration of less than sex months. Metastases in CNS and liver confer a
poor outcome. Small cell carcinomas have a poorer prognosis since metastases develop
early. In the majority of patients only palliative therapy is possible. Five year survival
figures for squamous cell carcinoma vary from 40-50% for stage I to less than 10% for
stages III and above.

Prophylaxis
Bronchogenic carcinoma is at least partially preventable by avoidance of smoking. The
risk of cancer comes down quantitatively with the reduction in the number of cigarettes
smoked and in those who give up smoking completely the increased risk cancer comes
down after a period of about 10 years to reach that in nonsmokers. Occupational exposure
to asbestos, environmental pollutants and radioactive materials should be reduced to the
minimum and personnel engaged in these industries should receive personal protection.