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Bronchogenic Carcinoma

Bronchial Carcinomas

Bronchogenic carcinoma is the leading cause of cancer death throughout the world and tobacco smoking is shown to be the single most important risk factor. Symptoms may include cough, dyspnea, hemoptysis and chest pain and the diagnosis is made using clinical, imaging and histopathologic criteria. Despite available therapy, the prognosis is poor, primarily because the majority of patients receive a late diagnosis.


Presentation

The clinical presentation may be nonspecific, but cough, hemoptysis, dyspnea and chest pain are lung-related symptoms that are reported in variable percentages [4]. In up to 25% of cases, however, an asymptomatic course is observed, which significantly impedes the ability to make the diagnosis [6].

Cough
  • A 30-year-old man patient was admitted to our clinic with complaints including cough, dyspnea, and chest pain. He had been diagnosed with pulmonary Langerhans' cell histiocytosis (LCH) 9 years previously.[ncbi.nlm.nih.gov]
  • We describe a clinical scenario of chronic and recurrent cough in a 41-year-old woman with no comorbidities. Her chest CT scan was suggestive of a mass lesion in the right main bronchus.[ncbi.nlm.nih.gov]
  • The electrolyte abnormality seen in him would be: (AIIMS May 08) A Hyponatremia B Hyperkalemia C Hypocalcaemia D Hypercalcemia A 60 year old man presents with non productive cough and hemoptysis for 4 weeks; He has grade III clubbing, and a lesion in[gradestack.com]
  • Most of the patients consulted doctor for chief complaint of cough and shortness of breath, the average duration of symptoms being 117.53 days.[ncbi.nlm.nih.gov]
  • Any known smoker, who presents with a recent-onset cough, or a change in their cough and respiratory function, should have a chest x-ray.[lecturio.com]
Pneumonia
  • In-hospital mortality due to postoperative pneumonia was 7 cases (31.8%). In the postoperative pneumonia group, microorganisms were isolated in 10 cases (45.5%).[ncbi.nlm.nih.gov]
  • However, she was admitted 6 years prior to current presentation with pneumonia and discharged home following parenteral antibiotic therapy.[ncbi.nlm.nih.gov]
  • He later developed pneumonia In alcoholics, aspiration pneumonia is common--bacteria enter the lung via aspiration of gastric contents. and fever. The patient expired soon thereafter.[peir.path.uab.edu]
  • Obstructive collapse 23. 2ry pneumonia Criteria of 2ry pneumonia: 1. Consolidation collapse. 2. Consolidation with no air bronchogram. 3. Consolidation with hilar mass. 4.[slideshare.net]
  • Lung abscess. pneumonia T.B. pulmonaiy infarction Other causes of pleural effusion &mediastinal syndrome Treatment: Operable When the tumor confined to the lung Away from carina by 2 cm No distant or localized spread Pneumonectomy irradiation Inoperable[meduweb.com]
Pleural Effusion
  • Pulmonary and nodal multiple myeloma with a pleural effusion mimicking bronchogenic carcinoma.[dx.doi.org]
  • Hereby, we describe a case of a patient with pulmonary plasmacytoma, who developed nodal and pulmonary MM with a pleural effusion, the radiological appearance of which mimicked bronchogenic carcinoma.[ncbi.nlm.nih.gov]
  • The patient also had axillary lymphnode metastasis on the same side as the chest swelling with a contralateral pleural effusion.[ncbi.nlm.nih.gov]
  • Pleural effusion Pathology: • Direct spread. • Lymphatic obstruction. • 2ry pneumonia. Radiolgical criteria: Pleural effusion without mediastinal shift due to underlying obstructive collapse 47. Chest wall invasion C.P: Focal chest pain.[slideshare.net]
  • Lung abscess. pneumonia T.B. pulmonaiy infarction Other causes of pleural effusion &mediastinal syndrome Treatment: Operable When the tumor confined to the lung Away from carina by 2 cm No distant or localized spread Pneumonectomy irradiation Inoperable[meduweb.com]
Hemoptysis
  • The most common site of primary is : (LQ) A Lung B Kidney C Breast D Stomach Most common symptom of primary lung carcinoma (AIIMS May 2011) A Cough B Hemoptysis C Weight loss D Chest pain A 60 years old chronic smoker presents with complaints of hemoptysis[gradestack.com]
  • A 45-year-old smoker was referred for evaluation of recent onset streaky hemoptysis and a large cystic lesion in the left lower lobe (LLL). Presence of air trapping in LLL was observed on computed tomography scan of thorax.[ncbi.nlm.nih.gov]
  • Nevertheless, 4 weeks after hospital discharge the patient died of massive hemoptysis. Fig. 1. Fig. 2. 1885-5857/ 2002 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved[revespcardiol.org]
  • Causes of hemoptysis 5.[slideshare.net]
  • Hemoptysis (25-50%) Tumour in the central airway Blood vessels resulting from tumour-induced angiogenesis are leaky and tortuous, predisposing them to easy rupture and causing hemoptysis Dyspnea (25%) Extrinsic or intraluminal airway obstruction Activation[epomedicine.com]
Hoarseness
  • He had dysphagia, weight loss and hoarseness of voice. Lab tests potassium of 2.5 mmol/l, with normal sodium, urea, creatinine. Bicarbonate 35 mmol/l.[endocrine-abstracts.org]
  • […] syndrome (Obstruction of SVC by tumor; more commin in SCLCl 2-4%)Impaired venous return (causing edema) from: Arms: limb edema Periorbital area: periorbital edema Ocular mucosal membranes: chemosis (visual disturbance) Pharynx and larynx: stridor and hoarseness[epomedicine.com]
  • […] segment RUL o Pancoast tumor superior sulcus tumor (4%) o Squamous cell most often o SVC obstruction (5%) § Most often small cell · Associated clinical findings o Horner's syndrome § Pancoast tumor o Elevated hemidiaphragm § Phrenic nerve paralysis o Hoarseness[learningradiology.com]
  • Lung tumors may grow to place pressure on the recurrent laryngeal nerve, resulting in hoarseness. Growing tumors may place pressure on the superior vena cava, resulting in its obstruction and symptoms of superior vena cava syndrome.[pathwaymedicine.org]
Weight Loss
  • He had dysphagia, weight loss and hoarseness of voice. Lab tests potassium of 2.5 mmol/l, with normal sodium, urea, creatinine. Bicarbonate 35 mmol/l.[endocrine-abstracts.org]
  • The cause of the marked weakness and weight loss which may accompany a small, localized malignancy is not clear.[jamanetwork.com]
  • Initial review of symptoms was unremarkable for cough, shortness of breath, or weight loss. Figure 1: Initial presentation of swollen, painful, left small finger distal phalanx.[healio.com]
  • A 73-years-old man presented to the colorectal clinic with a history of diarrhoea, bleeding per rectum and weight loss. He had no significant past medical illness. The clinical examination was unremarkable.[jpgmonline.com]
  • Weight loss. Shoulder, arm, or bone pain. Sometimes the cancer is diagnosed on routine examination, and the patient has no or minimal symptoms. Symptoms and signs are dependent upon the location and spread of the tumor. Risk Factors Smoking.[rxmed.com]
Anemia
  • Physical examination may be normal or may reveal Anemia, finger clubbing, enlarged lymph nodes Decreased breath sounds due to underlying malignant pleural effusion Wheezes due to accompanying COPD Facial swelling, plethora, dilated vessels and upper limb[lecturio.com]
  • […] antibodies; SOX protein antibody; SCLC associated; treated with 3,4-diaminopyridine), Peripheral neuropathy, Subacute cerebellar degeneration, Cortical degeneration Hematological: Trosseau’s syndrome (Migratory thrombophlebitis), Marantic endocarditis, DIC, Anemia[epomedicine.com]
Chest Pain
  • A 30-year-old man patient was admitted to our clinic with complaints including cough, dyspnea, and chest pain. He had been diagnosed with pulmonary Langerhans' cell histiocytosis (LCH) 9 years previously.[ncbi.nlm.nih.gov]
  • The primary modality of treatment is: (AIPG 2009) A Radiotherapy B Chemotherapy C Surgery D Supportive treatment Bronchial adenoma commonly present as : (LQ) A Recurrent hemoptysis B Cough C Dysponea D Chest pain About mesothelioma all are true except[gradestack.com]
  • pain (20%) – common in peripheral tumor Tumour involving pleural surface causing pleuritic chest pain Also due to mediastinal involvement Mediastinal involvement Superior vena cava syndrome (Obstruction of SVC by tumor; more commin in SCLCl 2-4%)Impaired[epomedicine.com]
  • Chest wall invasion C.P: Focal chest pain. Radiological manifestations: CXR: Bone destruction. Chest wall mass.[slideshare.net]
  • pain due to invasion Surgical treatment Palliative Laser therapy.[meduweb.com]
Bone Pain
  • […] renal calcium reabsorption hypercalcemia Associated with squamous cell carcinoma Clinical features: Stones, Bones, Groans, Moans, Psychic overtones Stones – renal stones and nephrocalcinosis; polyuria or polydipsia; impairment of renal function Bones – bone[epomedicine.com]
  • Shoulder, arm, or bone pain. Sometimes the cancer is diagnosed on routine examination, and the patient has no or minimal symptoms. Symptoms and signs are dependent upon the location and spread of the tumor. Risk Factors Smoking.[rxmed.com]
  • For instance, seizures, headache, personality changes, bone pain, abdominal pain, and jaundice. The common metastatic sites include lymph nodes, bones, liver, central nervous system (brain and spinal cord), and adrenal glands.[lecturio.com]
  • The most common extrapulmonary symptoms were weight loss in 60%, hoarseness of voice in 7 (8.6%), lower limb weakness in 2( 2.46%), bone pain in 5 ( 6.1%), Pancoasts syndrome in 3(3.7%).Clubbing was seen in 22.2%, out of which 8 were sqaumous cell carcinoma[ijri.org]
  • pain Spinal cord impingement Neurologic problems such as headache, weakness or numbness of limbs, dizziness, and seizures See Presentation for more detail.[emedicine.medscape.com]
Shoulder Pain
  • Pancoast tumors can derange the brachial plexus, resulting in shoulder pain, and plae pressure on afferent SNS fibers that travel above the lung apex and control ocular functions, resulting in "Horner's Syndrome" characterized by a triad of miosis, ptosis[pathwaymedicine.org]
Peripheral Neuropathy
  • . - Parathormone or prostaglandin E (hypercalcemia) - Calcitonin (hypocalcemia) - Gonadotropin (gynecomastia) - Serotonin (carcinoid syndrome) Other paraneoplastic syndromes include myopathy, peripheral neuropathy, acanthosis nigricans, and hypertrophic[histopathology-india.net]
  • neuropathy, Subacute cerebellar degeneration, Cortical degeneration Hematological: Trosseau’s syndrome (Migratory thrombophlebitis), Marantic endocarditis, DIC, Anemia, Granulocytosis, Leukoerythroblastosis Cutaneous: Acanthosis nigricans Renal: Nephrotic[epomedicine.com]
  • neuropathy, superior vena cava syndrome (compression/invasion of SVC causes venous congestion, circulatory compromise, dusky head, arm edema) Spread and classification Spreads along bronchus distally and proximally, into lung parenchyma to mediastinum[pathologyoutlines.com]

Workup

A thorough physical examination must be performed, but imaging studies are necessary to make a preliminary diagnosis [3]. Chest X-ray, CT, or MRI can identify the location of the tumor and bronchoscopy with subsequent histopathological examination, guided by findings from imaging studies, is mandatory in order to identify the underlying subtype [7].

Atelectasis
  • Undiagnosed and retained foreign bodies in lungs may result in serious complications such as pneumonia, atelectasis or bronchiectasis. We describe a clinical scenario of chronic and recurrent cough in a 41-year-old woman with no comorbidities.[ncbi.nlm.nih.gov]
  • Atelectasis and Postobstructive Pneumonitis Atelectasis results from endobronchial obstruction or extrinsic compression of a bronchus.[alpfmedical.info]
  • Arrhythmia occurred in 12 patients, atelectasis in eight patients, and pneumonia in five patients. Five patients had to be assisted with mechanical ventilation because of pulmonary function failure.[ncbi.nlm.nih.gov]
  • Adenocarcinoma and undifferentiated large cell carcinoma are generally peripheral lesions manifesting as solitary nodules or masses, whereas squamous cell carcinoma and small cell carcinoma are typically central and may manifest as hilar masses, atelectasis[ncbi.nlm.nih.gov]
Cavitary Lesion
  • The classic manifestation is a cavitary lesion in a proximal bronchus. This type is characterized histologically by the presence of keratin pearls and can be detected with cytologic studies because it has a tendency to exfoliate.[emedicine.medscape.com]
Hyponatremia
  • SIAD is characterized by hyponatremia, hypoosmolality, and less than a maximally diluted urine. Secretion of vasopressin by the tumor and inappropriate thirst are the causes of the syndrome.[journals.lww.com]
  • (Na Hyp0-osmotic plasma (Plasma osmolality Hyperosmotic urine (Urine osmolality 500 mOsm/kg) Hypernatremic urine (Urinary Na 20 mEq/L) Ectopic secretion of ADH retain free water in collecting ducts Euvolemic hyponatremia and concentrated urine Mild symptoms[epomedicine.com]
  • The electrolyte abnormality seen in him would be: (AIIMS May 08) A Hyponatremia B Hyperkalemia C Hypocalcaemia D Hypercalcemia A 60 year old man presents with non productive cough and hemoptysis for 4 weeks; He has grade III clubbing, and a lesion in[gradestack.com]
  • Antidiuretic hormone (ADH), inducing hyponatremia due to inappropriate ADH secretion; adrenocorticotropic hormone (ACTH), producing Cushing’s syndrome; parathormone, parathyroid hormone-related peptide, prostaglandin E, and some cytokines, all implicated[peir.path.uab.edu]
Calcium Increased
  • increases acidity) Moans – fatigue, myalgia, proximal muscle weaness, hypertension (calcified arterial walls), corneal calcification (slit-lamp) Psychic overtones – depression, lethargy, memory loss, confusion, coma ECG: shortened QT interval, prolonged[epomedicine.com]
Pleural Effusion
  • Pulmonary and nodal multiple myeloma with a pleural effusion mimicking bronchogenic carcinoma.[dx.doi.org]
  • Hereby, we describe a case of a patient with pulmonary plasmacytoma, who developed nodal and pulmonary MM with a pleural effusion, the radiological appearance of which mimicked bronchogenic carcinoma.[ncbi.nlm.nih.gov]
  • The patient also had axillary lymphnode metastasis on the same side as the chest swelling with a contralateral pleural effusion.[ncbi.nlm.nih.gov]
  • Pleural effusion Pathology: • Direct spread. • Lymphatic obstruction. • 2ry pneumonia. Radiolgical criteria: Pleural effusion without mediastinal shift due to underlying obstructive collapse 47. Chest wall invasion C.P: Focal chest pain.[slideshare.net]
  • Lung abscess. pneumonia T.B. pulmonaiy infarction Other causes of pleural effusion &mediastinal syndrome Treatment: Operable When the tumor confined to the lung Away from carina by 2 cm No distant or localized spread Pneumonectomy irradiation Inoperable[meduweb.com]

Treatment

For stages I and II, surgical removal of the tumor is indicated, whereas adjuvant chemotherapy or radiation therapy may be administered with a goal of maximizing the effects of surgery [5]. Etoposide, carboplatin, cislatin or irinotecan are recommended chemotherapeutic agents. In more advanced stages of the disease (III and IV), chemotherapy and possibly palliative radiation is used [6], but because the prognosis is very poor, palliative and symptomatic care is equally important to provide the patient with an adequate level of support.

Prognosis

Unfortunately, about 80% of patients who are diagnosed with lung cancer are already in advanced stages of the disease and the prognosis is very poor, even with all available therapy [3]. The TNM staging is used for classification of patients, ranging from I (localized disease) to IV (presence of distant metastases) [5]. With treatment, 5-year survival ranges from 67% in stage I to < 1 % in stage IV [6]. Moreover, SCLC recognized in early stages has a 5-year survival between 20-25%, whereas almost no patients survives five years when the tumor is diagnosed late [8].

Etiology

The exact cause remains unknown, but various carcinogenic events have been documented after use of tobacco and exposure to other carcinogens such as asbestos and radon [6]. There are two main types of lung cancer: small-cell (SCLC, constituting 15% of cases) and more commonly non-small cell (NSCLC), which is further divided into adenocarcinoma, squamous cell carcinoma and large cell carcinoma [8].

Epidemiology

In the United States, more than 220,000 new cases and almost 160,000 deaths occurred in 2015, making lung cancer the most common cause of cancer death [1]. A slight predilection toward male gender was observed [1], whereas the single most important risk factor is cigarette smoking [7]. Alcohol consumption, exposure to radon, asbestos and other occupational or environmental pollutants that are known lung carcinogens, but also genetic factors have shown to be additional risk factors [5]. Elderly patients are most frequently diagnosed, as a marked increase in incidence rates are seen after 60 years of life [7].

Sex distribution
Age distribution

Pathophysiology

The exact pathogenesis model remains to be elucidated, but several key mutations that presumably occur after exposure to tobacco and other carcinogenic substances have been discovered so far. Abnormal expression of epidermal growth factor receptor (EFGR), inactivity of p53, one of the main tumor suppressor genes, as well as K-RAS mutations are some of the most important [4].

Prevention

Avoidance and cessation of smoking is by far the most important preventive strategy against lung cancer [5]. Although implementation of mass screening is still not suggested, the use of imaging studies such as CT in regular screening of at-risk patients has been recommended [8].

Summary

Bronchogenic carcinoma, one of the most common malignant diseases worldwide, is the leading cause of death from cancers in the United States and the rest of the world [1]. The pathogenesis model almost invariably include mutations of various genes involved in cell cycle as a result of exposure to tobacco and other carcinogenic substances (asbestos, radon, alcohol, etc) [2]. Lung cancer is classified into small-cell (SCLC) and non-small cell (NSCLC) carcinoma, both having a very poor prognosis. The clinical presentation may be nonspecific, with respiratory complaints such as cough, hemoptysis, chest pain and breathing difficulties, but the onset is often insidious and the diagnosis is made in advanced stages of the disease in 80% of patients [3]. Imaging studies such as computed tomography (CT) or magnetic resonance imaging (MRI) and subsequent bronchoscopy with histopathological examination to determine the exact subtype is necessary to confirm the location and the type of bronchogenic carcinoma [3]. Treatment principles include surgery, chemotherapy and radiation, but overall 5-year survival rates are around 15% [4]. For this reason, cessation of tobacco smoking and avoiding exposure to other substances that are known to be involved in the pathogenesis is vital in reducing the burden of this fatal malignant disease [5].

Patient Information

Bronchogenic carcinoma (lung cancer) is the leading cause of death from a malignant disease worldwide, with more than 160,000 deaths in the United States in 2015. Its development is still incompletely understood, but various mutations as a result of tobacco exposure have been documented, suggesting the direct role of tobacco in this tumor. Additional substances that are brought into connection with lung cancer are radon and asbestos, whereas genetic factors have also been proposed. Signs and symptoms include breathing difficulties, cough that may be accompanied by blood expectoration (termed hemoptysis) and chest pain, but in up to a quarter of patients, an asymptomatic course is observed. Imaging studies such as plain radiography, computed tomography (CT scan) or magnetic resonance imaging (MRI) can be used to determine the location and size of the tumor, but to identify the exact subtype, a biopsy is necessary. Treatment depends on the stage of the tumor and includes surgery, chemotherapy and radiation, but despite available therapy, the prognosis is very poor, with overall 5-year survival rates of only 15%. For this reason, cessation of tobacco smoking and avoiding exposure is mandatory in reducing the risk of this highly fatal malignancy.

References

Article

  1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin 2016;66:7.
  2. Dela Cruz CS, Tanoue LT, Matthay RA. Lung Cancer: Epidemiology, Etiology, and Prevention. Clin Chest Med. 2011;32(4):10.1016/j.ccm.2011.09.001.
  3. Al Jahdali H. Evaluation of the patient with lung cancer. Ann Thorac Med. 2008;3(6):74-78.
  4. Aster, JC, Abbas, AK, Robbins, SL, Kumar, V. Robbins basic pathology. Ninth edition. Philadelphia, PA: Elsevier Saunders; 2013.
  5. Molina JR, Yang P, Cassivi SD, Schild SE, Adjei AA. Non–Small Cell Lung Cancer: Epidemiology, Risk Factors, Treatment, and Survivorship. Mayo Clin Proc. 2008;83(5):584-594.
  6. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.
  7. Wender R, Fontham ET, Barrera E Jr, et al. American Cancer Society lung cancer screening guidelines. CA Cancer J Clin. 2013;63(2):107-117.
  8. Jett JR, Schild SE, Kesler KA, Kalemkerian GP. Treatment of small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5):e400S-419S.

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