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03-18-2009, 10:42 AM
Bronchogenic Carcinoma

It is one of the common malignancy in males
Aetiology : à no definite aetiology
Incidence:
Male> female
Age: 50 — 70 yrs
Predisposing factors:
• Air pollution • Bronchial adenoma
• Smoking (3,4 benzpyrine) • Asbestosis
N.B. Cigarette pack years of cigarette smoked indicating the degree of risk of developing bronchogenic carcinoma.
i.e. the risk is increased 60 - 70 fold for man smoking two packs /d. for 20 yrs
Pathology
1- Central or hilar type In a main bronchus so, invade the mediastinum early
2- Peripheral In small bronchus & invade pleura early
Pan cost tumor à is an apical peripheral carcinoma
Naked eye appearance à Fungating mass
à Malignant ulcer
à Infiltrative type
Microscopic:

Who classification
Type I Type II Type III Type IV
Squamous cell Small cell car Adenocarcinoma Large cell carcin
carcinoma (oat cell car)
Spread à Direct à lung , pleura, rnediastinum.
à retrograde lymphatic • Hilar & mediastinum à Cx. L.N.
• Lymphatic à core pulmonale
à Haematogenous à bones, liver, brain
C/P
Patient is old male ( usually ) heavy smoker with chronic bronchitis complaining of change in the pattern of smoker cough?

I- Intra-thoracic manifestations
A- Bronchopulmonary presentation:
1- Asymptomatic (detected accidentally by routine x-ray as coin shadow)
2- Haemoptysis à Blood tinged sputum
à Red current jelly à Tissue debris
i.e. sputum consist of à Mucous
à RBCS
3- Bronchial obstruction
Ż Ż
Partial Complete
• Emphysema • Collapse
• Bronchiectasis
4- Pneumonia
5- Lung abscess ( due to 2ry infection)
6- Thoracic inlet syndrome (Pancost tumour) it invade the following structures
Upper 3 ribs
Sympathetic chain à (Horner $)
SVC à obstruction
Lower trunk of brachial plexus
Ż Ż
• pain in medial forearm • wasting of small muscle of hand
Subclavian artery à unequal pulse volume in both upper limbs
B - pleural presentation:
►Effusion:
• Malignant effusion à Massive
à Hemorrhagic
à Rapidly accumulation
• Serous: due to obstruction of azygos vein
• Chylous: due to obstruction of thoracic duct
• Empyema: due to rupture of malignant abscess into pleura
►Dry pleurisy may occur
C - Mediastinal presentation:
due to mediastinal L.Ns ( see later)

2- Extra-thoracic manifestation
Metastatic Non - metastatic
(paramalignant $)
due to production of abnormal metabolites by the tumor, commonly
without cell carcinoma
Clubbing & Osteoarthropathy
Neuro • Myopathy
• Neuropathy
• Myasthenia(Eaton
Lambert $)
• Cerebellar lesion
Endocrinal • Cushing $
• Carcinoid $
• Hyperparathyroidism
• ADH ­
Skin • Pruritis
• Herpes
• Dermatomyositis
• Acanthosis nigricans
Investigations
X- ray • coin shadow • cavity
• mediastinum mass • diaphragmatic paralysis
• effusion • rib erosion
CT scan chest
Sputum examination. à for malignant cells
Bronchoscopy à biopsy
L. N biopsy or scalene pad of fat
Mediastinoscopy ( for local extension)
D.D. • 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:
Medical ttt
• Cytotoxic drugs ( cyclophosphamide).
• irradiation to ŻŻ SVC obstruction , to treat haemoptysis or chest pain due to invasion
Surgical treatment
• Palliative
Laser therapy.
• Via bronchoscope to destroy the tumor, it is a palliative

Source: Internal Medicine Book of Dr.Osama Mahmoud (Ain Shams University)