Bronchongenic Carcinoma

Leon
Legaspi
Liao
Lim, AP
Lim, PJ
Lim, RD
Liquete
Llamas, KN
Llamas, MT
Lo
 A.C 49 y/o male
CC: Difficulty of breathing
6 months PTC

productive cough with no accompanying symptoms

Self medicated: Amoxicillin (500 mgs. Tab TID X 7
days) with relief

5 months PTC

Cough recurred with whitish phlegm, blood streaked

Sought consult
Advised to have Chest X-ray
Chest x-ray revealed a “mass” on the upper right lobe
Advised to go under CT scan

1 month PTC

Chest biopsy was done and histopath revealed NSCLC

Scheduled to undergo chemotherapy and radiotherapy
Review of systems:

(+)Significant weight loss

(+)Loss of appetite
(+)Dysphagia
(+)2-3 pillow orthopnea

Past Medical History:

(+) Hypertension

Personal History:
(+) Smoking
(+) Alcoholic drinker
Pertinent Physical Examination:
Tachypneic
Hyposthenic
Dullness on the right upper lobe
No rales
Histopath findings:
Non-small cell carcinoma
Histopathology – Non small cell CA
Bronchogenic
Carcinoma
 Bronchogenic Carcinoma
• Most frequently diagnosed major cancer in
the world
• Most common cause of mortality
worldwide
• Largely due to carcinogenic effect of
cigarette smoking
• Occurs most often between 40 and 70
years (peak incidence of 50’s and 60’s)
 Bronchogenic Carcinoma
• Arises by a stepwise accumulation of
genetic abnormalities that transform
benign bronchial epithelium to neoplastic
tissues
• Unlike many other cancers, the major
environmental insult that inflicts genetic
damage is known
 Bronchogenic Carcinoma
• Etiology
– Tobacco smoking
– Industrial hazards (radiation, uranium,
asbestos)
– Air pollution (radon)
• Genetic predisposition
– Inherited mutations to rb and p53 genes
– 1st degree relatives of lung cancer probands
 Bronchogenic Carcinoma
• Arises most often in and about the hilus of
the lung
• About ¾ of the lesions take their origin
from first-order, second-order, and third
order bronchi
 Bronchogenic Carcinoma
• Tumor classification (WHO)
– Important for consistency in treatment
– Provides a basis for epidemiologic and biological
studies

Kumar, et. al. (2005). Robbins and Cotran Pathologic Basis of Disease. 7th ed. Elsevier: China. pg. 759
 Bronchogenic Carcinoma
• Relative proportion of • For clinical use (on
major categories: the basis of likelihood
– Squamous cell of metastasis and
carcinoma (24-40%) response to
– Adenocarcinoma treatment):
(25-40%) – Small cell carcinoma
– Small cell carcinoma (metastatic; high initial
(20-25%) response to chemo)
– Large cell carcinoma – Non-small cell
(10-15%) carcinoma ( less
metastatic and
responsive)
 Bronchogenic Carcinoma
• TNM International Staging System
– Used for NSCC particularly in preparing
patients for curative attempts with surgery or
radiotherapy
– Provides useful prognostic information
 Radiologic signs of Bronchogenic
Carcinoma
• Atelectasis
– Segmental
– Lobar
• Unilateral hilar enlargement
• Overinflation, obstructive
• Mediastinal mass
• Apical pulmonary opacity
• Cavitation
• Segmental consolidation
• Parenchymal mass
• Mucoid impactation
• Poorly defined, irregular, non-homogenous density
 Atelectasis
• a state of incomplete expansion of a lung
or any portion of it
• loss of lung volume – lung collapse
• there is a decrease or absence of air in
the alveoli
• It is always a secondary lesion and is
therefore a sign of disease rather than a
disease in itself. Its causes can be
grouped into six general categories
Causes:
2. Bronchial obstruction (resorption atelectasis)
– Intrinsic
– Extrinsic
3. Space-occupying process
− pneumothorax, pleural fluid, diaphragmatic
elevation, herniation of abdominal viscera into the
thorax, and large intrathoracic tumors
4. Paralysis or paresis resulting in inability to
expand a lung completely
1. Restriction of motion as a result of pleural
disease or injury.
• chronic constrictive pleuritis - causes a ↓ in volume of
one hemithorax
• pleural infections and thoracic or upper-abdominal
trauma
2. Adhesive atelectasis - non-obstructive
airlessness in patients with inactivation,
decrease, or loss of surfactant.
3. Cicatrization atelectasis - volume loss found in
patients with local or general pulmonary fibrosis
 Radiographic signs of Atelectasis
• Direct Signs ( due to lobar volume loss)
– Displacement of interlobular fissures
– air bronchograms
• Indirect Signs
– Diaphragmatic elevation:
– Juxtaphrenic Peak (upper lobe atelectasis)
– Mediastinal shift
– Compensatory overinflation of normal lung
– Hilar displacement
– Reorientation of hilum or bronchi
– ULA
– LLA
– Approximation of the ribs
– Flat waist sign
– Increased lung opacity
– Absence of air bronchograms
– Absence of air bronchograms suggests central
bronchial obstruction
– Mucus bronchograms
– Shifting granuloma sign
 Radiologic sign of bronchogenic
carcinoma
• Atelectasis - may be segmental or lobar

minor fissure
is elevated,
indicating
that there is
some
atelectasis.
A: The mass obscures the upper
cardiac border and aorta and
fades off into the lung superiorly.
There is some mediastinal shift to
the left and elevation of the left
hemidiaphragm.
B: Arrows point to the displaced
fissure, with the partially
atelectatic upper lobe anterior to it
• most readily seen in the right upper lobe
– Atelectasis results in elevation and concavity
of the secondary interlobar fissure laterally.
– A convexity medially with greater opacity
represents the tumor mass.
• the inferior margin of the lobe resembles the
reversed letter S (Golden's sign).
Hilar Enlargement
 Overinflation

Overinflation due to Normal lung

obstruction
Mediastinal Mass
 Apical Pulmonary Opacity
• Pancoast Tumor
• “superior sulcus tumor”
• Results from local extension of a tumor
growing in the apex (superior sulcus) of
the lung
– Commonly arises from:
• A bronchogenic carcinoma (adenocarcinoma or
squamous cell carcinoma)
– arising in or near the superior sulcus and invading the
adjacent extrathoracic structures by direct extension.
• 4 cardinal signs of Pancoast Syndrome
1. mass in the pulmonary apex
2. Destruction of adjacent rib (R1-R2) or
vertebra
3. Horner’s syndrome
4. Pain radiating down the arm
• Signs, Symptoms and Complications
 involvement of C8, T1 & T2 nerves
• (+) shoulder pain
– Radiates in the ulnar distribution of the arm
• Loss of sensation & paresthesias in forearm &
hand (ulnar)
• Atrophy of hand muscles
 Horner’s Syndrome
• Extension to the sympathetic chain & stellate
ganglion.
• Ipsilateral ptosis, miosis & anhydrosis (triad)
• Rib/s destruction due to rapid growth of
the tumor
• Paraneoplastic syndromes
• Radiograph findings:
 Chest X-ray
• Apical Density with or without Rib Destruction
 Computed Tomography
• Assist in evaluating bone destruction
• Presence of other nodules in the lungs
• Invasion of tissues by the tumor
 MRI
• Superior to CT scan in the study of Pancoast
tumors
• Advantage of multiple projections
• Better at delineating invasion of the
– brachial plexus & spinal canal
– Thoracic and cervical soft tissues
• Soft-tissue invasion and bone destruction
may be observed as well.
Cavitation
Consolidation

(+) consolidation at
the right base with
small bilateral
pleural effusions
Segmental
consolidation

Perihilar
consolidation
Parenchymal Mass
• Right upper lobe
– Tumor enlargment
– Golden’s sign
• Middle lobe atelectasis
• Elevation of right hemidiaphragm
Radiologic signs of Metastasis
 Pleural Effusion
• Normally, the pleura cannot be seen on
chest radiographs
– Exceptions:
• where the lungs contact each other at the junction
lines
• where the visceral pleura infolds to form the
fissures.
 Pleural Effusion
• most common clinical manifestation of pleural
pathology.
• A mismatch between the rates of inflow and
outflow of fluid in the pleural space leads to a
pleural effusion.
• Mechanisms in the formation of pleural
effusions:
– (1) increased capillary hydrostatic osmotic pressure,
– (2) decreased colloid osmotic pressure
– (3) increased microvascular permeability
– (4) decreased lymphatic pleural drainage
– (5) decreased pleural surface pressure
– (6) transdiaphragmatic passage of peritoneal fluid
 Pleural Effusion
• Pleural effusion together with a visible
pulmonary tumor mass
– indicates involvement of the pleura by direct
extension or as the result of metastasis.
 Radiographic Features of
Pleural Effusion
• depends on the patient's position and mobility of
the pleural fluid
• lateral decubitus chest radiograph
– most sensitive radiographic projection for identifying
pleural fluid
– detect as little as 5 mL of pleural fluid
• PA chest radiograph
– accumulation of at least 200 mL of pleural fluid is
needed to cause blunting of the lateral costophrenic
angles
 Pleural Effusion

• AP chest radiograph
– A homogeneous left-
sided inferior opacity
with concave upper
margin, higher
laterally than medially
 Pleural Effusion
• Left lateral decubitus
view
– reveals free-flowing
pleural effusion as a
uniform band of soft-
tissue density along
the chest wall
 Computed Tomography of Pleural
Effusion
• CT signs to aid in distinguishing between
pleural effusion and ascites in the
peritoneal cavity
– diaphragm sign
– the displaced crus sign
– interface sign
– the bare-area sign
• Diaphragm sign
– ascites - inside the dome of the diaphragm
– pleural fluid outside the dome
• Location of the diaphragm
– readily identified in ascites
– may not be identified in pleural effusion
• Displaced crus sign
– anterolateral displacement of the
diaphragmatic crus, when pleural fluid collects
between the crus and the spine
– ascitic fluid would result in the opposite
displacement of the diaphragmatic crus

•Enhanced CT scan reveals

displacement of diaphragmatic
crus away from vertebral body
• Interface sign
– a hazy interface between pleural fluid and the
liver or the spleen
• Bare-area sign
– uses the restriction of peritoneal fluid by the
coronary ligaments along the bare area over
the posteromedial surface of the right lobe of
the liver, where pleural fluid is free to collect,
as a means of differentiating ascites from
pleural fluid
• The most accurate of these signs in the
evaluation of peridiaphragmatic fluid are
the interface and bare-area signs.

•Enhanced CT scan shows

low-attenuation opacity
posterior to liver,
representing pleural fluid.
Hazy interface (arrows) with
liver and lack of bare area
(curved arrow) signify pleural
effusion as opposed to
ascites.
 Bronchogenic carcinoma with
metastases
• The large hilar tumor on
the left produces:
– lower-lobe atelectasis
– a pleural metastasis in
the left lateral thorax
– pleural effusion
– metastases to the right
paratracheal nodes
Role of CT Scan
 Computed Tomography
• Major imaging of choice in the evaluation of
patients with bronchogenic carcinoma
• More sensitive than standard radiography
• Role in
– Detection of primary masses in patients suspected of
having carcinoma with normal x-ray
– Staging of lung cancer
– Guide surgical management and determination of
appropriate methods for surgical staging
 ROLE OF CT
• excellent in detecting acute and chronic changes
in the lung parenchyma
• evaluation of chronic interstitial processes
(HRCT)
• detection of airspace disease and cancer
• primary method of detecting pulminary embolism
and aortic dissections (CT Angiography)
• standard method for evaluating abnormalities
seen in x-ray
• evaluating findings of uncertain acute
significance
 What are the details that can be
gathered from CT?
• CT scanning are required for better delineation of the
abnormality detected on plain radiographs.
• CT can also be helpful in excluding a benign lesion and
in preoperative staging.
• CT of the chest is an important informative tool that
helps in detailed imaging of the primary tumor and its
anatomic relationship to other structures, and it provides
information with respect to the size of mediastinal lymph
nodes and the status of the pleural space.
• CT can best be thought of as a technique that provides a
roadmap for more accurate surgical staging.
CT in Bronchogenic Carcinoma
• Primary mass
CT in Bronchogenic Carcinoma
• Lymphadenopathy
CT in Bronchogenic Carcinoma
• Metastases
CT in Bronchogenic Carcinoma
• Pleural Effusion
• Airway obstruction
– Atelectasis, pneumonia
• Cavitations
 Role of MRI
** Main indication: for evaluation of the heart and
great vessels, the mediastinum and hila, and
the chest wall.

• High soft tissue contrast discrimination

– Allowing vasculature and lesion in mediastinal and
hilar region to be defined
– evaluate the heart, major vessels, mediastinum and
hilar structures because of the natural contrast
provided by flowing blood.
– ability to image vascular structures without contrast
media
 Role of MRI
• Useful in staging superior sulcus tumors
– Which can invade the apical chest wall & involve the
subclavian vessel and brachial plexus
– provides excellent assessment of the tissue
characteristics of the mass
– assessment of the chest wall invasion by apical tumors

• Evaluation of local invasion and detection of hilar

lymphadenopathy.

• Multiplanar capability of MRI enables a more

accurate evaluation of hilar lymph nodes,
aortopulmonary window lymph nodes, and
subcarinal region lymph nodes
 Radiotherapy
• Radiation therapy,
− treatment method that uses high-energy, ionizing
radiation (e.g., gamma rays) to kill cancer cells.
• Ionizing radiation is produced by a number of
radioactive substances
- cobalt (60Co)
- radium (228Ra)
- iodine (131I)
- radon (221Rn),
- cesium (137Cs)
- phosphorus (32P)
- gold (198Au)
- iridium (192Ir)
- yttrium (90Y)
• Applied to shrink a tumor removed by surgery
• To relieve symptoms
• To destroy malignant cells in a tumor that cannot
be removed surgically.
• Specific side effects: hair loss and skin
disorders, fetal damage, increased susceptibility
to infection, tachycardia (increased heart rate),
changes in taste perception, anorexia (loss of
appetite), malaise, nausea, and vomiting
 Role of Radiotherapy
• Primary care
• Adjuvant therapy
• Palliative therapy
 Table 44.5 Summary of Current Strategies fo Non-Small Cell Lung Cancer
Stage Surger Chemo- Radio- Combined Comments
y therapy therapy chemoradio-
therapy
I and II 1st line Adjuvant – 2nd line no Survival improvenment
stage IB, (=4%)
IIA, IIB Radiotherapy for inoperable
IIB 1st line No No 1st line patients
Neoadjuvant
(T3N0M0) neoadjuvant chemoradiotherapy
Pancoast improves survival in this
subset of stage II
IIIA 2nd line Neoadjuva No 1st line Combined
nt – 2nd line chemoradiotherapy followed
by surgery feasible, but
more data are needed to
IIIB 1st line No No Neoadjuvant recommend
Neoadjuvantroutinely
(T4N0- 1st line chemoradiotherapy followed
1M0) by surgery may be
Resectable considered in carefully
IIIB No No No 1st line selected
Treatmentpatients
similar to stage
unresectab IIIA, IIIB malignant effusion
le is treated like stage IV
IV no 1st line 2nd line no Radiotherapy for palliation
only

Textbook of Respiratory Diseases 4th ed. Mason, Robert et al 2005

 Radiotherapy
• Palliative Therapy
– Indication: when primary tumor is causing
urgent severe symptoms
– such as bronchial obstruction with pneumonitis
– hemoptysis,
– upper airway or superior vena cava obstruction,
– given as a course of 30–40 Gy over 2–4
weeks
– provides relief of intrathoracic symptoms:
hemoptysis, dyspnea, cough, atelectasis, and
vocal cord paralysis
Thank you