BRONCHIAL CA

SCENARIO

• 55 y/o man, a smoker of 30 pack years presented to GP d/t cough with haemoptysis, chest pain, dyspnoea, and a 6 kg LOW for the past 3 months.

• O/E:– Clubbing of the finger– Consolidation of the Rt lower lobe

• CXR showed a 3 cm mass lateral to Rt main bronchus.• After further invx, a biopsy of the mass was

performed. It was subsequently diagnosed to be a carcinoma on histological evaluation.

• State the risk factor for lung CA in this pt.- smoking

• What are the other risk factors for lung CA?- industrial hazards: uranium / asbestos- scarring: old infarcts/metallic FB/wounds/old healed granuloma-genetic: oncogenes/tumour suppressor genes deletion (c-myc, k-ras, p53)

• What are the precursor lesion for lung CA?- goblet cell hyperplasia- squamous dysplasia @ CA in situ- atypical adenomatous hyperplasia

• Explain the pathophysiology of each symptoms and signs that he presented with:a) Coughb) Haemoptysisc) Chest paind) Dyspnoeae) LOW 6 kgf) finger clubbing

• Cough:- neoplasm infiltrate the AW wall stimulate cough reflex- respi infection- hypersecretion of mucus

• Haemoptysis:- alveolar is highly vascular when tumour erode blood vessels of the lung leakage of blood into bronchial tree blood being coughed up

- as tumour cell grow it needs its own blood supply secrete angiogenesis factor sometimes the growth is too fast lead to necrosis of the tumour’s center rupture of necrotic area bleeding

Cough reflex

• Cough receptor: diffusely in respi tract / diaphragm / GIT• Afferent (sensory): internal laryngeal nerve (branch of

CN X) to cough centre• Cough centre: in medulla• Efferent (motor): to abdominal ms, intercostal ms,

diaphragm, glottis, vocal cords.• Mechanism:

• Chest pain:- tumour spread to the pleura parietal pleura has somatic type of pain fibre pleuritic pain- DY/DX somatic, visceral, neuropathic pain?

• Dyspnoea:- bronchial obstruction reduced air entry

• LOW 6 kg:- LOA - tumour produce TNF secreted into blood hypothalamus inhibit hunger centre- increase amount of energy expenditure BMR ↑ despite the intake of food ↓

• Finger clubbing:- ↑ growth hormone in dss state d/t ↑↑ in GF production excessive cellular tissue in the nail bed

- ↑ blood flow in clubbed finger d/t vasodilatation (not hyperplasia of blood vessel in nail bed) vasodilator eg: PG, bradykinin vasodilatator probably inactivated in the lung of normal person but when there is dss process @ left-right shunt, defective inactivation occur

- clubbing occur when organs supplied by vagus nerve are affected coz in bronchogenic CA, vagotomy causes reversal of clubbing.

Reference: The aetiology of clubbing and hypertrophic osteoarthropathy. Dickinson CJ. Eur J Clin Invest. 1993 Jun;23(6):330-8

• Reasons for consolidation:- atelectasis- secondary infection (dr effat: any obstruction that occur in liquid of the body owez followed by infection)

• Complications of bronchogenic CA:- obstruction: partial focal emphysema. Total atelectasis. - local invasion: pleura/pericardium/nerve/SVC/ chest wall/oesophagus/Pancoast’t tumour- mets

Case continued..

TEST RESULTNa 120K 3.8

Ca 3.2

• Interpret the blood invx result. Explain each abnormality.- Hyponatremia: release of ADH- Hypercalcemia: release of PTH-related protein by tumour cell

• What is paraneoplastic syndrome?- collection of symptoms/signs- d/t damage to organs that are remote from the site of primary tumour or its mets- mech: substances produce by tumour cells

• What are the hormones/hormone-like factors elaborated in bronchial CA?- small cell CA: ADH (SIADH) and ACTH (Cushing’s)- squamous cell CA: PTH (hypercalcemia)

• RIGHT SIDE:– Poorly differentiated tumour cell– Increased mitotic xtvt– hyperchromatism– Increased N:C ratio– Pleomorphism (marked variation in shape & size)

Squamous cell with keratin pearl

Bronchoscopy was done and the sample taken.

Despite treatment, he died. Post-mortem was done.

• Left lung

• Tumour cell at the inferior part of lower lobe demonstrates area of central cavitation surrounded by fibrosis. (cavitation: probably because tumour outgrew its blood supply).

• Compression of main bronchi

• At the bottom most: consolidation.

• Describe the basis of classification of lung CA:- small cell CA- non small cell CA: squamous / adenoCA / large cell

• Features of small cell CA

• 12. DY/DX squamous cell & adenoCA:a) genderb) smoking associationc) locationd) sizee) growth ratef) microscopy

Quick guide to mx..

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1. KIESSELBACH’S PLEXUSICA↓

OPHTALMIC ARTERY

ECA