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Bronchial carcinoma

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this is according to the pathology dsl questions back when i was in my 2nd year of med school

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• 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.

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• 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

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

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• 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

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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:

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• 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 ↓

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• 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

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• 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

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Case continued..


Ca 3.2

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

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• 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)

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• 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.

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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.

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• 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

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Quick guide to mx..

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