Bronchial Carcinoma - Long Case Discussion With Questions & Answers.

Mr …, 52 years old, a clerk, normotensive, nondiabetic, smoker, hailing from …, presented with
frequent cough for … months, which is present throughout the day and night. The cough is usually
dry, sometimes associated with slight mucoid sputum expectoration. Occasionally, the patient noticed
streaks of frank blood with sputum during coughing. There is one episode of massive hemoptysis …
days back. For the last … days, he is also complaining of right sided chest pain, which becomes worse with deep inspiration, coughing and also on lying down on right side. The patient also complains of loss of appetite, substantial loss of weight, weakness and malaise for ... days. His bowel and bladder habits are normal. There is no history of fever, hoarseness of voice, difficulty in deglutition, contact with TB patients. He smokes about 25 sticks a day for the last 30 years. He used to take some cough syrup and occasionally antibiotics, the name of which he cannot mention.

Examination:
Respiratory System
(Supposing right sided)
Inspection:

• Movement is restricted on right upper chest
• There is radiation mark on the chest (if any).

Palpation:

• Trachea is central in position
• Apex beat is in left 5th intercostal space, just medial to the midclavicular line
• Vocal fremitus is reduced (or absent) in right upper chest
• Pleural rub is present (mention where).

Percussion:

• Percussion note is dull in right upper chest (mention up to which space)
• Upper border of the liver dullness is in the right 5th intercostal space in the midclavicular line
• Cardiac dullness is normal.

Auscultation:

• Breath sound is reduced (or absent)
• Vocal resonance is reduced (or absent)
• Few crepitations (may be present)
• Pleural rub is present (mention where).

Examination of the other systems reveals no abnormalities.

1. What is your diagnosis? 
My diagnosis is bronchial carcinoma with metastasis (in right supracalvicular Lymph node).

2. Why bronchial carcinoma?
The patient is elderly and heavy smoker. There is history of cough with hemoptysis and marked loss
of weight. On examination, the patient is emaciated, has generalized clubbing with nicotine stain and
examination of chest shows evidence of mass lesion. All the features are suggestive of bronchial carcinoma.

3. What are your differential diagnoses?
As follows:

• Pulmonary TB
• Other mass lesion (hydatid cyst, dermoid cyst, neurofibroma).

4. Why pulmonary TB is not your primary diagnosis?
This may be pulmonary tuberculosis, because all the features like cough, hemoptysis and weight
loss are present in tuberculosis. However in this case, there is no history of fever or contact with TB
patient. The patient has gross clubbing, enlarged supraclavicular lymph node, which is hard in
consistency and evidence of mass lesion in chest. All these are against pulmonary tuberculosis.


5. What investigations do you suggest in bronchial carcinoma?
As follows:
1. X-ray chest P/A view (homogeneous irregular opacity, with sun-ray appearance may be seen.
There may be collapse, pleural effusion, hilar lymphadenopathy, widening of mediastinum, raised
hemidiaphragm, and rib erosion or destruction).
2. Sputum for malignant cells (exfoliative cytology).
3. CT scan of chest (MRI is not helpful for primary lesion).
4. CT guided FNAC.
5. FNAC (or biopsy) of lymph nodes (if present).
6. Fiber optic bronchoscopy and biopsy (or bronchial washing and brushing).
7. PET-CT scan is the investigation of choice (highly sensitive and specific for mediastinal staging).
8. To see evidence of metastasis: USG of whole abdomen, X-ray skull, isotope bone scan, etc.
Sometimes, CT scan of chest and abdomen, even MRI may be needed.
9. Others:

• Complete blood count, ESR
• If pleural effusion, then fluid cytology. Pleural biopsy may also be done
• Liver function test, renal function test (before chemotherapy, if needed)
• Pulmonary function test specially FEV1 (DLCO below 60% predicted is associated with a
• mortality rate of 25% due to pulmonary complications).

6. Why bronchoscopy should be done?

 Bronchoscopy should be done:

• To see the mass and to take biopsy for tissue diagnosis. This will guide further management.
• If the carcinoma involves first 2 centimeter of either main bronchus, it indicates the tumor is
• inoperable.
• If carina is wide and there is loss of sharp angle of carina, it indicates presence of enlarged
• madiastinal lymph nodes (may be malignant or reactive). Biopsy can be taken by passing a needle
• through bronchial wall.
• Vocal cord paralysis on the left indicates left recurrent laryngeal nerve palsy and indicates an
• inoperable case.

7. Have you examined the eyes of the patient? What did you look for?

 I have examined the eyes for partial ptosis, miosis and enophthalmos, which indicates Horner’s

syndrome. It is commonly found in Pancoast’s tumor. Fundoscopy may show papilledema, if secondary metastasis in the brain.

8. If sputum shows malignant cells, would you do bronchoscopy and biopsy? 

Yes, to see histological type. This is helpful for therapy and prognosis. If squamous cell carcinoma,

radiotherapy is the treatment. If small cell carcinoma, chemotherapy is necessary.

9. What are the histological types of bronchial carcinoma?

 Four types:

•  Squamous cell carcinoma in 35%
•  Small cell carcinoma in 20%
•  Adenocarcinoma in 30%
•  Large cell carcinoma in 15%.

10. What are the causes or risk factors of bronchial carcinoma?

As follows:

• Cigarette smoking is the major risk factor. Even passive smoking causes 1.5 times increase in the risk of bronchial carcinoma.
• Other factors are exposure to asbestos, silica, beryllium, cadmium, chromium, arsenic, iron oxide, radon, radiation, petroleum products and oils, coal tar, products of coal combustion.
• Adenocarcinoma may develop in nonsmokers and in old scar.

11. How to treat bronchial carcinoma?

 As follows:

1. Non-small-cell carcinoma:

• Surgery should be done, if the tumor is localized to lobe or segment. (It is curative if the stage is T1N0M0)
• If surgery is not possible, radiotherapy or chemotherapy or combined therapy should be given.
• In squamous cell type, radiotherapy is advised (it is especially indicated in SVC obstruction,
• repeated hemoptysis and chest pain caused by chest wall invasion or skeletal metastasis).
• Chemotherapy is less helpful in non-small-cell type.

2. Small-cell-carcinoma:

• Even small, metastasis occurs early. 
• Surgery is less helpful. 
• Chemotherapy is usually given.
• Radiotherapy may be added (continuous hyperfractionated accelerated radiotherapy, CHART, in which total dose is given in smaller, but more frequent fractions offer the best survival).
• Usual chemotherapy—intravenous CDV (cyclophosphamide, doxorubicin and vincristine) or CE (cisplatin plus etoposide). Chemotherapy is given every 3 weeks for 3 to 6 cycles.

3. Other treatments: These are usually palliative.

• Laser therapy with fiberoptic bronchoscopy.
• Endobronchial therapy—tracheobronchial stent, cryotherapy, laser, brachytherapy (a radioactive source is placed closed to the tumor).
• RFT (radiofrequency thermal ablation).
• Pleural drainage or pleurodesis (in pleural effusion).
• Drug—steroid to improve appetite, morphine or diamorphine for pain (along with laxatives if constipated). Oral candidiasis should be treated.
• Short courses of palliative radiotherapy are helpful for bone pain, severe cough or hemoptysis

10. What is the prognosis?

If it is localized and surgical resection is possible, the prognosis is good. Otherwise:

• Non-small-cell carcinoma—50% 2 year survival without spread, 10% with spread
• Small cell carcinoma—median survival is 3 months if untreated, 1 to 1½ year with treatment.