BRONCHIAL TUMOURS

Bronchial tumours, widely divided in to primary lung tumours and secondary or metastatic cancer. The majority of primary lung tumour is bronchial carcinoma, and It is one of the most common cancer world – wide, It causes 18% of all cancer death. Cigarette smoking is by far the most important single factor in the causation of the lung cancer. It is thought to be directly responsible for at least 90% of lung carcinomas, and the risk is directly proportional to the amount smoked and to the tar content of the cigarettes. Risk falls slowly after smoking cessation, but remain above the risk of non- smokers.

Bronchial Carcinoma Is the commonest cause of cancer death in men or women in the UK. More women now die from lung cancer than breast cancer in the UK and USA. In practical term we can divide bronchial cancer in to two groups. 1- Non- small cell lung cancers ( NSCLC), that accounts for 75%-80% of all lung cancers, these include ( squamous, adenocarcinoma and alveolar cell cancer) 2- Small cell lung cancer (SCLC), that account for 20% - 25%of all lung cancers.

Clinical features Lung cancer presents in many different ways. Most Commonly, symptoms reflect local involvement of the bronchus, but may also arise from spread to the chest wall or mediastinum,from distant blood borne spread or, less commonly, as a result of a variety of non-metastatic paraneplastic syndrome. A- Local tumour effect -Persistent cough, is often dry but it might associate with purulent sputum if there is secondary infection or change in usual cough.

-Haemoptysis, is a common symptoms especially in tumour arising from central bronchi, occasionally large tumours invade large blood vessels, that can cause massive haemoptysis. -Chest pain, that could indicate chest wall involvement with the tumour. -Unexplained SOB, due to narrowing of bronchial tree or bronchial obstruction. -Hoarseness of voice, indicate involvement of Lt recurrent laryngeal nerve. -Dysphagia, could be due to large tumour invading or narrowing oesophagus.

-Shoulder pain due to apical tumours that invades brachial plexus and cause wasting or weakness of small muscles of the hands. B- Metastatic tumour effects. - Cervical /supraclavicular LN enlargement. - Palpable live edge. -Bone pain or pathological fracture due to bone metastasis -Neurological manifestation due to cerebral metastasis. -Hypercalcaemia due to bone metastasis ( the patient may present with polyuria and poly dypsia with abdominal pain).

C-Non –metastatic extra pulmonary manifestation of lung cancer. 1- Endocrine -Inappropriate ADH secretion that cause hyponatremia. -Ectopic ACTH( adrenocorticotrophic ) hormone secretion,that cause Cushing's syndrome. -Hypercalcaemia due to secretion of parathyroid hormone -Carcinoid syndrome. -Gynaecomastia 2- Neurological -Polyneuropathy -Myelopathy -Cerebellar degeneration -Myasthenia like syndrome( Lambert- Eaton Syndrome)

3- Others - Clubbing of fingers -Hypertrophic pulmonary osteoarthropathy -Nephrotic syndrome -Polymyositis and dermatomyositis. Physical signs Examination is usually normal unless there is significant bronchial obstruction, or the tumour has spread to pleura, mediastinum or supraclavicular LNs. A tumour obstructing a large bronchus produce a physical sign of collapse.

A monophonic or unilateral wheeze, suggests the presence of fixed bronchial obstruction, and the presence of strider indicates obstruction at or above the level of Carina. Phrenic nerve paralysis, cause unilateral diaphragmatic paralysis, that will give dull percussion with absent breath sound in lung base. Involvement of the pleura may produce plural rub or Effusion. Bronchial cancer is the common cause of Superior vena cava syndrome, that initially presents as bilateral jugular vein engorgement and later as oedema affecting face, neck arm and conjunctivae

Horner syndrome; It represents unilateral (meiosis, ptosis, enophthalmos and Anhidrosis), this is due to direct involvement of the sympathetic chain by the tumour. Investigations: The main aims of investigations are to confirm the diagnosis, establish the histological cell type and define the extend ( stage) of the disease. 1- Blood tests including sodium, calcium, liver function test 2- CXR, is important investigation, the common radiological features of bronchial cancer are;

-Unilateral hilar enlargement - peripheral pulmonary opacity -Lung, lobe or segmental collapse -Plural effusion -Broadening of mediastinum -Enlarged cardiac shadow -Elevation of hemidiaphragm -Rib or bone distruction

3- CT chest (Staging CT), to determine the site and the extend of the tumour, and some time helps to determine the site for the biopsy through bronchoscopy. 4- Flexible Bronchoscope, around three quarters of primary lung tumours can be visualised using a flexible bronchscope. Bronchial biopsies and brush samples can be taken for pathological examination, and a direct assessment can be made of operability as judged by proximity of central tumour to carina. If the tumour is not visible at bronchoscopy, washing and brushing can be taken from radiologically affected lung Segments.

5-CT or USS guided biopsy, is important method for diagnosis especially for peripheral lesions that is not accessible through bronchscopy. This method carries a small risk of Pneumothrax. 6- Sputum cytology, can be valuable diagnostic aid in patients not fit for bronchoscopy. 7- Plural biopsy, is indicated when there is plural effusion. 8- Mediastinoscopy, especially in patients with mediastinal mass or Mediastinal LN enlargement. 9- some times thorachoscopy or thoracotomy are required to obtain diagnosis.

10- In patients with metastatic disease the diagnosis can often be confirmed by needle aspiration or biopsy of affected LNs, skin lesions, liver or bone marrow. 11- others like Bone scan, MRI or CT head 12- new investigation is PET scan ( Positron Emission Tomography ).