Indication of radiotherapy in bronchial carcinoma?

1Indications of radiotherapy in bronchial carcinoma
2common types of bronchial carcinoma
3Management of bronchial carcinoma
4Extra-pulmonary manifestations of bronchial carcinoma
5Hypertrophic pulmonary osteoarthropathy

Indications of radiotherapy in bronchial carcinoma:

-Most frequently used in the treatment of Squamous cell carcinoma.
-Used in SVC obstruction.
-Used in recurrent hemoptysis.
-Additionally, it can be used Chest pain / skeletal metastasis.
-Also can be used in Bronchial obstruction.

Now someone may ask that what is the treatment purpose Chemotherapy sensitive and Radiotherapy sensitive-


-In treatment of Small cell carcinoma Chemotherapy sensitive is usually used.
-In treatment of Squamous cell carcinoma Radiotherapy sensitive is usually used.

There are some common types of bronchial carcinoma:

1.Adenocarcinoma which incidence rate is about 35-40%

2.Squamous cell carcinoma, which incidence rate is 25-30%

3.Small cell carcinoma which incidence rate is 15%

4. Large cell carcinoma, which incidence rate is 10-15%

Now people may ask, which carcinoma is most dangerous in all of this type? And Why?

Answer: Small cell carcinoma is most dangerous because of it has capability of quick & wide-spread metastasis within the lung parenchyma.

Which is peripheral & central bronchial carcinoma? What is the significance?

Answer: Squamous cell carcinoma is a peripheral carcinoma, and it grows largely. It is a late-diagnosed carcinoma because it occurs without producing symptoms, so it cannot be detected in earlier stage.

Adenocarcinoma and Small cell carcinoma is Central carcinomas. The most interesting part is produces early symptoms, so it can be diagnosed early. So the mortality rate is low compared to other bronchial carcinomas.

Management of bronchial carcinoma:

Positive history of patient:

-Smoking history: The patient has a long-standing smoking history. It could be 20-30 years .

-Atmospheric pollution – More in urban dwellers.

Occupational history: exposure to asbestos, silica, beryllium, cadmium, and chromium.

Symptoms:

-Usually a disease of old age.

-Usually present with a chronic cough.

-Haemoptysis is the common complaint from the patient side .

-Every carcinoma patienthas as history of weight loss. So in brochinalcarcinoma weight loss is present.

-Patient is suffering from chronic low grade fever.

-Patient also complained of severe chest pain.

-Malaise.

-Shortness of breath, which causes tachypnea

-Hoarseness of voice.

-Features of distant spread or paraneoplastic syndrome.

-May be asymptomatic in < 5% of cases.

Signs:

-Patient may be cachectic.

-Clubbing may be present.

-Enlarged supraclavicular lymph node.

-Signs of pleural effusion.

-Signs of lobar collapse.

-Signs of unresolved pneumonia.

-Signs of superior venacaval obstruction.

-Horner’s syndrome – In apical tumor.

-Features of direct mediastinal or distant metastasis.

-Features of paraneoplastic syndrome – e.g. such as- Cushing syndrome, syndrome of inappropriate diuretic hormone secretion (SIADH), hypercalcaemia, carcinoid syndrome, myasthenia, dermatomyositis, venous thrombosis, etc.

Investigations for diagnosis of bronchial carcinoma:

– Chest X-ray is the initial investigation for the diagnosis of bronchial carcinoma.

-CT scan of the chest.

-CT guided FNAC.

-Fibreoptic bronchoscopy.

-Bronchoscopic biopsy and histopathology are the confirmatory tests for diagnosis of bronchial carcinoma.

-Supraclavicular metastatic lymph node biopsy and histopathology.

-Pleural fluid study -hemorrhagic.

-Full blood count – Anaemia.

-ESR – Raised.

-Other investigations: – Serum calcium level, liver function tests, serum electrolytes, PET, etc.

Treatment:

-Surgery: In stage- I and stage-Il disease.

Radiotherapy: who are fit and who have a slowly growing squamous cell carcinoma.

Chemotherapy: To treat small carcinomas. Regular cycles include:

-Intravenous cisplatin and etoposide, or

-Intravenous Cyclophosphamide, Vincristine, and Doxorubicin [Mnemonic-CVD].

-Combined radiotherapy & chemotherapy can increase the median survival from 3 months to well over a year.

-Adjuvant chemotherapy and radiotherapy following surgery.

-Laser therapy and stenting: palliation of symptoms caused by major airway obstruction.

Extra-pulmonary manifestations of bronchial carcinoma:

 Non-metastatic:

1)Endocrine:

-Inappropriate anti-diuretic hormone (ADH) secretion, causing hyponatraemia

-Ectopic adrenocorticotrophic hormone (ACTH) secretion

-Hypercalcaemia due to secretion of parathyroid hormone (PTH)-related peptides

-Carcinoid syndrome

-Gynaecomastia

2) Neurological:

-Polyneuropathy

– Myelopathy

-Cerebellar degeneration

– Myasthenia (Lambert-Eaton syndrome)

3) Other:

-Digital clubbing.

-Hypertrophic pulmonary osteoarthropathy.

-Nephrotic syndrome.

-Polymyositis & dermatomyositis.

-Eosinophilia.

Metastatic manifestations:

1) Metastasis to mediastinum:

-Involvement of esophagus may cause dysphagia.

-If the pericardium is involved, arrhythmia and pericardial effusion may occur.

-Superior venacaval obstruction.

-Left recurrent laryngeal involvement may cause vocal cord paralysis, which is manifested by voice alteration and ‘bovine’ cough.

2)Metastasis to other sites:

-Brain: Focal neurological defects, epileptic seizures, personality change.

-Liver: Jaundice.

-Bones: Bone pain.

-Skin: Skin nodules.

-Anorexia & weight loss.

There are some keyword for better differentiation:

>Endocrine (SIADH, ACTH, carcinoid, etc.) indicate : small cell carcinoma.

>Clubbing indicates non-small cell carcinoma.

>Hypercalcaemia indicates squamous cell carcinoma.

> Gynaecomastia indicate : large cell carcinoma.

Common radiological findings which are present in bronchial carcinoma:

-Unilateral hilar enlargement.

-Peripheral pulmonary opacity.

-Lung, lobe or segmental collapse.

-Pleural effusion.

-Broadening of mediastinum.

-Enlarged cardiac shadow.

-Elevation of a hemidiaphragm.

-Rib destruction.

Another similar condition, like bronchial carcinoma, is hypertrophic pulmonary osteoarthropathy.

Hypertrophic pulmonary osteoarthropathy:

This is characterized by periostitis of the long bones, most commonly the distal tibia, fibula, radius, and ulna. This causes pain and tenderness over the affected bones and often pitting edema over the anterior aspect of the shin.

Investigation: X-ray shows sub-periosteal new bone formation.

Causes:

Most frequently associated with bronchial carcinoma.

Can occur with other tumors.

Diagnosis: Combination of:

-Clubbing. Pain and tenderness over the affected bones.

– Thickening of the periosteum and synovium (features of periostitis)

-Sub-periosteal new bone formation.

FAQ

A 60-year-old man presents with a six-week history of cough, feeling unwell, loss of weight.
He has occasional haemoptysis and smoking of 20-pack-year.
A)What is the most important diagnosis?

Answer: Most important diagnosis: Lung cancer.

B)What clinical findings will you get by examining the chest?

Answer:Clinical findings by examining chest:
Engorged vein -> Due to superior vena caval obstruction.
Features of mass lesion, collapse, pleural effusion.

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