BRONCHOGENIC CARCINOMA

EPIDEMIOLOGY
Most common cause of cancer-related death in both
men and women.
Sex: Increase in cancer incidence among women
Age: Uncommon < 40 years
Anatomy: Right > Left
Upper Lobe > Lower Lobe
Central / Peripheral Location.
Etiology / Risk Factors
Tobacco smoking / Passive smoke.
Air pollution
Exposure to asbestos: Asbestos exposure increases the
risk 4- or 5-fold.
Exposure to uranium or radon increases the risk of
non–small cell ca.
Exposure to toxic agents
Arsenic, Nickel (Sq. cell carcinoma),
Chromium & Chloromethyl ether (Small Cell
Carcinoma)
Main histopathological types
Squamous cell carcinoma – 30-35%

Adenocarcinoma - 30-35%

Large-cell undifferentiated – 15-20%

Small ( oat ) cell - 20-25%

( Neuroendocrine origin)
Squamous cell carcinoma
Accounts for approximately one-third of all cases
of bronchogenic carcinomas.
 Smoking Squamous metaplasia.

 Arise from central bronchi and ulcerate through

the mucosa into the surrounding lung
parenchyma.

 Common cause of the Pancoast syndrome.

Endobronchial SCC leads to bronchial

obstruction and post obstructive pneumonia.
Adenocarcinoma
Most common cause of lung cancer in women and
nonsmokers.
Most common cell type associated with lung scarring
from other causes ("scar carcinoma").
Arise from the periphery of the lung. The pleural
surface (peripheral) which is retracted (puckered) over
the neoplasm.
Often detected as asymptomatic nodule on a routine
chest radiograph.
Broncho-alveolar cell carcinoma
 A subtype of adenocarcinoma.
A rises from the alveoli
 Less aggressive with better prognosis.
Apperance-patchy pneumonia,homogenous
consolidation of one lobe or multiple nodules
Cavitation-unusual
Mimics benign condition - Consolidation.

 Air Bronchogram –obvious feature.

 Large Cell Carcinoma
 Large cell carcinoma represents 10-20% of
bronchogenic tumors.
 Tend to be present peripherally, like
adenocarcinomas
 Large, bulky, well-circumscribed with extensive
hemorrhage and necrosis.

Locally aggressive, metastasize early, and are strongly

associated with smoking.
Small Cell Carcinoma
Accounts for approximately 20% of all lung
cancers, associated with smoking and is of
neuroendocrine origin

Arise from large central airways and is very

aggressive, metastazing early.

Paraneoplastic syndromes.

Most common cause of superior vena cava

syndrome
CLINICAL PRESENTATION
Symptoms : Related to –
 Local tumor growth
 Mediastinal invasion
 Chest wall invasion
 Metastasic disease
 Paraneoplastic syndrome.
 Systemic symptoms
Fatigue, weight loss, anorexia, cachexia,
fever.
Local Tumor Growth - Central / Peripheral

 Centrally located tumours - Symptoms including cough,

localized wheezing, hemoptysis, focal atelectasis,
dyspnea, or post obstructive pneumonitis.

 Peripherally located tumours are usually asymptomatic

but may present with hemoptysis.
Tracheal Carinal Involvement in Squamous Cell
Carcinoma.
 Mediastinal invasion – involvement of adjacent
structures.

On the left side, the recurrent laryngeal nerve

involvement manifests with hoarseness and ipsilateral
vocal cord paralysis.

Phrenic nerve involvement manifests as

diaphragmatic paralysis and positional dyspnea.
MEDIASTINAL
INVASION
 Rarely the esophagus involvement may
produce dysphagia and recurrent aspiration
pneumonia.
Pericardial involvement causes pericardial
effusions, tamponade, or dysrhythmias,
diagnosis is confirmed using
echocardiography.
Intrathoracic Metastases
- result from hematogenous, lymphatic or
intra-alveolar tumor dissemination.

Intra-alveolar spread is most often seen

with bronchioloalveolar carcinoma and
results in multicentric lung involvement.
MULTI CENTRIC INVOLVEMENT
CHEST WALL
INVASION
Rib Destruction
Right upper lobe tumors or paratracheal adenopathy
can compress the superior vena cava (SVC) and cause
the SVC syndrome.

Pancoast tumor, may invade local neural structures

and produce a characteristic syndrome of pain and
possible Horner's syndrome.
Right hilar mass and Precarinal Lymphadenopathy
LYMPHADENOPATHY
Pancoast tumor
Pancoast tumor (1%) arises in the superior sulcus of the lung
apex.

The most common tissue type is squamous cell carcinoma.

Invades the pleura , rib & neurovascular structures.

Brachial plexus involvement cause arm pain and paresthesias

in ulnar nerve distribution.
Invasion of sympathetic ganglion - Horner syndrome.

Unilateral Apical cap on affected side - flat, uniform density

Rib erosion.
Left Superior Sulus Tumour
Pleural Invasion
Pleural involvement occurs in 8-15% of lung cancer
patients.

Manifests as pleural effusions, pleural masses or rarely

pneumothorax.

 Effusion due lymphatic obstruction or due to direct

pleural invasion by the tumor.

Confirmed by thoracentesis, closed pleural biopsy or

pleuroscopy.
Pleural Involvement
Distant Metastasis
Most common sites of metastases are bone, brain,
liver, and adrenal - carry a poor prognosis and high
morbidity
PATIENT

WORK-UP
History and Physical Exam –
Chest X-Ray
CT Scan
Role of MRI
Bone Scan.
Nuclear Medcine – PET Scan
Histopathological Confirmation.
 Bronchoscopy - Transbronchial Needle Biopsy
 Transthoracic needle biopsy
 Mediastinoscopy
 Open surgical biopsy
 Thoracoscopy
IMAGING FEATURE
Peripheral tumours ( arising beyond the
hilum)
Central tumours (arising close to the hilum)
Diffuse tumours.
Peripheral tumours
Approx 40% of tumours arise beyond segmental bronchi and in
30% present as solitary radioopacity.

Central tumours
The cardinal imaging signs of a central tumour are
collapse/consolidation of the lung beyond the tumour and the
presence of hilar enlargement, signs that may be seen in isolation
or in conjunction with one another.
Central Mass
Possible CXR features –
 Lobar collapse
 Consolidation – “ Pneumonia”
 Lung Abscess / Cavitating lesion.
 Paralysed Hemidiaphragm
 Hilar Lymphadenopathy
Miscellaneous Presentations-
 Apical mass ± rib erosion
 Miliary mottling – Lymphangitis carcinomatosis.
 SHAPE
Peripheral tumours – spherical or oval.
Lobulation / Umbilication – indicates uneven
growth rates.
Pancoast’s tumours may resemble pleural
thickening. however, majority of peripheral lung
cancers are approximately spherical or oval in
shape.
-Corona radiata (numerous fine strands radiating
into the lung from a central mass)

-Pleural tail sign(the ‘tail’ probably represents

either plate-like atelectasis secondary to
bronchial obstruction beyond the mass, or septal
oedema due to lymphatic obstruction.)

-Ill-defined resembling pneumonia

CORONA RADIATA SIGN
Spiculated Margins
PLEURAL
TAIL SIGN
Growth Pattern
Pulmonary malignancies grow at a relatively predictable
rate. The growth rate of an SPN is usually expressed as
the doubling time, or the time it takes for a nodule to
double its volume.
Bronchogenic carcinoma has a doubling time of
between 1 month and 2 years. Therefore, a doubling
time of less than 1 month or greater than 2 years
characterizes a lesion as benign.
Air bronchogram / Cavitation
Air bronchogram –Alveolar cell carcinoma.
Air bronchogram may idenitified in majority of the
cases by HRCT.
Bubble like areas of low attenuation – due patent
small bronchioles / cystic spaces within the tumour.
Cavitation (16%)– Squamous cell Ca.
Eccentric with irregular wall of thickness of > 8 mm.
 LUNG CAVITATIONS
In bronchial carcinomas,cavitations are found in
15% of the cases with air lucencies.
Most commonly squamous cell carinomas cavitate.
Cavitations are also seen in active tuberculosis.
Also seen in Lung Abcess[a fluid level often noted
in abscess]
Also in cavitating pulmonary infarct or hematoma.
 LUNG CAVITATIONS-CAUSES
Infective:Anerobic ,staphylococcal pneumonia
Pumonary Embolism,infarction
Wegener’s granulmatosis,Rh nodules
Staphylococcal Pneumonia
Progressive massive fibrosis.
LCH
Neoplastic,metastasis,hodgkin’s disease.
Thickness of cavity wall –
 Benign vs malignant lesions.
 Less than 1 mm - Benign lesion
 More than 16 mm - Malignant lesion
A cavitating right lower lobe sq. cell carcinoma
CT scan shows cavitation and air-fluid level
L Sq. cell carcinoma with an air fluid level
Left Pulmonary mass with eccentric
cavitation.
 SPN
A solitary pulmonary nodule (SPN) is
defined as a single intraparenchymal lesion
less than 3 cm in size and not associated
with atelectasis or lymphadenopathy.
A lesion greater than 3 cm in diameter is
called a mass.
Solitary pulmonary nodule
 CAUSES FOR SPN
1)NEOPLASAMS
Bronchial carcinoma
Hamartoma
Bronchial adenoma
Mesenchymal neoplasams
Lymphoma
Solitary metastasis
2)INECTIONS
Septic embolus
Round pneumonia
Lung abcess
Infectious granulomas-TB,Histoplasmosis etc
Parasitic hyadtid cyst,amebic abcess etc
3)VASCULAR
Infarct
AVM
P A artery
Hematoma
4)COLLAGEN VASCULAR DISEASES
Wegener’s granulomatosis
5)CONGENITAL
Foregut malformations
Sequestraion
Bronchogenic cyst,Mucocele
6)MISCELLANEOUS
Round pneumonia
Amyloidoma
Calcification
Rare – plain radiograph / MRI.
6-10% Bronchogenic Ca. by CT.
Tumours > 5 Cms size.
Dystrophic - areas of tumour necrosis.
Intrinsic – mucinous adenocarcinoma.
Amorphous / Cloud like calcification
Calcified granulomatous areas
 Post-Obstructive Pneumonitis
Following f/s that pneumonia due to obstructing tumour.

 Golden’s S sign.

 Pneumonia confined to one lobe.

 Expansion of consolidated lobe.

 Visible irregular stenosis of supplying bronchus.

 Visible central mass

 Localized pneumonia - > 2 weeks / recurs in the same lobe

within a short interval.

 Dilated fluid filled bronchi –CT/MRI

Golden’s S sign
Complete left lung collapse secondary to
bronchogenic carcinoma of left main bronchus.
 BRONCHIAL STENOSIS
BRONCHOGENIC CARCINOMA

Fibrous Stricture [eg tuberculosis]

Broncholithiasis

Extrinsic Compression [as seen in

lymphadenopathy,neoplasm]
Obstructive Pneumonitis with
Atelectasis of the RUL

Increased opacity in the right tracheobronchial and

paratracheal region suggests a mass or lymphadenopathy in
that region.
Role of CT Scan
Include lung cancer screening, evaluation of SPN,
Staging, Follow-up.

Nodule with ill-defined, irregular, spiculated

border – Malignant.

CT densitometry.

Air bronchogram & cavitations and

pseudocavitations.
CT for Staging Cancer
 Determining tumor extension.

 Local invasion - Chest wall, Pleura,

Mediastinum,Mainstem bronchus, Vessels.

Hilar and mediastinal lymph node metastases.

CT is useful in demonstrating extrathoracic metastases.

 TNM classification of lung cancer
Primary Tumor(T)
T0:No evidence of primary tumor
Tis:carcinoma in situ
T1:Tumor 3 cm or less surrounded by lung or
visceral pleura, but without evidence of invasion
proximal to lobar bronchus.
T2:Tumor more than 3 cm or tumor invading
visceral pleura or associated with obstructive
pneumonitis or atelectasis; involving less than
entire lung; proximal extent of visible tumor
must be within a lobar bronchus or at least 2 cm
distal to carina.
T3:Tumor of any size with direct extension into
chest wall, diaphragm, or mediastinal pleuraor
pericardium without involving heart, great vessels,
trachea, esophagus, or vertebral body; also
includes superior sulcus tumors and
T4:Tumor of any size invading mediastinum or
involving heart ,great vessels, trachea,esophagus,
vertebral body,or carina or presence of malignant
pleural effusion
 Nodal Involvement(N)
Nx: can not assess regional lymph node
N0:No demonstrable metastasis to regional lymph nodes
N1:metastasis to peribronchial or the ipsilateral, or
both,hilar lymph nodes,including direct extension

N2:metastasis to ipsilateral mediastinal lymph nodes

and subcarinal lymph nodes

N3:metastasis to contralteral mediastinal lymph

nodes,contralateral hilar lymph nodes,ipsilateral or
contralateral scalene or supraclavicular lymph nodes
Distant metastasis(M)
Mx: distant metastasis can not be assessed
M0:No distant metastasis
M1:Distant metastasis present
Small cell Ca. of left bronchus
Diaphragmatic Paralysis
Retrocardiac masses
Role of MRI
MRI is not useful as an initial imaging tool
Advantage:
Lack of ionizing radiation,
Superior contrast resolution
Natural contrast to image vascular structures.
Multiplanar capability
The multiplanar capability of MRI enables a
more accurate evaluation of hilar lymph
nodes, aortopulmonary window lymph
nodes, and subcarinal region lymph
nodes, compared with that of CT.

In particular, MRI is useful in the evaluation

of superior sulcus tumors and tumoral
invasions.