Page 140 - Medicine and Surgery

P1: FAW
BLUK007-03 BLUK007-Kendall May 25, 2005 17:29 Char Count= 0

136 Chapter 3: Respiratory system

4 Large cell anaplastic carcinomas are poorly differenti- Investigations
ated lesions composed of large cells with nuclear pleo- X-ray evidence only when 1–2 cm (still identifies over
morphism and frequent giant cell forms. 90% of carcinomas). The edge of the lesion appears
typically fluffy or spiked, some may cause cavitation
or collapse. Hilar node enlargement or effusions are
sometimes evident.
Complications
CT is useful for small lesions but not yet proven to
1 Intra-thoracic: Distal pneumonia, lobar collapse and
be useful in widespread screening. It is mainly used to
consolidation, pleural effusions, left recurrent laryn-
assess the extent and spread, especially lymph nodes
geal nerve palsy (hoarse voice), superior vena cava
(see Table 3.22).
obstruction, brachial neuritis (particularly apical tu-
Sputum cytology: Examination of expectorated spu-
mour (Pancoast tumour)), Horner’s syndrome (sym-
tum by cytology.
patheticparalysiscausingpartialptosis,myosis,anhy-
Cytology of pleural effusion: Examination of pleural
drosis, enophthalmos), rib erosion, pericarditis, oe-
fluid.
sophageal obstruction.
Percutaneous needle aspiration/biopsy under CT
2 Metastases: Haematogenous spread to bone (pain or
guidance. Open lung biopsy may be needed, partic-
fractures), brain, liver, adrenal gland.
ularly for alveolar cell carcinoma.
3 Endocrine (10%, usually small cell carcinoma): Anti-
Bronchoscopy and biopsy.
diuretic hormone, ectopic ACTH secretion. Hyper-
calcaemia seen with squamous cell carcinoma is due
to secretion of a parathyroid hormone related peptide
(PTH-like peptide). Management
4 Neuromuscular: Neuropathy, myopathy, myositis, 1 Identification of histological type is essential.
dementia, cerebellar degeneration. 2 Surgery for all non-small cell carcinomas where possi-
5 Eaton Lambert syndrome: Rare non-metastatic man- ble (see page 95). Surgical resection may be attempted
ifestation of small cell carcinoma causing defective in limited alveolar cell carcinoma.
acetylcholine release at the neuromuscular junction 3 Chemotherapy and adjuvant radiotherapy is consid-
resulting in proximal muscle weakness with absent ered in all patients, although chemotherapy is less ef-
reflexes. fective in non-small cell carcinoma.
6 Systemic: Weight loss, anaemia, clubbing, hyper- 4 Palliative radiotherapy, laser therapy and tracheo-
trophic pulmonary osteoarthropathy (HPOA – this bronchial stents.
is clubbing associated with peripheral joint pain and Surgical treatment:Key elements that offer a reasonable
stiffness in the wrists and ankles caused by a periosti- prospect of success are
tis. It tends to occur more often in squamous cell and tumour within a lobar bronchus or at least 2 cm distal
adenocarcinoma). to the carina.

Table 3.22 Staging of bronchial carcinoma
Stage TNM group Clinical
Stage I T1 N0 M0 Smaller than 3 cm distal to the carina without spread.
T1 N1 M0 Smaller than 3 cm distal to the carina with (N1) spread to ipsilateral hilar nodes.
Stage II T2 N0 M0 Tumour larger than 3 cm, 2 cm distal to the carina invading the visceral pleura (T2), without
spread.
T2 N1 M0 Tumour larger than 3 cm, 2 cm distal to the carina invading the visceral pleura (T2), with
spread to ipsilateral hilar nodes.
Stage III All T3/T4 Tumours involving the carina (T3), involving mediastinal structures (T4), with spread to
All M1 or N3 contralateral nodes (N3) or metastases (M1).