Bronchogenic Carcinoma

(Lung Cancer)

Thoracic department
 Definition

Bronchogenic carcinoma refers

to the malignant tumor which
grows in the bronchus.
Originating from mucus or
gland of bronchus.
 Incidence and mortality
 Bronchogenic carcinoma has increased
remarkable in incidence and mortality
during half of last century and has become
the most frequent visceral malignant
diseases of men.The mortality of lung cancer
hold the first place among all kinds
carcinomas.
 ❚Historical note
♦100 years ago 200 cases reported
♦1895 Roentgen diagnosis possible
♦1904 Sauerbruch negative-pressure cabin
♦1912 Davies first lung lobectomy
♦1941 Zhang Jizheng pneumonectomy
 Epidemiology
❚Morbidity
♦19th century rare disease
♦Before 1950s be rising
♦Recent 50 years increased sharply
leading cause of cancer death
 Etiology
 The cause of lung cancer is unknown.It is
believed that there are following related
factors.
 1. Excessive cigarette smoking:Smoking
index(Brinkman Index) is equal to cigarettes
per day smoking time(years).
 Passive smoking is also a carcinogen factor.
 Etiology
 2.Atmospheric pollution.It was found that
carcinogenic factor is benzpyrene .
 3.Occupational factors.
 4Radioactivity in the atmosphere .
 5.Diets and Nutrition.
 6.Chronic irritation.
 7.Genetic factors.
 Pathology And Classification
 1. According to the position of tumor

arising from ,it can be divided into two

types .
 Central type:Tumor arises from main

bronchus, lobar and segmental bronchus .

Peripheral type : Tumor arises beyond
segmental bronchus .
❚Lung carcinogenesis

columnar Injury squamous

epithelium metaplasia
Risk factors
carcinoma
in situ

metastatic infiltrating
carcinoma carcinoma
Return
Central type
Tumor arises from
main bronchus, lobar
and segmental
bronchus
Peripheral type :
Tumor arises beyond
segmental bronchus .
 Pathology And
Classification
 2.According to cytology,it is convenient
to classify into four kinds of types.
 (1).Squamous cell carcinoma.
 (2).Small cell anaplastic carcinoma.
 (3).Large cell anaplastic carcinoma.
 (4).Adenocarcinoma(including alveolar
cell carcinoma).
 Pathology And
Classification
 According to the different principles of

management,it is divided into two types.

 SCLC:small cell lung carcinoma.

 NSCLC:non small cell lung carcinoma.

carcinoma
❚Anatomic location
Upper
Right Middle
lower
Upper
Left
lower
Central
Peripheral
Return
 肺癌的发病
50 率
50

发 40
病
率 30 25
（ 20
20
%

） 10 5
0 鳞癌 小细胞癌 腺癌 大细胞癌

病理类型
Histological classification of lung cancer
Classification Percentage
NSC 75%
Adenocarcinoma 35%
Squamous cell carcinoma 30%
Large Cell carcinoma 10%
SCC 20%
Carcinoids 4%
Rare 1%

Return
 鳞状细胞癌 Squamous
carcinoma
 最多见，约50%+ 。
 多见于老年人（ 50± ）。
 男性居大多数 , 与吸烟有关系密切。
 常见于中央型。
 生长速度较缓慢，病程较长。
 对放疗化疗较敏感。
 手术切除率高。
 一般先淋巴结转移、血行转移晚， 5 年生存
率高。
 鳞状细胞癌 Squamous
carcinoma

 这是一个发生于肺中央
（与绝大多数鳞状细胞
癌一样）的鳞状细胞癌。
它刚好阻挡右主支气管。
肿瘤质地坚韧，切面呈
浅白色到到黝黑色。
鳞状细胞癌 Squamous
carcinoma
 鳞状细胞癌 Squamous
carcinoma
 这是一个鳞状细胞癌

，其中一部分肿瘤组
织出现中央腔洞，可
能因为肿瘤的生长速
度过快，超出了血液
供应的能力。
 小细胞癌 Small cell
carcinoma
 发病率仅次于鳞癌。
 年龄较轻， 40 左右。
 男性多，与吸烟有关。
 大多为中央型。
 恶性程度高，生长快。较早出现淋巴（为主）
、血行广泛转移。
 对放疗、化疗较敏感。
对放疗、化疗较
 但预后最差。
小细胞癌 Small cell
carcinoma
 小细胞癌 Small cell
carcinoma
 小细胞 ( 燕麦细胞 ) 退变癌
出现在此处肺的中心部位，
并向周围广泛地传播。这个
肿瘤切面质地软 , 分为小裂
片，颜色为白色到黑色的外
观。这里看到的肿瘤引起了
左肺主支气管阻塞，因此远
端的肺组织塌陷。燕麦细胞
癌具有很强的浸润性，经常
在肺内原发部位长到一定体
积之前就已广泛转移。
 腺癌 Adeno carcinoma
 发病率居第三位。
 年龄较小，女性多见。
 多为周边型。
 早期一般没有症状，多为 X 线发现（球型病变）
。
 生长较缓慢。可早期发生血行转移，淋巴转移晚
。
 对放疗、化疗敏感性低
 肺泡细胞癌 Alveolar cell
carcinoma
 是腺癌的一种类型。
 肿瘤起源于肺泡粘膜上皮或支气管粘膜上
皮。较少见。
 常位于肺周边。分化程度较高，生长缓慢
，淋巴、血行转移晚。
 但可直接播散。
 分型： 结节型：呈单个或多个结节灶
 弥漫型：形态类似支气管肺炎
细支气管肺泡癌：双肺可见弥漫性大小不等的片状影
 肺泡细胞癌 Alveolar cell
carcinoma

 细支气管肺泡癌是
肺腺癌的另一类型。
这里是肺实变多病
灶变异的粗略外观
大多数右上肺叶呈
现黑 - 白色到灰色
外观。
腺癌 Adenocarcinoma
 大细胞型 Large cell
carcinoma
甚少见
半数起源于大支气管，细胞大胞
浆丰富胞核形态多样，细胞排列
不规则，分化程度低。
预后很差。
常发生脑转移后才被发现。
常发生脑转移后才被发现
 ❚Invasion and Metastasis

♦Local infiltrate
Bronchial lumen
Direct extension
 Intrapulmonary
nodes
♦Lymphatic Pulmonary hilum
metastasis nodes

Mediastinum
nodes

Cervical nodes
♦Distant metastasis
Liver

Pv Bone
Lung cancer
Brain
Other

Return
❚TNM staging

♦T-Primary Tumor
♦N-Lymph node
♦M-Metastasis
Primary Tumor
Primary Tumor
Lymph node
 Clinical features
 There are no symptoms of early lung
cancer in some patients.
 Symptoms caused by lung cancer are
non-specific:perhaps an audible wheeze
or a slight cough,symptoms of infection
(fever ,purulent sputum) , of obstruction
(wheezing,dyspnea), or ulceration of
bronchial mucosa (hemoptysis).
 Clinical features
 1.Respiratory symptoms.
 (1).Cough:
 (2).Hemoptysis:
 (3).Dyspnea.:

 (4).Wheeze or stridor:
 (5).Chest pain :
 (6).Fever:
 Clinical features
 2.Symptoms caused by the near organs or tissue
involved by tumor.
 (1).Dysphagia.

 (2).Hoarseness:invasion of the recurrent laryngeal nerve

 (3).Pleural effusion due to invasion of the pleura.

 Clinical Features
 (4).Horner’s syndrome.It is caused by invading the
cervical sympathetic ganglia on the involved side
the pupil is small ptosis of the up eyelids,retraction
of the eyeball and no sweat of the face.
 (5)Cardiac effusion
 Clinical fetures
 (6).Superior vena caval syndrome. Due to
obstruction of the superior vena caval,the
patient may have noticed that his collar is tight,
the neck is enlarged and the jugular vein and
the veins of anterior chest wall are distension
and edema of the face.
 3.Symptoms caused by metastasis.liver,
skeleton,brain, supra clavicle lymph nodes.
nodes
 Clinical fetures
 4.Paraneoplastic syndrome.Because tumor cell
can secrete ectopic hormone ， antigen or
enzyme the patients with Lung Cancer
sometimes may have some paraneoplastic
syndrome Including:
 (1) Collagen tissue disorder such as finger
clubbing , hypertrophic pulmonray
osteoarthropathy 。
 Clinical features
 (2)Endocrine disorders including Cushing’s
syndrome ,syndrome of inappropriate
antiduretic hormone secretion(SIADHS),
 (3) Neuropathic or myopathic disorders
including polyneuritis ,cerebellar
degeneration,mental abnormalitis etc
 (4) others.
Diognostic techniques
 Radiographic Findings
 The appearance on the x-ray film depends
on the position ,size and stage of the tumor
1.Peripheral type :It may be various such
as infiltrative or nodular, lobulated or
umbilicus sign,liner protrusions from the
shadow into the surrounding lung,
cavitation which is often eccentric
irregular in the inner wall owing to the
necrosis of the neoplasm.
lobulated
•肿瘤中心部分液
化坏死，呈厚壁
偏心空洞，内壁
凹凸不平 。

cavitation which is
often eccentric
irregular in the inner
wall owing to the
necrosis of the
neoplasm.
右肺下叶周围型肺癌：下叶背段见一较大肿块
，
内可见一偏心小空洞伴有液平。
 Radiographic Findings
2 Central type
 (1) Direct appearance :Unilateral
enlargement of the hilar shadow due to
the tumor itself or enlarged lymph nodes.
 (2) Indirect appearance :Including local
emphysema;obstructive pneumonia
either lobal or segmental; obstractive
atalectasis (collapse) lobe or segment.
•肿瘤向外生长
时—肺门不规则
肿块（肿块由
癌肿及肺门淋
巴结融合成）

enlargement of
the hilar shadow
due to the tumor
itself or enlarged
lymph nodes
obstractive atalectasis (collapse) lobe
Fig1 Atelectasis,Right upper
lobe
Fig3 Mass With Fuzzy,Right
Fig4 Mass In right
Lobe,Lateral
portion
Fig5 Cavitating Bronchial
 Advantage of CT:
 (1) Some small lesion, lesion behind of
cardiac or blood vessel,and pathology
located in apical of lung can be found by
CT which can’t be found by chest x-ray.
 (2) Lymph nodes along hilar or
mediastinum can be found by CT.
lobulated or umbilicus sign,liner
protrusions from the shadow into the
surrounding lung
 Examination of sputum
 Cytologic examination of bronchial

secretions(or sputum)may reveal

exfoliated malignant cells recognizable to
the pathologist who is specially trained
for such work.The sputum must to be
fresh, send on time, repeat(4-6 times).
 Bronchoscope
 Bronchoscope may verify the existence of
tumor , of Central type, and cytologic diagnosis
of lung cancer should be obtained though FBC
 Blind biopsy may be help to the diagnosis of
the tumor beyond the range of bronchoscope
vision when tumors are not visualized
Fig 1 Normal Trachea Fig 2 Normal Carina
Fig 3 Squamous Cell Fig 4 Adenocarcinoma
Carcinoma, Trachea Left Lingular Bronchus
Fig 5 Adenocarcinoma Fig 6 Extrinsic Pressure
Right Truncal Intermedus Trachea
 Lung Biospy
 1.Biopsy with fiberoptic bronchoscope;
2.Transthoracic neddle biopsy with CT
directed or B type ultrasonic;
 3.Biopsy with thoracoscopy ;
 4.Biopsy with medistinoscopy;
 5.Exploratory thoracotomy.
 Diagnosis
 1.Symptom -free: General investigation of high risk
group (male,morn than 40 years old,cigarette
consumption 20/per day). Taking a x-ray film and
examining sputum for cancer cell every half year
 Early stage of the bronchogenic carcinoma Refers to
the tumor is still located at the bronchus ,no invade
the hilar lymph nodes,pleura as well as distant
metastases,its diameter is often <3cm.
 Diagnosis
Diagnosis procedure:
 1.X-ray film(-) and sputum for cytology (-) →
FBC(-) →follow up once a month /year.

 2. X-ray film(+) and sputum for cytology (+) → FBC

to identify the cancer cell type → CT , MRI →

therapy.
 Diagnosis

Diagnosis procedure:
 3. X-ray film(-) and sputum for cytology (+)→

ruling out the tumor of upper respiratory tract

first→ FBC.

 4 X-ray film(+) and sputum for cytology (-)→

FBC(-) →lung biopsy.

 Differential diagnosis
 1.Solitary nodule: Tuberculoma, Benign Tumor

 2.Cavitation:Lung Abscess, Tuberculosis,

 3. Enlargement of hilar shadow: Hamartoma

 4.Others: Pleural Effusion,Widening Of

Mediatinal.
 结核球
tuberculoma
•多见于青年，
病程长 , 常位
于上叶后段或
下叶背段
•X 线密度不均
匀 , 有时有钙
化点 , 肺内常
有散在结核灶
。
•常见儿童、
青年
•多有结核中
毒症状
•结核实验阳
性
•抗痨有效
粟粒性结核 miliary
tuberculosis
•常见青年
•全身毒性
症状明显
•抗痨有效
•X 线以上
中叶明显
❚ Pulmonary
Tuberculosis

Lung cancer Tuberculoma

Miliary Tuberculosis Bronchioloalveolar
carcinoma
 肺脓肿 Lung
abscess
•有明显感染症
状，痰多，脓性
.
•抗痨无效
•X 线空洞壁较薄
，内壁光滑
•常有出血。
肺脓肿 Lung
abscess
❚ Pulmonary Infection

Pulmonary abscess Lung cancer

 Treatment
 1.Rresection by operation ;
 2.Radiotherapy ;
 3.Chemotherapy;
 4.Immunotherapy ;
 5.Traditional Chinese medicine therapy etc.
 The therapeutic principle of lung cancer is
comprehensive: rescect the tumor as far as possible
then combine with other treatments ; other treatments
first then operation depending on the cytologic type,
position,size and stage of the tumor.
手术治疗

Operation
 手术类型 Type
肺叶切除（袖状切除）
Lobectomy
全肺切除
pneumonectomy
楔型切除
Limited resection
肺叶切除（袖状切
除） Lobectomy
隆突成型术
全肺切除
pneumonectomy
全肺切除
pneumonectomy
楔型切除 Limited
resection
 Treatment
SCLC:
 Ⅰ Chemotherapy , operation.
 Ⅱ Chemotherapy,radiotherapy.
NSCLC:
 Ⅰ Operation.
 Ⅱ Most :operation→chemotherapy
 Small parts: radiotherapy.
 Treatment
Ⅲ: Operation + chemotherapy;
 radiotherapy +chemotherapy.
Ⅳ: chemotherapy+ radiotherapy(relieve
some symptoms,such as pain, dyspnea,
obstruction etc).