UNIDAD DIDACTICA III
C. - FACTORES TACTICOS A CONSIDERARSE
People who smoke tobacco have a much greater risk of developing a malignant tumour than those who do not. The risk depends upon the number of cigarettes smoked, the age of starting to smoke and the timespan of smoking. The concept of pack-years is described at the beginning of this chapter.
The disease is more prevalent in urban dwellers than in rural dwellers. There is also evidence that exposure to carcinogens, either at work or leisure, can result in the development of the disease. Working with radioactive materials, nickel, uranium, chromates or industrial asbes- tos is associated with an increased risk of bronchial carcinoma.
Pathology
The majority of tumours originate in the large bronchi and spread by direct invasion of the lung, chest wall and medi- astinal structures. The tumour grows to occlude the lumen of the bronchus and then atelectasis distal to the growth will occur. There are various types (Table 6.5).
Clinical features
Seventy per cent of patients present with local symptoms. The onset is insidious and the clinical features may present in a variety of ways.
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Cough. This is the most common feature and is often ignored by the patient who may associate it with smoking. Initially, the cough is dry and irritating but may become productive if infection occurs in accumulated secretions.Tidy’s physiotherapy
Table 6.5 Histology of bronchial tumours
Histology Proportion of bronchial cancers (%)
Characteristics
Squamous cell 50 Locally invasive, cavitation sometimes occurs Oat/small cell 25 Small lung
primary, rapidly dividing, metastasise early
Large cell 12 Intermediate
between squamous and oat/small cell Adenocarcinoma 12 Slowly growing,
metastasises late, often peripheral lung tumours Miscellaneous 1 For example,
alveolar oat cell carcinoma
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Haemoptysis. There are recurrent small spots of blood in the sputum.•
Dyspnoea. This is highly variable and may be severe when there is pulmonary collapse or pleural effusion.•
Pain. Dull, deep-seated pain is common but it may be pleuritic in nature or intercostal when there is rib disease.•
Malaise and weight loss. These are associated with late stages of the disease.•
Secondary concomitant disease. Pneumonia or lung abscess may arise as a result of a tumour.•
Hoarseness of the voice. This is a result of left recurrent laryngeal nerve involvement by tumour of the left hilum.•
Stridor. This is a result of narrowing of the trachea or main bronchus.•
Facial swelling. This is a result of superior vena caval obstruction following invasion of the mediastinum.•
Arm and shoulder pain. These are caused by tumour at the apex of the lung (Pancoast tumour) invading the brachial plexus.Metastases
Metastases are common in patients with bronchial carci- noma and may include the following.
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Cerebral metastases. These may cause stroke, headaches and epilepsy.•
Bone metastases. The patient may present with spinal cord compression, pathological fracture and bone pain.•
Liver metastases. The patient may present with jaundice and hepatomegaly (an enlarged liver). Non-metastatic presentations include finger clubbing, and neuromuscular and endocrine abnormalities.Investigations
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Chest radiograph. This is essential for any patient presenting with haemoptysis and will demonstrate over 90% of lung tumours. Small tumours or those close to the hilum may be missed.•
CT scanning. This may be used to identify smaller lesions. It may also be used to assess suitability for surgery by demonstrating metastatic spread.•
Histopathology. Sputum culture may have evidence of tumour cells. Three (early morning) samples should be obtained.•
Bronchoscopy. This is used to obtain tissue samples and may also be used to assess operability.•
Percutaneous needle biopsy. This may be useful for the histological assessment of a peripheral tumour.•
Pleural aspiration and biopsy. These may be used for the patient who presents with a pleural effusion.Treatment
The appropriate treatment may be surgery, chemotherapy and/or radiotherapy. Essentially, drug therapy is to relieve symptoms and includes analgesics, antibiotics and anti-emetics.
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Surgery. This involves removing the lobe or lung. It is possible only while the tumour remains localised and in the absence of metastases. Stenting is another option for localised disease.•
Chemotherapy. Cytotoxic drugs are used with increasing regularity. Results are mixed but anaplastic tumours tend to respond to this type of treatment.•
Radiotherapy. This is used symptomatically particularly to relieve pain and obstruction.•
Laser phototherapy. This can be used to treat persistent localised disease.The prognosis depends upon the type of tumour, but the overall length of survival is around one year. Surgery can prolong life in some patients. In the terminal stages attention should be paid to the patient’s general well-being and mental state. Some patients benefit from hospice care and adequate opiate analgesia is essen- tial for pain.
supply may be normal but there is inadequate oxygen uptake from the affected alveoli. There may be disruption in blood supply to oxygenated alveoli, or shunt, resulting in obstruction of passage of oxygen from the lungs into the blood in the affected area. Diseases associated with this type are early chronic bronchitis and emphysema, pneumonia, asthma, acute pulmonary oedema, pulmo- nary embolism, pulmonary fibrosis and ARDS.