About Non Meta-static extra-pulmonary manifestations of bronchial carcinoma

Endocrine: Inappropriate secretion of antidiuretic hormone (ADH), Ectopic ACTH secretion, Hypocalcaemia, Carcinoid Syndrome, Gynaecomastia

Neurological: Polyneuropahty, Myelopathy, Carebellar Degeneration.

Others: Digital clubbing, Hypertrophic pulmonary osteoarthropathy, Nephrotic syndrome, Myasthenia, Polymyosisitis and dermatomyositis.

Finger clubbing and hypertrophic pulmonary osteoarthropathy can also be regarded as paraneoplastic, or non-metastatic syndromes. Two of the endocrine syndromes, inappropriate ADH secretion and ectopic ACTH secretion are associated.

With small cell carcinoma. Hypercalcaemia is usually caused by a squamous carcinoma. Associated neurological syndromes may occur with any type of bronchial carcinoma but perhaps most often with small cell tumours.

Physical Signs in the Chest:

Examination is usually normal unless significant bronchial obstruction has been produced, or spread to the pleura or mediastinum has taken place. A tumour obstructing a large bronchus produces the physical signs of collapse or occasionally obstructive emphysema.

Pulmonary infection beyond an obstructing tumour gives rise to pneumonia that usually responds slowly to treatment, an underlying bronchial carcinoma is suspected from the relative absence of physical signs usually associated with neumonia.

Involvement of the pleura produces the physical signs of pleurisy or or pleural effusion. Occasionally a massive tumour may cause the signs of a large pleural effusion.

Radiological examination revealing presentations of bronchial carcinoma:

Central tumour: Hilar glandular involvement, Peripheral tumour in apical segment of a lower lobe can look like an enlarged hilar shadow on the straight X ray.

Peripheral pulmonary Opacity: Usually irregular but well circumscribed. May have irregular cavitation within it. Can be very large.

Lung, lobe or segmental collapse: Usually caused by tumour within the bronchus causing occlusion. Whole lung collapse can be produced by compression of main bronchus by enlarged lymph glands.

Pleural effusion: Usually indicates tumour invasion of pleural space, very rarely a manifestation of infection in collapsed lung tissue distal to a bronchial carcinoma.

Broadening of mediastinum enlarged cardiac shadow, elevation of hemidiaphragm: Manifestations of mediastinal invasion. If a raised hemidiaphragm is caused by phrenic nerve palsy screening will show it to move paradoxically upwards when patient sniffs.

Rib destruction: Direct invasion of the chest wall or blood borne metastatic spread can cause osteolytic lesions of the ribs.

Spread to the mediastinum: Mediastinal structures are involved by spread to mediastinul lymph glands or by direct extension of the tumour mass. Evidence of mediastinal spread almost invariably means that the tumour is inoperable.

Mediastinal Invasion – Structures involved and clinical manifestations:

Structures Involved : Left recurrent laryngeal neve

Clinical Manifestations : Left recurrent laryngeal neve Hoarse voice and bovine cough. Non pulsatileSuperior vena cava distension of neck veins.Oedema and cyanosis of head, neck, hands and arms. Dilated anastomotic veins on chest wall.

Oesophagus: Dysphagia, initially for solids

Phrenic nerve : Paralysis of a hemidiaphragm may cause breathe-Lessness, but more often is an X ray finding.

Pericardium : Cardiac tamponade

Trachea Stridor

 

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