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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 120-123

Approach to lung cancer


1 Department of Respiratory Medicine, Apollo Main Hospital, Chennai, Tamil Nadu, India
2 Department of Respiratory Medicine, Sundaram Medical Foundation, Chennai, Tamil Nadu, India
3 Department of Statistics, Apollo Hospital, Chennai, Tamil Nadu, India

Date of Submission01-Dec-2020
Date of Decision10-Mar-2021
Date of Acceptance15-Mar-2021
Date of Web Publication28-Apr-2021

Correspondence Address:
T Suresh Babu
Departments of Respiratory Medicine, Post Graduate, Apollo Main Hospital, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/japt.japt_1_20

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  Abstract 


Aim: This study was done to study the utility of various biopsy techniques in diagnosing lung cancer and also to study the clinical/pathological and radiological features of lung cancer. Materials and Methods: This is a prospective and cross-sectional study, conducted in Apollo Main Hospital, in which confirmed cases of lung carcinoma were included in the study. These patients were admitted during 1 year from 2019 to 2020. Data such as demographics (age of the patients and sex), smoking status, histopathological type, clinical presentation, radiological features, and clinical stage of the disease were obtained. Patients had undergone one or more biopsy techniques based on clinical, radiological features decided by treating physician. Results: Thirty-one patients undergone bronchoscopy with narrow band imaging (NBI) in which findings were, 13 patients showed endobronchial growth, 7 showed extrinsic growth, no abnormal gross appearance in 11 patients, 11 were NBI negative, and 20 were NBI positive. Out of 28 bronchial wash cytology samples, 21 showed no atypical cells and 7 showed positive for atypical cells. Twenty-three patients had undergone bronchial biopsy in which 14 showed malignancy in Histopathological examination (HPE) and no evidence of malignancy in eight patients. Twenty-eight patients undergone computed tomography (CT)-guided lung biopsy, in which 27 patients tested positive for malignancy. Conclusions: The result of the study demonstrates that CT-guided lung biopsy is an effective procedure in diagnosing peripherally located lung cancer with the low rate of complications with an accuracy of 96.4%.

Keywords: Adenocarcinoma, bronchoscopy, computed tomography-guided biopsy


How to cite this article:
Babu T S, Sridhar R, Lawrence R, Ramakrishnan B, Narasimhan R. Approach to lung cancer. J Assoc Pulmonologist Tamilnadu 2020;3:120-3

How to cite this URL:
Babu T S, Sridhar R, Lawrence R, Ramakrishnan B, Narasimhan R. Approach to lung cancer. J Assoc Pulmonologist Tamilnadu [serial online] 2020 [cited 2021 Aug 2];3:120-3. Available from: http://www.japt.com/text.asp?2020/3/3/120/314963




  Introduction Top


Lung cancer became a separate entity in the 18th century, since then it has evolved to become the most common cancer in the present times. Currently worldwide, lung cancer is the most common cancer, prevalent among both men and women. Furthermore, lung cancer is the leading cause of mortality among both sexes worldwide. In India, it is the second most common cancer in men and the fifth most common cancer in both men and women together. The lung cancer 5-year survival rate (18.6%) is lower than many other leading cancer sites, such as colorectal (64.5%), breast (89.6%), and prostate (98.2%). More than half of people with lung cancer die within 1 year of being diagnosed. According to recent studies, due to increased awareness among people regarding association of smoking with lung cancer, various new modalities to diagnose lung cancer, the mortality and morbidity of lung cancer is on a declining trend. This study was done to study the utility of various biopsy techniques in diagnosing lung cancer and also to study the clinical/pathological and radiological features of lung cancer.

Objective

The objective of this study is to study the utility of various biopsy techniques in diagnosing lung cancer.


  Materials and Methods Top


This is a prospective and cross-sectional study, conducted in Apollo Main Hospital, Chennai, Tamil Nadu, in which confirmed cases of lung carcinoma were included in the study. These patients were admitted during 1 year (from 2019 to 2020). Data such as demographics (age of the patients and sex), smoking status, histopathological type, clinical presentation, radiological features, and clinical stage of the disease were obtained. The patient had undergone one or more biopsy technique based on clinical, radiological features decided by treating physician.


  Results Top


There were total 49 patients, of which 41 were male and 8 were female, of these 53.1% were smokers [Figure 1]. The mass lesion seen in computed tomography (CT) chest were, 20.4% left upper lobe (LUL), 18.4% right lower lobe, 14.3 right upper lobe, 8.2% in left lower lobe, and 2% bilateral upper lobe [Figure 2]. At the time of presentation to the hospital, 75.5% had no pleural effusion in CT chest, 24.5% presented with either right or left side pleural effusion in the CT chest. Thirty-one patients undergone bronchoscopy with narrow band imaging (NBI) in which findings were, 13 patients showed endobronchial growth, 7 showed extrinsic growth, no abnormal gross appearance in 11 patients, 11 were NBI negative, and 20 were NBI positive. Out of 28 bronchial wash cytology samples, 21 showed no atypical cells and 7 showed positive for atypical cells. Twenty-three patients had undergone bronchial biopsy in which 14 showed malignancy in HPE and no evidence of malignancy in eight patients. Twenty-eight patients undergone CT-guided lung biopsy, in which 27 patients tested positive for malignancy and one patient tested negative [Refer [Table 1]. 14.3% patients presented with extrapulmonary metastasis, 4.1% had mets in pericardium, 6.1% in liver, 2.0% in chest wall, and 2.0% in bone [Figure 3]. Out of the 49 patients, the most common presentation of lung cancer is adenocarcinoma 32.7%, followed by poorly differentiated carcinoma of 10.2%, squamous cell carcinoma 8.2%, and small cell carcinoma of 6.1% [Figure 4].
Figure 1: Incidence of bronchogenic carcinoma in smokers

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Figure 2: Sites involved in CT chest

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Figure 3: Frequent sites of extra pulmonary metastasis

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Figure 4: Distribution of Histopathological type of lung cancer

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Table 1: Various techniques in diagnosing lung cancer

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  Discussion Top


Lung cancer is the most common cause of cancer-related death worldwide. Studying the age distribution in this work shows that the highest incidence of bronchogenic carcinoma was seen in the sixth and 7th decade of life. Average age group in our study is 63.3 which is closely related to several previous Indian studies (58).[1] It is well-known that males are prone to lung cancer than the females. The male predominance (83.7% in males) in our study is higher than several western studies. The possible reason could be increased smoking prevalence among females in Western countries, which is less common in Asian countries. However, there is an increase in proportion of females 7.9% in 2008-16.3% in our study; the explanation for this could be due to increased exposure to pollution or passive smoking. The prevalence of lung cancer in smokers is 46.9%, which is very low when compared with several Indian and western studies. None of the females included in our study group were smokers and 56.1% of males involved in our study were smoker. Hence, other risk factors other than smoking should be considered that include passive smoking, genetic predisposition, biomass fuel, and air pollution.

Patients commonly experience multiple symptoms, both lung-specific (cough, breathing changes, chest pain, and hemoptysis), and systemic (loss of weight or appetite and fatigue).[2] According to Rawat et al.'s study, cough was the common symptom (72.90%).[3] In many previous studies, cough is present in more than 65% of patients at the time lung cancer is diagnosed.[4] Chest pain (40.8%) is the most common symptoms in the whole study group, followed by cough (32.7), hemoptysis (28.6%), shortness of breath (22.4%), and loss of weight (22.4%). The reason for chest pain in lung cancers could be, spread of lung cancer to bones/chest wall and a pancoast tumor located in the apex compressing brachial plexus and cervical sympathetic plexus.

A review of 21 studies published in British Journal of General Practice found that, 20%–23% of chest X-rays in people who had symptoms of lung cancer were falsely negative.[5] In our study, 57.1% of chest X-rays were normal during the time of diagnosis. The main causes for missing lesions in the chest X-ray imaging are, poor viewing conditions, hasty visual tracking, interruptions, hidden areas of lung, and inadequate image quality are the most important.[6]

Out of 49 patients, chest X-rays of 9 (18.4%) patients showed pleural effusion and CT chest of 12 (24.5%) patients showed pleural effusion. In patients with lung cancer, the incidence of pleural effusion ranges between 7% and 23%.[7] The most common reason for pleural effusions in lung cancers are, involvement of pleura and obstruction of lymphatics leading to decreased absorption of pleural fluid. The direct involvement of pleura in lung cancer leading to formation of pleural effusion, where malignant cells are detected in pleural fluid is called as malignant effusion and due to obstruction of lymphatics leading to decreased absorption of pleural fluid where malignant cells are not detected in effusion is called paramalignant effusion. According to Sahen SA presenting with malignant pleural effusion, lung cancer was the most frequent cause, whereas the second most common cause was breast carcinoma.[8]

Mass lesion seen in CT chest more predominantly involved LUL, the reason for upper lobe predominant is low ventilation and perfusion in upper lobe compared to lower lobe, which may leads to stagnation of carcinogenic particles.

There are several techniques such as bronchoscopy, lung CT-guided biopsy, cryobiopsy and endobronchial ultrasound (EBUS), which extended the range in diagnosing lung cancer. The yield of these various techniques depends on the various factors such as the location of the lesion, size of the lesion, and operators' skill. The diagnostic yield of bronchoscopy in diagnosing lung cancers includes bronchial biopsy – 60.8%, bronchial wash for cytology – 28.5%, and bronchial brushing – 50%. According to Ping shizu, the diagnostic yield from bronchial biopsy alone for lung cancer was 37.9%.[9] However, in our study, the yield for bronchial biopsy is higher, there were only three cases in which bronchial wash was positive in which biopsy and brush were negative. Although the yield is very poor, bronchial wash is safe, simple, and quick procedure. It is always better to compare all these three procedures together (bronchial biopsy, bronchial wash, and bronchial brush) which results in a better yield.

Over the past decade, advanced imaging technique, such as NBI has greatly expanded the diagnostic utility of bronchoscopy.[10] However, in our study, 31 patients underwent bronchoscopy with NBI, NBI detected gross malignant lesion in ten patients and failed to detect lesion in 21 patients. This is contrary to several studies done previously,

The result of the present study demonstrates that CT-guided lung biopsy is an effective procedure with low rate of complications; our study showed that CT-guided lung biopsy has an accuracy of 96.4%. Its advantage includes real-time imaging, providing excellent visualization of anatomy and safely obtaining biopsies from deep-seated lesions. The main disadvantage in CT-guided lung biopsy is exposure to radiation and complications such as pneumothorax. There were other procedures which have a good yield, but the patients who underwent those procedures were very less. EBUS is a minimally invasive, but a highly effective procedure in diagnosing lung cancer, infections and other disease causing enlarged lymph nodes of the chest. It provides physician to perform transbronchial needle aspiration. The main advantages are real-time imaging of the airway/blood vessels/lymph nodes/lungs, act as alternative for highly invasive procedures like mediastinoscopy with a good yield, patient recover quickly and go home on the same day and no complications like pneumothorax, seen in CT-guided lung biopsy.

Several studies including both Indian and western studies have previously reported that squamous cell carcinoma is the most common pathological subtype of lung cancer. However, in our study, the most common histopathological cell type is adenocarcinoma 32.7%, followed by poorly differentiated carcinoma of 10.2%, squamous cell carcinoma 8.2%, and small cell carcinoma of 6.1%. The incidence of adenocarcinoma is higher in our study compared to the other studies such as (11.3%) RadziKo et al.[11] and (18.5%) Shetty et al.[12] Adenocarcinoma of the lung usually occurs in nonsmokers, 46.9% of patients in our study are smokers which is low compared to other studies. Smoking is the most common cause in squamous cell carcinoma and small cell carcinoma. Hence, the possible reason for raise in adenocarcinoma in spite of smoking could be the change in the pattern of smoking and change in cigarette design associated with shift to low tar filter cigarettes.[11] The other reasons could be passive smoking, exposure to radon gas/asbestos, air pollution, and hereditary.


  Conclusions Top


In this study, the highest incidence of lung cancer was in the sixth and seventh decades of life. Smoking prevalence is less in our study compared to the previous studies. In histological examination, adenocarcinoma was relatively more frequent than any other type. CT-guided biopsy is more accurate in diagnosing peripheral lung cancer. Various techniques have various yield depending on site, type of tumor, accessibility, operator skill, and tumor morphology.

Acknowledgment

The authors would like to thank to the Department of Pathology, Radiology, and Medical Oncology, Apollo hospitals, Chennai, Tamil Nadu, India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Prasad R, James P, Kesarwani V, Gupta R, Pant MC, Chaturvedi A, et al. Clinicopathological study of bronchogenic carcinoma. Respirology 2004;9:557-60.  Back to cited text no. 1
    
2.
Hamilton W, Peters TJ, Round A, Sharp D. What are the clinical features of lung cancer before the diagnosis is made? A population based case-control study Thorax 2005;60:1059-65.  Back to cited text no. 2
    
3.
Rawat J, Sindhwani G, Gaur D, Dua R, Saini S. Clinico-pathological profile of lung cancer in Uttarakhand. Lung India 2009;26:74–6.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Kvale PA. Chronic cough due to lung tumors: ACCP evidence-based clinical practice guidelines. Chest 2006;129:147-53.  Back to cited text no. 4
    
5.
Bradley SH, Abraham S, Callister ME, Grice A, Hamilton WT, Lopez RR, et al. Sensitivity of chest X-ray for detecting lung cancer in people presenting with symptoms: A systematic review. Br J Gen Pract 2019;69:e827-35.  Back to cited text no. 5
    
6.
Austin JH, Romney BM, Goldsmith LS. Missed bronchogenic carcinoma: Radiographic findings in 27 patients with a potentially resectable lesion evident in retrospect. Radiology 1992;182:115-22.  Back to cited text no. 6
    
7.
Johnston WW. The malignant pleural effusion. A review of cytopathologic diagnoses of 584 specimens from 472 consecutive patients. Cancer 1985;56:905-9.  Back to cited text no. 7
    
8.
Sahn SA. Malignancy metastatic to the pleura. Clin Chest Med 1998;19:351-61.  Back to cited text no. 8
    
9.
Zhu PS, Charles D. Poirier, Michel Gagnon, Thomas Vandemoortele European Respiratory Journal 2014;44: P676.  Back to cited text no. 9
    
10.
Yarmus L, Feller-Kopman D. Bronchoscopes of the twenty-first century. Clin Chest Med 2010;31:19-27.  Back to cited text no. 10
    
11.
RadziKo E, Glaz P, Roszkowski K. Lung cancer in women age, smoking, histology, performance, status, stage, initial treatment and survival. Population based study of 20561 cases. Ann Oncol 2002;13:1087-93.  Back to cited text no. 11
    
12.
Shetty C, Lakhar B, Gangadhar V, Ramachandran N. Changing pattern of bronchogenic carcinoma Indian Radiol Imaging 2005;15:233-8.  Back to cited text no. 12
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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Introduction
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