Clinicopathological profile of patients with bronchogenic carcinoma at a tertiary care center in Western India
Dharitri Thakkar1, Pradipkumar Damor2, Kamlesh Vithalani1
1 Department of TB and Chest, P. D. U. Medical College, Rajkot, Gujarat, India
2 Department of TB and Chest, Smt. NHL Municipal Medical College, Ahmedabad, Gujarat, India
|Date of Submission||19-Oct-2018|
|Date of Decision||05-Dec-2018|
|Date of Acceptance||13-Jan-2019|
|Date of Web Publication||1-Jul-2019|
Dr. Dharitri Thakkar
“Parijat,” Gyanjivan Society, Street No. 3, Raiya Road, Rajkot, Gujarat
Source of Support: None, Conflict of Interest: None
Background: Bronchogenic carcinoma is the most common malignancy all over the globe in terms of incidence and mortality, especially in males. Its increasing incidence in nonsmokers and females is also an important concern. Objectives: The objective of this study was to study various demographic, clinical, radiological, and histopathological features of patients with confirmed diagnosis of lung cancer. Patients and Methods: Patients with confirmed histopathological diagnosis of bronchogenic carcinoma attending a tertiary care center in western India were included in the study. Results: A total of 50 patients were studied. Of 50, 45 were male and 5 were female. Average age of the patient was 59.92 years. Forty-six (92%) patients were current or ex-smokers, whereas only 4 patients were never-smokers. Cough (90%) followed by chest pain (62%) was the presenting symptom. Soft-tissue density mass lesion was the most common radiographic finding. Adenocarcinoma (36%) followed closely by squamous cell carcinoma (32%) was the diagnosed histological subtype. Of 50, 9 (18%) patients had evidence of distant metastasis at the time of diagnosis. Conclusions: This study concludes that adenocarcinoma was the most common subtype even in smokers. A high index of suspicion and prompt investigations in a patient with respiratory symptoms should be employed to diagnose patients at an early stage.
Bronchogenic carcinoma is the most common malignancy all over the world in terms of both incidence and mortality. There were estimated 1.8 million new cases in 2012 (12.9% of total), 58% of which occurred in the developing countries. It also remains the most common malignancy in men worldwide (1.2 million, 16.7% of total). It is the most common cause of death from cancer worldwide, accounting for 1.59 million deaths per year (19.4% of total). In females, incidence rates are lower than that of males, but its incidence and mortality are rising.
In India, the incidence and mortality of lung cancer are rising, mainly due to changing smoking practices. Studies have emphasized the association of smoking habit with bronchogenic carcinoma and differences in relative risk rates in different communities based on the smoking habit. Significant epidemiological and cell type differences exist in India as compared to the West. The males are predominant sufferers, with average age around 54 years. Squamous cell carcinoma is the most common type, followed by adenocarcinoma, small-cell carcinoma, and large-cell carcinoma. Adenocarcinoma mostly occurs in nonsmokers and females. The incidence of adenocarcinoma is rising in India.,
Tobacco smoking is the most common cause of bronchogenic carcinoma. The etiological association between smoking and lung cancer was reported in the 1940s and was established in the 1950s by epidemiological research., The first US Surgeon General's Report on Smoking and Health was published in 1964 and concluded that cigarette smoking was causally related to lung cancer.
Following the cessation of smoking, the risk of developing carcinoma of the lung has been shown to decline progressively with time. However, even after 10–20 years of smoking cessation, the risk is still about 2.5 times that of nonsmokers. Other risk factors include exposure to occupational and environmental pollutants, passive smoking, and chronic lung diseases.,,
The present study aims at studying various demographic characteristics, clinical features, and results of various radiological and pathological investigations.
The objectives of the present study were to study various demographic characteristics, clinical features, and diagnosis of patients with bronchogenic carcinoma.
This cross-sectional, observational study was carried out at the Department of Pulmonary Medicine at a Tertiary Care Level Medical College located in Western India. All patients with confirmed diagnosis of bronchogenic carcinoma by histopathological examination of material obtained by transthoracic needle aspiration, pleural fluid aspiration, or lymph node fine-needle aspiration cytology (FNAC) were included in the study. Patients with only radiological diagnosis of bronchogenic carcinoma (without histopathological confirmation) were not included in the study. Informed written consent was obtained from patients before enrollment in the study.
| Results|| |
A total of 50 patients were included in this study. Of 50 patients, 45 patients were male and 5 patients were female. The ratio of male: female was 9:1. The mean age of the patients was 59.92 years, i.e., about 60 years. The mean age in females was 56 years. The average age in males was 60.35 years. The youngest patient was of 41 years, whereas the oldest patient was of 80 years. The highest number of patients belonged to the age group of 51–60 years (19 patients, 38%). Of 50 patients, 27 (54%) belonged to rural areas, whereas 23 (46%) belonged to urban areas.
The symptoms and signs seen in the patients included in this study are given in [Table 1] and [Table 2].
In the present study, 33 patients (66%) presented with right lung lesion, whereas 16 patients (32%) had left lung lesion. One patient had bilateral lesions on chest X-ray, with multicentric lung lesions. Upper and middle zone lesions were more common than lower zone lesions. The most common radiographic pattern was soft-tissue density mass lesion (n = 33, 66%) followed by pleural effusion (n = 10, 20%) and signs of collapse (n = 8, 16%). Other findings were mediastinal widening, nodular pattern, rib erosion, cavitation, and combination of findings [Table 3].
Of 50, 9 (18%) patients had evidence of distant metastasis, which included metastasis in liver (n = 7), adrenal glands (n = 1), and skeletal system and brain (n = 1).
Forty-six patients (92%) were chronic smokers, which included 45 males and 1 female. Out of 46, 40 patients used to smoke bidis, 4 used cigarettes, whereas 2 were chillum smokers. Only 4 patients were nonsmokers. Thus, smoker: nonsmoker ratio was 11.5:1. Of 5 female patients, 4 had a history of exposure to biomass fuel, one of which was also a smoker. Eight patients had prior history of tuberculosis.
Diagnostic method employed
In the present study, in 40 patients, the diagnosis was established by cytopathological examination of tissue obtained by transthoracic aspiration, out of which 23 were performed under ultrasonography guidance and 17 were performed under computed tomography guidance. FNAC from external lymph node (cervical/supraclavicular) was performed in 6 patients. All 46 results thus obtained were positive for malignancy. Remaining 4 patients had undergone fiberoptic bronchoscopy, examination of bronchoalveolar lavage (BAL) fluid, and endobronchial biopsy. Endobronchial biopsy and BAL were positive for malignant cells in 4 and 3 patients, respectively.
Thoracentesis and cytological examination of pleural fluid for malignant cells was performed in 13 cases. Out of 13 cases, cytological examination was positive for malignant cells in 10 patients (77%), whereas 3 patients (33%) had negative cytological examination of pleural fluid. Cytological examination of sputum for malignant cells was positive in 4 patients.
Of 50 patients, 18 (36%) had been diagnosed with adenocarcinoma, 16 (32%) with squamous cell carcinoma, 2 (4%) with small-cell carcinoma while cell type could not be confirmed in 14 (28%) patients. Thus, adenocarcinoma was the most common histopathological type in the present study followed closely by squamous cell carcinoma. No patient was diagnosed with large-cell carcinoma [Figure 1].
Age distribution according to histopathological subtype is as follows [Table 4] and [Figure 2]. Four of five female patients had adenocarcinoma, while one female patient was diagnosed with squamous cell carcinoma. Of 18 patients diagnosed as adenocarcinoma, 4 were nonsmokers, while 14 were smokers. All 16 patients with squamous cell carcinoma were smokers.
The mean age of the patients was 59.92 years, i.e., about 60 years. The highest numbers of patients were in the age group of 51–60 years (19 patients, 38%). This data are similar to other Indian studies.,,,
Of 50 patients included in the study, 45 patients were male and 5 patients were female. The ratio of male:female was 9:1. This ratio is higher as compared to other Indian studies conducted by Pujari VV et al. (ratio – 4.12:1), Dhandapani S et al. (ratio – 3.9:1), and Sundaram V et al. (ratio – 4.3:1).,,
In the present study, 46 patients (92%) were chronic smokers, which included 45 males and 1 female. Only 4 patients were nonsmokers. Thus smoker: nonsmoker ratio was 11.5:1. The ratio of smoker: nonsmoker ratio was higher as compared to other studies, for example, Gupta D et al. reported a ratio of 3.6:1, whereas Kashyap S et al. reported ratio of 2.4:1. The higher male-to-female ratio and higher ratio of smokers in our study may be attributed to different smoking practices and other social factors in our region.
In the present study, the most common radiographic pattern was soft-tissue density mass lesion (n = 33, 66%) followed by pleural effusion (n = 10, 20%) and signs of collapse (n = 8, 16%). Similar findings were reported in the study conducted by C P Sharma et al. (mass lesion – 49.9%, collapse – 14.2%, pleural effusion – 8.8%, and combination pattern – 24.4%). Saha A et al. reported collapse in 26.92%, mass lesion in 26.92%, nodules in 13.46%, consolidation in 18.72%, and pleural effusion in 10.58% of cases.
Of 50 patients, 18 (36%) had adenocarcinoma, 16 (32%) had squamous cell carcinoma, 2 (4%) had small-cell carcinoma while cell type could not be confirmed in 14 (28%) patients. Thus, adenocarcinoma was the most common histopathological type in the present study followed closely by squamous cell carcinoma.
Most of the Indian studies have reported either higher or almost similar proportion of adenocarcinoma as compared to squamous cell type.,, This observation is different as compared to western countries where a higher percentage of squamous cell type is reported. Furthermore, adenocarcinoma might be surpassing squamous cell type in frequency in India as demonstrated by various studies [Table 5].
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