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Y4 Respiratory Medicine > 4. Lung Cancer and Pleural Disease > Flashcards

4. Lung Cancer and Pleural Disease Flashcards

1
Q

Invasive Sx of lung cancer

A

Chest wall pain ( may be pleuritic or central and tight, or insidious ache) , hoarse voice ( left recurrent laryngeal nerve), vasc invasion eg. SVC, dysphagia as mediastinal LN invades into oeso, Horner’s syndrome, shoulder pain and arm weakness/ wasting

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2
Q

Metastatic Sx of lung ca

A

Headches, seizures

Pleural and pericardial effusion, airway compression or SVC/RLN invasion

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3
Q

Sx of SVCO

A

Facial and upper limb oedemaa
Venous distention of upper body
Headaches
Pemberton’s sign- facial plethora and distress, stridor after lifting arms above head

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4
Q

Most common cause of SVCO

A

Small cell lung cancer or lymphoma

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5
Q

Tx of SVCO

A

Dexa to reduce oedema assoc with lymphadenopathy
Anticoag to tx acute ep where thrombosis is likely pri cause
Radio and chemo to treat underlying cause
SVC stenting to relief Sc

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6
Q

Common sites of lung ca spread

A

Supraclavicular, mediastinal and hilar lymph node,
Brain, bone, liver,adrenal glands,
pleura, lung, skin,

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7
Q

Paraneoplastic syndrome of squamous cell carcinoma

A

Ectopic PTH like hormone - hypercal , May be assoc w/ bone metastases and bone invasion

Hypertrophic pulmonary osteoarthropathy assoc with Finger clubbing and periostits

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8
Q

Paraneoplastic syndrome of SCLC

A

SIADH: MOST COMMON, hyponatraemia (pts may look euvolaemic)
Ectopic ACTH, hypoK
Cerebellar Sx
Eaton lambert Sx
Limbic encephalitis

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9
Q

Pathology of SIADH

A

Inappropriately concentrated urine in SIADH

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10
Q

Hypercal Sx

A

Confusion, constipation, thirst, fatigue

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11
Q

Tx of hypercal and hypoNa

A

IV fluid first step, add diuretic to increase excretion, then IV bisphosphonate to prevent rebound

Fluid restriction for hypona and salt supplemments

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12
Q

What is carcinoid syndrome

A

Usually due to liver metastasis from a carcinoid tumour. Diarrheoa, dry skin, flushing, palpitations

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13
Q

What scale tests pts abilityu to tolerate chemo

A

ECOG PS

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14
Q

What is V/Q scan done for

A
  • For borderline pts
  • Usually due to coexisting emphysema → check if removing damaged part would have adverse effect on lung fx
  • Also if pt has high risk of dyspnoea
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15
Q

What tests should be done before Ix of cancer

A

ECOG, PFT, ET, check pt’s daily fitness

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16
Q

What is Ix of choice for staging lung cancer

A

CT CA w/ contrast - early indication of stage
If CT shows lymphadenopathy can use EBUS

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17
Q

When is CT PET used in lung cnacer

A

When not stage 4- gives more accurate picture of such ca, can identify metastases, and high sensitivitty for N and M staging. May show uptake even if no other findings elsewhere

or can be used if doubt over incurable disease ( 3B vs 4) if tissue confirmation is not available

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18
Q

False +ve and -ve in PET-CT scan

A

TB, sarcoid, other inflammatory lesions
low uptake in primary lesion (carcinoid, lipidic adenocarcinoma), uncontrolled diabetes and lesions

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19
Q

What can mediastinocopy be useful for in lung cancer Ix

A

For mediastinal LN before surgery
Indications include:
- PET pos MLC
- N1 disease
- Central tumor
- Tumor >3cm with high FDG uptake

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20
Q

Downsides of PET

A

Doesn’t diff between tumour and infxn

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21
Q

N staging for lung cancer

A

0- no spread
1- on same side
2- hilar/ central (mediastinal) lymph gland spread ( surgery only if N2a or below i.e. singular station in mediastinum only)
3 - opp side of tumour/up to neck

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22
Q

M staging for lung ca

A

1a - intrathoracic
1b - extrathoracic
1c - multiple

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23
Q

marker for lung adenocarcinoma

A

TTF1, cK7, p63

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24
Q

markers for squamous cell carcinoma

A

CK5/6, p63, -ve for CK7, TTF1

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25
Q

Contraindications for bronchoscopy

A

FEV1 unacceptable compared to predicted values, coagulopathy eg. liver disease, anti coag, SpO2 <92

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26
Q

How to obtain tissue in lung for pathology:
1. For tumours visible in airway
2. For main lesions in lung, esp peripheral of larger lesions
3.To stage mediastinum and hilum LNs
4. For those with poorer resp reserve
5. For biopsy for excluding lymphoma
6. To stage cancer, also for small lesions that are difficult to get to
7. For pleural effusion

A
  1. Bronchoscopy
  2. CT guided biopsy (LA applied to skin and radiological guided needle passed through skin and lung to mass)
  3. Endobronchial ultrasound
  4. EBUS FNA
  5. EBUS biopsy
  6. CT PET, may need lobectomy to prove ( following resection)
  7. pleural aspiration
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27
Q

Why can’t CTGBx be done for central lesions

A

risk hitting impt structures, incr. risk of pneumothorax

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28
Q

What is Mx for pt with LN spread

A

Chemo and radio, usually won’t do surgery due to node spread

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29
Q

First test for lung ca

A

CXR

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30
Q

What could reduced transfer factor and early drop in sats in pt with significant COPD be due to

A

Emphysema

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31
Q

Local Sx of lung cancer

A

Cough ( may be clear mucus?), wheeze/ stridor, HAEMOPTYSIS

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32
Q

Mx of SVCO

A

Steroids and stent
consider anticoag based on rapidity of Sx

33
Q

Tissue Dx for SVCO

A

Sample peripheral lymph node to confirm Small cell Lung Cancer - non invasive

34
Q

Tx for cerebal mets

A

Dexa to reduce oedema
Consider pophylatic anti epileptics

35
Q

What mutation is important to consider in lung cancer and when. What does presence of this EGFR mean

A

EGFR, in non-smokers with sever cancer
EGFR mutation allows for targeted therapy, use tyrosine kinase inhibitors rather than systemic chemo

36
Q

Risk factors for pri spontaneous pneumo

A
  • Young males
  • Tall, thin
  • Smoking
  • Cannabis
37
Q

Pathology of PSP

A

Apical blebs/ emphysema like changes that rupture and create air leak

38
Q

What famillial gene disorder can increase risk of PSP

A

Folliculin

39
Q

CXR signs of PSP

A

Loss of lung markings and lung edge moves medially

40
Q

What can cause SSP

A

TB, PCP , any CLD, emphysema, asthma, ILD,CF

MARFAN’S is associated with it

41
Q

Signs of tension pneumoT

A
  • Airway deviated to the other site on CXR
    • Could be palpated
  • B→ Only blood? on side with TP, no lung tissue
    Vasc appearance may not be obv due to pneumoT
  • C→ Heart also deviated to other side
  • D→ diaphragm should be higher on right, but is higher on left instead due to tension pneumothroax pushing to the other side
    (may have blunted CPA if hv haemothorax)
  • E→ Larger ICSt
42
Q

Pneumothorax Mx algorithm

A

Bilateral/ haemodynamically unstable then chest drain
Pri pneumo: If size >2 and or breathless, then aspirate with cannula. Otherwise discharge and review

Sec pneumo: If size >2 or breathless, chest drain, if not then aspirate with cannula, unless less than 1 cm then admit and high flow oxygen, observe

43
Q

Mx of open pneumoT

A

COver wound over 3 sites to allow air to escape from chest cavity

44
Q

Where should therapeutic acspiration with needle take place

A

ICS2 MCL

45
Q

Possible complication of chest drain insertion and px

A

Re expansion P oedema if drain more than 1.5l w/o hrs break
- collapsed lung is allowed to expand suddenly
- If pressure is released very quickly, shifting of fluid from intravascular to interstitial space may occur → PO

PX includes
- Cough, chest discomfort, hypoxemia
- Shock and death if sever

46
Q

When should thoracic surgery be done for penumothorax

A

VATS done where chest drainage not successful or for pt with recurrent PTX or bilat PTX

Bleb removal, apical stapling, talc pleurodesis to prevent recurring

47
Q

What should not be done after PTX

A

No scuba divinf, no flying for 2 weeks, no heavy lifting for one month

48
Q

What are the main diseases that can cause pleural fluid accumulation

A

LVSD, CAP, PTE
SVCO, RVF– due to increased intravascular pressure in pleura and systemic vasc pressure
Atelctasis due to decreased pleural pressure
ascites

49
Q

What is massive haemothorax and its mx

A

Blood drainage >1.5 l after closed thoracostomy/ chest drain and continuous bleeding at 0.2 L/hrs for at least 4 hrs

Usually surgical mx

50
Q

Ligth’s criteria

A

Exudate is
P to s protein ratio > 0.5
LDH ratio >0.6
P LDH >2/3 upper limit normal (>145)

51
Q

Causes of exudates

A

Infxn ( esp pneumonia) , cancer, inflm diseases, amiodarone and methothrexate

52
Q

Causes of transudates

A

Heart failure, liver failure, fluid overload, hypoALB, nephrotic Sx, hypothyroidism

53
Q

How to Ix pleural effusion

A

Early- CXR (homogenous shadowing) , USS if contemplsting prognosis, CT for ant potential causes eg. pleural ca

Pleural asp for culture and sensitivity etc.

Medial throacoscopy or VATS if biopsy needed

54
Q

Are transudates more likely to be bilateral or unilateral

A

BIlatersl

55
Q

Main tx for transudative Pleural effusion

A

Diuretic

56
Q

When should pleural thoracic USS be done for pleural effusion. If diff to assess on USS, or if complicated or innoculated, what should be done instead?

A

before procedures
CT CAP

57
Q

what do these appearances in pleural fluid suggest

frank pus
blood stain
frank blood
Milky
bile

A

Empyema
malignamcy, pulm infarction, infxn, TBetc.
haemothorax
chylothorax
biliary fistyla

58
Q

When is pH low in pleural fluid

A

In pleural infx, malignancy

59
Q

when is glucose very low

A

In empyema

60
Q

What does haematocrit suggest in pleural fluid

A

Separates blood stained effusions from haemothorax

61
Q

What does high amylase suggest in pleural fluid

A

Oesophagus rupture to pancreatis

62
Q

Main treatment for pleural effusion

A

Therapeutic thoracocentesis

63
Q

Vitals in massive pleural effusion

A

May be tachycardic with low BP

64
Q

Possible blood test results for malignant pleural effusion

A

Hyopna, hyperca, anaemia, deranged LFT

65
Q

CXR position of heart in massive Pleural Effusion

A

Pushed away from location of PE cross midline

66
Q

Risk factors for Lung Ca

A

Smoking, asbestos

67
Q

Most common lung cancer

A

Non-Small cell lung cancer
- Adenocarcinoma most common,followed by squamous cell

68
Q

Whhat is the most aggressive llung vanver that usually presents at stage 4

A

SCLS

69
Q

Lung cancer Tx

A

Anatomical resectn - may remove bronchus
- Segmentectomy accepted for early stage lung cancer, not inferior to lobectomy
Non-anatomical resection→ doesn’t affect bronchus, used foer samll tumours now

70
Q

Complication of lung surgery’

A
  • Long thoracic innervates seratus anterior, should spare during resection or will cause winged scapular
71
Q

IF ICD is done for pleural effusion and it is bubbling, should it be removed or left in

What does continuous bubbling mean

A

Left in, as air is leaking
Continuous- may have subcutaneous emphysema ( air outside chest cavity but beow soft tissue)

72
Q

What is the function of the interstitium

A

For gas exchange

73
Q

When is the pt more likely to get empyema

A

If pleural fluid is acidotic

74
Q

How to diff parapneumonic effusion from other kinds of pleural effusion

A

Can see air bronchodgram

75
Q

What can cause whiteout of lung ( complete opacification of one hemithorax) and how to differentiate these causes

A
  • pneumonectomy, huge pleural effusion or complete collapse of the lung
  • Mediastinum pushed away in pleural effusion, pulled in collapse
76
Q

Sx and txof cardiac tamponade

A
  • 1/3 of pts may have pulsus paradooxuss, Kussmaul’s sign, beck’s triad → hypotension, JV distension, muffled heart sound
    • Due to cardiac fluid surrounding the heart
      • Venous return to heart is low as surrounded by fluid around heart

-Tx is pericardial window (surgery)to evacuate fluid from heart

77
Q

what is the safe triangle for chest drain

A

oirders are Pec major, latissimus dorsi and 5th ICS ( nipple)

78
Q
A

Y4 Respiratory Medicine (6 decks)

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