4. Lung Cancer and Pleural Disease Flashcards
Invasive Sx of lung cancer
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
Metastatic Sx of lung ca
Headches, seizures
Pleural and pericardial effusion, airway compression or SVC/RLN invasion
Sx of SVCO
Facial and upper limb oedemaa
Venous distention of upper body
Headaches
Pemberton’s sign- facial plethora and distress, stridor after lifting arms above head
Most common cause of SVCO
Small cell lung cancer or lymphoma
Tx of SVCO
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
Common sites of lung ca spread
Supraclavicular, mediastinal and hilar lymph node,
Brain, bone, liver,adrenal glands,
pleura, lung, skin,
Paraneoplastic syndrome of squamous cell carcinoma
Ectopic PTH like hormone - hypercal , May be assoc w/ bone metastases and bone invasion
Hypertrophic pulmonary osteoarthropathy assoc with Finger clubbing and periostits
Paraneoplastic syndrome of SCLC
SIADH: MOST COMMON, hyponatraemia (pts may look euvolaemic)
Ectopic ACTH, hypoK
Cerebellar Sx
Eaton lambert Sx
Limbic encephalitis
Pathology of SIADH
Inappropriately concentrated urine in SIADH
Hypercal Sx
Confusion, constipation, thirst, fatigue
Tx of hypercal and hypoNa
IV fluid first step, add diuretic to increase excretion, then IV bisphosphonate to prevent rebound
Fluid restriction for hypona and salt supplemments
What is carcinoid syndrome
Usually due to liver metastasis from a carcinoid tumour. Diarrheoa, dry skin, flushing, palpitations
What scale tests pts abilityu to tolerate chemo
ECOG PS
What is V/Q scan done for
- 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
What tests should be done before Ix of cancer
ECOG, PFT, ET, check pt’s daily fitness
What is Ix of choice for staging lung cancer
CT CA w/ contrast - early indication of stage
If CT shows lymphadenopathy can use EBUS
When is CT PET used in lung cnacer
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
False +ve and -ve in PET-CT scan
TB, sarcoid, other inflammatory lesions
low uptake in primary lesion (carcinoid, lipidic adenocarcinoma), uncontrolled diabetes and lesions
What can mediastinocopy be useful for in lung cancer Ix
For mediastinal LN before surgery
Indications include:
- PET pos MLC
- N1 disease
- Central tumor
- Tumor >3cm with high FDG uptake
Downsides of PET
Doesn’t diff between tumour and infxn
N staging for lung cancer
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
M staging for lung ca
1a - intrathoracic
1b - extrathoracic
1c - multiple
marker for lung adenocarcinoma
TTF1, cK7, p63
markers for squamous cell carcinoma
CK5/6, p63, -ve for CK7, TTF1
Contraindications for bronchoscopy
FEV1 unacceptable compared to predicted values, coagulopathy eg. liver disease, anti coag, SpO2 <92
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
- Bronchoscopy
- CT guided biopsy (LA applied to skin and radiological guided needle passed through skin and lung to mass)
- Endobronchial ultrasound
- EBUS FNA
- EBUS biopsy
- CT PET, may need lobectomy to prove ( following resection)
- pleural aspiration
Why can’t CTGBx be done for central lesions
risk hitting impt structures, incr. risk of pneumothorax
What is Mx for pt with LN spread
Chemo and radio, usually won’t do surgery due to node spread
First test for lung ca
CXR
What could reduced transfer factor and early drop in sats in pt with significant COPD be due to
Emphysema
Local Sx of lung cancer
Cough ( may be clear mucus?), wheeze/ stridor, HAEMOPTYSIS
Mx of SVCO
Steroids and stent
consider anticoag based on rapidity of Sx
Tissue Dx for SVCO
Sample peripheral lymph node to confirm Small cell Lung Cancer - non invasive
Tx for cerebal mets
Dexa to reduce oedema
Consider pophylatic anti epileptics
What mutation is important to consider in lung cancer and when. What does presence of this EGFR mean
EGFR, in non-smokers with sever cancer
EGFR mutation allows for targeted therapy, use tyrosine kinase inhibitors rather than systemic chemo
Risk factors for pri spontaneous pneumo
- Young males
- Tall, thin
- Smoking
- Cannabis
Pathology of PSP
Apical blebs/ emphysema like changes that rupture and create air leak
What famillial gene disorder can increase risk of PSP
Folliculin
CXR signs of PSP
Loss of lung markings and lung edge moves medially
What can cause SSP
TB, PCP , any CLD, emphysema, asthma, ILD,CF
MARFAN’S is associated with it
Signs of tension pneumoT
- 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
Pneumothorax Mx algorithm
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
Mx of open pneumoT
COver wound over 3 sites to allow air to escape from chest cavity
Where should therapeutic acspiration with needle take place
ICS2 MCL
Possible complication of chest drain insertion and px
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
When should thoracic surgery be done for penumothorax
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
What should not be done after PTX
No scuba divinf, no flying for 2 weeks, no heavy lifting for one month
What are the main diseases that can cause pleural fluid accumulation
LVSD, CAP, PTE
SVCO, RVF– due to increased intravascular pressure in pleura and systemic vasc pressure
Atelctasis due to decreased pleural pressure
ascites
What is massive haemothorax and its mx
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
Ligth’s criteria
Exudate is
P to s protein ratio > 0.5
LDH ratio >0.6
P LDH >2/3 upper limit normal (>145)
Causes of exudates
Infxn ( esp pneumonia) , cancer, inflm diseases, amiodarone and methothrexate
Causes of transudates
Heart failure, liver failure, fluid overload, hypoALB, nephrotic Sx, hypothyroidism
How to Ix pleural effusion
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
Are transudates more likely to be bilateral or unilateral
BIlatersl
Main tx for transudative Pleural effusion
Diuretic
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?
before procedures
CT CAP
what do these appearances in pleural fluid suggest
frank pus
blood stain
frank blood
Milky
bile
Empyema
malignamcy, pulm infarction, infxn, TBetc.
haemothorax
chylothorax
biliary fistyla
When is pH low in pleural fluid
In pleural infx, malignancy
when is glucose very low
In empyema
What does haematocrit suggest in pleural fluid
Separates blood stained effusions from haemothorax
What does high amylase suggest in pleural fluid
Oesophagus rupture to pancreatis
Main treatment for pleural effusion
Therapeutic thoracocentesis
Vitals in massive pleural effusion
May be tachycardic with low BP
Possible blood test results for malignant pleural effusion
Hyopna, hyperca, anaemia, deranged LFT
CXR position of heart in massive Pleural Effusion
Pushed away from location of PE cross midline
Risk factors for Lung Ca
Smoking, asbestos
Most common lung cancer
Non-Small cell lung cancer
- Adenocarcinoma most common,followed by squamous cell
Whhat is the most aggressive llung vanver that usually presents at stage 4
SCLS
Lung cancer Tx
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
Complication of lung surgery’
- Long thoracic innervates seratus anterior, should spare during resection or will cause winged scapular
IF ICD is done for pleural effusion and it is bubbling, should it be removed or left in
What does continuous bubbling mean
Left in, as air is leaking
Continuous- may have subcutaneous emphysema ( air outside chest cavity but beow soft tissue)
What is the function of the interstitium
For gas exchange
When is the pt more likely to get empyema
If pleural fluid is acidotic
How to diff parapneumonic effusion from other kinds of pleural effusion
Can see air bronchodgram
What can cause whiteout of lung ( complete opacification of one hemithorax) and how to differentiate these causes
- pneumonectomy, huge pleural effusion or complete collapse of the lung
- Mediastinum pushed away in pleural effusion, pulled in collapse
Sx and txof cardiac tamponade
- 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
- Due to cardiac fluid surrounding the heart
-Tx is pericardial window (surgery)to evacuate fluid from heart
what is the safe triangle for chest drain
oirders are Pec major, latissimus dorsi and 5th ICS ( nipple)
