Approach To Patients With Lung Cancer And Pleural Effusions

Question 1

Cigarette smoking carcinogen facts

Answer 1

90% of Lung cancers are in active smokers

60x greater chance of developing cancer with heavy smoking (2 packs a day for 20yrs)

Women are more susceptible to tobacco smoke carcinogens then men

Passive smoking increases risk of lung cancer and smoking pipes/cigars, just not as much as cigarettes

Linear correlation between frequency of cancer and pack-year cigarette smoking

Question 2

P-450 genes and cancer

Answer 2

Having polymorphisms in the monoxygenase P-450 genes can increase the susceptibility to carcinogens found in cigarette smoke

Question 3

Symptoms seen in carcinomas of the lung that provide an overall poor prognosis

Answer 3

Hoarseness

Chest pain

SUC syndrome

Pericardial/pleural effusion

Persistent segmental atelectasis

Pneumonitis

Also any metastatic spread symptoms (such as hepatomegaly, bone pain or neurologic change )

Question 4

Tumor node metastasis

Answer 4

Used to stage cancer

1) look at the size of the tumor and how deep into the basement membrane it goes into (grade)
2) look to see how many lymph nodes it has reached (stage)
3) does distant metastasis exist?

Question 5

Edema and effusions overview

Answer 5

Edema: accumulation of fluid in interstitial tissues

Effusions: accumulation of fluid in body cavities

Is caused due to an imbalance in the two opposing forces

• vascular hydrostatic pressure (if this goes up causes edema)
• protein colloid osmotic pressure (if this goes down causes edema)

note transudates is a type of edema and effusion that is protein poor and non-inflammatory

Question 6

What diseases are common to see transudates in?

Answer 6

Heart failure

Renal disease

Liver failure

transudate is low protein and few cells, almost all water

Causes are:

• increased hydrostatic pressure
• decreased plasma osmotic pressure e
• increased sodium and water retention
• lymphatic obstruction is present (causes increased hydrostatic pressure indirectly)

Question 7

What is the most common physiological disturbances associated with reduced plasma osmotic pressures?

Answer 7

Inadequate synthesis or loss of albumin levels

Most commonly seen in:

• liver diseases
• nephrotic syndromes
• protein malnutrition

Question 8

Inflammation related effusions and edema

Answer 8

Caused almost always by vascular permeability increased due to inflammation mediators

Shows high protein content and water edema/effusions (compared to transudates)

Question 9

Serious inflammation

Answer 9

Exudate that leads to effusions that are cell-poor, protien high and water high.

Fluid is not infected by destructive organisms and does not contain large number of leukocytes

Is a result of increased vasculature permeability

Question 10

Fibrinous inflammation

Answer 10

Exudate that develops due to increased vascular permeability and/or a local procoagulant stimulus

The exudate contains heavy amounts of fibrin and fibrinogen as well as eosinophils which can cause extracellular fibrosis production

Exclusive to inflammation of the linings of body cavities (pericarditis, pleuritis, meningitis)

Question 11

Purulent inflammation

Answer 11

Exudate that is pus
- contains neutrophils, necrotic cells and edema fluid

Most frequent cause is inflammation due to infections w/ bacteria that causes liquefactive tissue necrosis

Question 12

Pleural euffsions

Answer 12

Usually defined as increased unneeded fluid of serous a cellular clear fluid within the pleural surface

Causes include:

• increased hydrostatic pressure (CHF)
• decreased osmotic pressure (Nephrotic syndrome)
• decreased lymph drainage (mediastinal carinomatosis)
• increased vascular permeability (pneumonia)

Question 13

Hydrothorax

Answer 13

Subtype of pleural effusions that are non inflammatory collections of serous fluid within the pleural cavities

Fluid is clear and star colored (yellow)

Can be unilateral or bilateral

Most common cause is cardiac failure, but can also be seen in renal failure and liver cirrhosis

Question 14

Hemothorax

Answer 14

Subtype of pleural effusions that are non inflammatory collections of blood

Almost always a fatal complication of ruptured aortic aneurysm or vascular trauma

Question 15

Chylothorax

Answer 15

Subtype of pleural effusions that are non inflammatory collections of milky appearing fluid

Contains lymph and emulsified fats

Most common causes are thoracic duct trauma or obstruction

Can also be caused by malignancies

Question 16

Empyema

Answer 16

Localized yellow-green pus composed of mass amounts of neutrophils and leukocytes

Often evolve by themselves but can organize into fibrous adhesions which can ultimately cause restrictive lung diseases

Question 17

Lights criteria for differentiating transudate from exudate

Answer 17

Is an exudate is one or more of the following is met:

• pleural fluid protein levels > (0.5 x serum protein content)
• pleural fluid LDH levels > (0.6 x serum LDH activity)
• pleural fluid LDH levels >2/3 upper reference value for serum