Case 17- Lung Cancer

Question 1

Lung cancer differentials

Answer 1

Metastatic cancer, pneumonia, pulmonary TB, sarcoidosis, IPF, COPD

Question 2

Small cell lung cancer

Answer 2

Central location
Rapid tumour growth
Earl metastasis
Strongly liked to smoking
Mutation- 1-myc

Paraneoplastic syndromes;
-ADH (SIADH- hyponatraemia)
-ACTH (cushings- potentially bilateral adrenal hyperplasia (ACTH encourages growth))
-Lamert Eaton syndrome

Small cell- the A’s (small A)

Question 3

Non small cell lung cancer

Answer 3

85% total cancers

Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma

Small amount suitable for surgery (mediastinoscopy prior to surgery)

Question 4

Adenocarcinoma

Answer 4

Most common cancer type
Most common cancer in non smokers
Mutations- EGFR, ALK, KRAS
Distant metastasis common

Paraneoplastic syndromes;

-Gynaecomastia
-HPOA

Question 5

Squamous cell carcinoma

Answer 5

Central
Strong association with smoking
Direct spread to hilar lymph nodes
Associated with cavitating lesions

Paraneoplastic syndromes;
-PTHrP (PTH related protein) leads to hypercalacemia
-HPOA
-TSH (hyperthyroidism)
-Clubbing

Squamous=squashy (does all the weird things eg. PTHrP/TSH/HPOA etc.)

Question 6

Large cell carcinoma

Answer 6

Late metastasis
Poor prognosis

Question 7

Alveolar cell cancer

Answer 7

Lots of sputum

Question 8

Pan coast tumour

Answer 8

Predominantly NSCLC
Severe localised pain in axilla/ shoulder
Horner syndrome
Atrophy of arm/ hand muscles
Hoarseness (presses on recurrent laryngeal nerve)
Oedema of arm, facial swelling and morning headaches

Question 9

Extra pulmonary manifestations of lung cancer

Answer 9

Recurrent laryngeal nerve palsy- hoarse voice

Phrenic nerve palsy- raised hemidiaphragm on CXR

SVC obstruction- facial swelling, distended veins, Pembertons sign

Horner syndrome- pancoast tumour. Partial ptosis, anhidrosis, miosis

SIADH- ectopic ADH secretion (small cell)

Cushing’s syndrome- ectopic ACTH (small cell)

Hypercalcaemia- ectopic PTHrP (squamous cell)

Limbic encephalitis- small cell

Lambert-Eaton Myasthenic Syndrome- small cell

Question 10

Suspected lung cancer management

Answer 10

Get patient on 2 week wait pathway for a CXR and bronchoscopy with biopsy
Sputum/ throat culture (rule out infection)
Bloods- FBC (infection, thrombocytosis), UE (contrast), LFT (metastasis), culture (infection), bone profile (metastasis or PTH release)
PFT- baseline pulmonary function. Suitable for a pneumectomy or lobectomy
Staging scan- contrast enhanced CT chest, abdomen, pelvis or PET

Involve cardiothoracic surgeons early- may require palliative care involvement (early too)

Question 11

Asbestosis Sx

Answer 11

Dyspnoea on exertion, cough (dry and non productive), crackles, clubbing

Question 12

Mesothelioma Sx

Answer 12

Dyspnoea and non pleuritic chest pain
Fever, sweats, weight loss, fatigue
Painless Pleural effusion (signs and symptoms one would expect)

NB- only 20% have pre existing asbestosis

Question 13

Suspected Mesothelioma Management

Answer 13

2 week wait for CXR
FBC- anaemia (SOB), UE (contrast)
PFT- can be restrictive or obstructive picture
CT thorax
Bronchoalveolar lavage- microscopic asbestos bodies
Diagnosis is made with thoracoscopy with histology

Tell them they may be eligible for industrial compensation

Question 14

Contraindications to chest drain

Answer 14

INR >1.3
Platelet count <75
Pulmonary bullae
Pleural adhesions

Question 15

Re expansion pulmonary oedema

Answer 15

Cough and dyspnoea after drain insertion
Due to losing too much fluid at once (no more than 1L over 6 hours)

Question 16

Cardiac causes of clubbing

Answer 16

Cyanotic congenital heart disease
Bacterial endocarditis
Atrial myxoma

Question 17

Respiratory causes of clubbing

Answer 17

Lung cancer
CF, bronchiectasis, empyema
TB
Mesothelioma, asbestosis
IPF

Question 18

Other causes of clubbing

Answer 18

CD UC
Liver cirrhosis

Question 19

Investigations for coal workers pneumoconiosis

Answer 19

CXR- upper zone fibrosis
Spirometry- restrictive lung function tests

Question 20

Features of lung cancer

Answer 20

Persistent cough
Haemoptysis
Dyspnoea
Chest pain
Weight loss anorexia
Hoarseness
SVC syndrome

Question 21

Lung cancer examination findings

Answer 21

Monophonic wheeze
Supraclavicular or cervical lymphadenopathy
Clubbing
Anorexia

Question 22

FBC in lung cancer

Answer 22

Thrombocytosis

Question 23

Contraindications for lung cancer resection

Answer 23

General health
Metastases present
FEV1 <1.5
Malignant pleural effusion
Tumour near hilum
Vocal cord paralysis
SVC obstruction

Question 24

Features of HPOA

Answer 24

Inflammation of bones and joints in wrists and ankles (swollen, painful, difficult to move)
Clubbing
Periostitis- will see thickened bone margins in long bones

Question 25

Lambert Eaton syndrome

Answer 25

Myasthenia syndrome associated with SCLC (can also occur independently as an autoimmune disorder (voltage gated calcium channels/ increased strength after repetition))

Question 26

Features of LE syndrome

Answer 26

Repeated muscle contraction leads to increased muscle strength (in contrast to MG)
Limb girdle weakness (lower limbs first)
Hyporeflexia
Autonomic Sx- dry mouth, impotence, difficult micturition

NB- ophthalmoplegia and ptosis not a common feature (as in MG)

EMG- incremental response to repetitive electrical stimulation

Question 27

Management of LE syndrome

Answer 27

Test underlying cancer
Immunosuppression (Prednisolone or azathioprine)
IV immunoglobulin and plasma exchange

Question 28

Asbestosos and lung disease

Answer 28

Asbestosis is caused by inhaling asbestos, but pleural plaques are most common (benign and don’t change)
Bronchogenic carcinoma (adenocarcinoma) is the most common malignancy caused by asbestosis, then mesothelioma