Case 17- Lung Cancer Flashcards
Lung cancer differentials
Metastatic cancer, pneumonia, pulmonary TB, sarcoidosis, IPF, COPD
Small cell lung cancer
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)
Non small cell lung cancer
85% total cancers
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma
Small amount suitable for surgery (mediastinoscopy prior to surgery)
Adenocarcinoma
Most common cancer type
Most common cancer in non smokers
Mutations- EGFR, ALK, KRAS
Distant metastasis common
Paraneoplastic syndromes;
-Gynaecomastia
-HPOA
Squamous cell carcinoma
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.)
Large cell carcinoma
Late metastasis
Poor prognosis
Alveolar cell cancer
Lots of sputum
Pan coast tumour
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
Extra pulmonary manifestations of lung cancer
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
Suspected lung cancer management
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)
Asbestosis Sx
Dyspnoea on exertion, cough (dry and non productive), crackles, clubbing
Mesothelioma Sx
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
Suspected Mesothelioma Management
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
Contraindications to chest drain
INR >1.3
Platelet count <75
Pulmonary bullae
Pleural adhesions
Re expansion pulmonary oedema
Cough and dyspnoea after drain insertion
Due to losing too much fluid at once (no more than 1L over 6 hours)
Cardiac causes of clubbing
Cyanotic congenital heart disease
Bacterial endocarditis
Atrial myxoma
Respiratory causes of clubbing
Lung cancer
CF, bronchiectasis, empyema
TB
Mesothelioma, asbestosis
IPF
Other causes of clubbing
CD UC
Liver cirrhosis
Investigations for coal workers pneumoconiosis
CXR- upper zone fibrosis
Spirometry- restrictive lung function tests
Features of lung cancer
Persistent cough
Haemoptysis
Dyspnoea
Chest pain
Weight loss anorexia
Hoarseness
SVC syndrome
Lung cancer examination findings
Monophonic wheeze
Supraclavicular or cervical lymphadenopathy
Clubbing
Anorexia
FBC in lung cancer
Thrombocytosis
Contraindications for lung cancer resection
General health
Metastases present
FEV1 <1.5
Malignant pleural effusion
Tumour near hilum
Vocal cord paralysis
SVC obstruction
Features of HPOA
Inflammation of bones and joints in wrists and ankles (swollen, painful, difficult to move)
Clubbing
Periostitis- will see thickened bone margins in long bones
Lambert Eaton syndrome
Myasthenia syndrome associated with SCLC (can also occur independently as an autoimmune disorder (voltage gated calcium channels/ increased strength after repetition))
Features of LE syndrome
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
Management of LE syndrome
Test underlying cancer
Immunosuppression (Prednisolone or azathioprine)
IV immunoglobulin and plasma exchange
Asbestosos and lung disease
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
