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year 4 CDM 2 > Case 17: lung, mets, MM > Flashcards

Case 17: lung, mets, MM Flashcards

1
Q

Lung cancer risk factors

A
  • Smoking even passive, this risk is proportional to pack years
  • Age: 60-70, male
  • Radiation exposure
  • Chemicals: asbestos, acetaldehyde, beryllium, arsenic, nickle, chromium, formaldehyde
  • Air pollution
  • Family history
  • HIV
  • Beta carotene supplements in heavy smokers
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2
Q

Lung cancer symptoms

A
  • Shortness of breath
  • Cough
  • Haemoptysis(coughing up blood)
  • Finger clubbing
  • Wheeze or stridor
  • Recurrent pneumonia
  • Weight loss, malaise and lethargy
  • Hoarseness (invasion of recurrent laryngeal nerve) and dysphagia (compression)
  • Lymphadenopathy - supraclavicular then axillary
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3
Q

Lung cancer examination

A
  • Reduced expansion on affected side
  • Diminished breath sounds
  • hepatomegaly
  • Clubbing: in NSCLC
  • Hands: nicotine staining, clubbing
  • Neck: lymphadenopathy
  • Chest: signs of pulmonary collapse, pleural effusion or consolidation
  • Superior vena caval obstruction
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4
Q

Paraneoplastic syndrome

A
  • Hypercalcaemia: Often due to production of parathyroid hormone-related peptide (PTHrP).
  • Cushing’s syndrome: Due to ectopic adrenocorticotropic hormone (ACTH) production.
  • SIADH (Syndrome of Inappropriate Antidiuretic Hormone secretion): Leading tohyponatraemia
  • Lambert-Eaton myasthenic syndrome (LEMS): A neuromuscular disorder caused by antibodies directed against voltage-gated calcium channels in the presynaptic nerve terminals. Muscles weakness, bilateral ptosis and autonomic symptoms
  • Clubbing
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5
Q

Paraneoplastic syndrome in NSCLC

A

Hypertrophic pulmonary osteoarthropathy - presents with clubbing and arthralgia (esp wrists and ankles)

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6
Q

What lymph nodes may be affected by lung cancer

A
  • Initially: ipsilateral peribronchial, ipsilateral hilar nodes
  • Later: mediastinal nodes, contralateral hilar nodes, supraclavicular nodes
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7
Q

Pancoasts tumour

A
  • Cancer in the top of the lung - usually non small cell
  • Chest wall pain
  • Horner’s syndrome: miosis, anhydrosis, partial ptosis and enophthalmos
  • Pain in T1 dermatomal distribution due to apical tumour invading chest wall, interrupting sympathetic chain and invading T1 nerve root
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8
Q

Lung cancer investigations (not imaging)

A

bedside: full set of obs, sputum culture, pulmonary function tests (spirometry)

bloods:
- FBC to look for anaemia and raised platelets
- U+Es
- LFTs to look for liver mets
- LDH may be raised in SCLC
- calcium may be raised in squamous NSCLC

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9
Q

Lung cancer imaging

A
  • CXR
  • contrast enhanced CT chest abdo pelvis for staging
  • PET CT for metastases
  • bronchoscopy with endobronchial ultrasound- take biopsy
  • Transthoracic biopsy (CT guided)
  • Fine Needle aspiration (FNA) of affected lymph node
  • Fluid cytology from a pleural effusion if present
  • Plain bone x-ray and bone scans to exclude metastasis
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10
Q

Lung cancer special tests

A
  • sputum and pleural effusion cytology
  • biopsy via bronchoscopy, needle or surgery
  • lung function tests
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11
Q

Imaging in different types of lung cancer

A
  • SCLC: imaging of upper abdomen as cancer can spread to the liver and adrenal glands
  • NSCLC considered for radical treatment: Pulmonary function tests, Contrast CT TAP, V/Q scan, US, mediastinoscopy, laryngoscopy, PET-CT
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12
Q

Molecular features of lung cancer

A
  • Adenocarcinomas can have specific mutations in: EGFR, MAPK and PI3K signalling pathways. Can determine treatment
  • Adenocarcinomas: EGFR and ALK mutations develop in non-smokers, KRAS and BRAF mutations are more associated with smokers
  • NSCLC: Translocation of ALK and EML4
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13
Q

Lung cancer: features associated with adverse features

A
  • Large tumor size (>3 cm)
  • Nonsquamous histology
  • Metastases to multiple lymph nodes
  • Brain metastasis
  • Age
  • Vascular invasion
  • Poor performance status and weight loss >10%
  • Increased LDH
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14
Q

Management of lung cancer

A
  • conservative:- smoking cessation
  • medical:- radiotherapy for stages 1-3- chemotherapy as adjunct to surgery/ radiotherapy
  • surgical:- lobectomy (1st line for stages 1-2)
  • Advanced disease: Systemic therapy with tyrosine kinase inhibitors or immunotherapy
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15
Q

Extrapulmonary manifestations of lung cancer

A
  • Small cell lung cancer: can cause paraneoplastic syndrome
  • RLN palsy: hoarse voice due to a tumour pressing on the nerve
  • Phrenic nerve palsy: diaphragm weakness causing SOB
  • Horner’s syndromeis a triad of partial ptosis, anhidrosis and miosis. It can be caused by aPancoast tumour(tumour in thepulmonary apex) pressing on thesympathetic ganglion.
  • Syndrome of inappropriate ADH(SIADH) can be caused byectopic ADHsecreted by asmall cell lung cancer. It presents withhyponatraemia.
  • Cushing’s syndromecan be caused byectopic ACTHsecretion by asmall cell lung cancer.
  • Hypercalcaemiacan be caused byectopic parathyroid hormonesecreted by asquamous cell carcinoma.
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16
Q

Lung cancer: compressive and obstructive symptoms

A
  • Compressive symptoms: dysphagia due to oesophageal compression. Hoarseness due to recurrent laryngeal nerve compression
  • Local invasion: pleural effusion, SVC obstruction
  • SVC obstruction: bulging veins on forehead, papilloedema, Pemberton sign
  • Pemberton’s sign: worsening of SOB/ facial congestion/cyanosis when raising arms until they touchside of face (seen in SVC obstruction)
  • Metastatic: liver, bone, brain, adrenal gland
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17
Q

Lambert-Eaton Myasthenic syndrome

A
  • Caused by antibodies produced by the immune system against small cell lung cancer cells
  • Causes weakness in proximal muscles, diplopia, ptosis, slurred speech and dysphagia
  • Autonomic dysfunction: dry mouth, blurred visi
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18
Q

Referral criteria for lung cancer (2 week wait): patients over 40 with

A
  • Clubbing
  • Lymphadenopathy(supraclavicularor persistent abnormal cervical nodes)
  • Recurrent or persistent chest infections
  • Raised platelet count (thrombocytosis)
  • Chest signs of lung cancer
  • Consider a CXR in patients >40 who have two or more unexplained symptoms in patients that have never smoked or one or more unexplained symptoms in patient that have smoked
  • Unexplained symptoms: cough, SOB, fatigue, chest pain, weight loss, loss of appetitie
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19
Q

Investigations for lung cancer

A
  • CXR: first line, show hilar enlargement, peripheral opacity, pleural effusion and collapse
  • Staging CT of chest, abdomen and pelvis: assesses stage, lymph node involvement and metastasis
  • PET-CT
  • Bronchoscopy with endobronchial ultrasound (EBUS): detailed assessment of tumour and US guided biopsy
  • Histological diagnosis: either bronchoscopy or percutaneous biopsy
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20
Q

Treatment options: NSLC

A
  • MDT meeting discussion
  • Surgery: first line in stages 1,2 and 3A, followed by adjuvant chemo. Remove primary tumour and regional lymph nodes
  • Radiotherapy: Stages I-III not suitable for surgery aiming for cure. Use high dose CHART or cure.
  • Chemotherapy: in addition to surgery or radiotherapy (adjuvant chemotherapy). Used in stage III-IV (palliative). Uses either carboplatin or cisplatin with gemcitabine or vinorelbine
  • Endobronchial treatment with stents and debulking: palliative in bronchial obstruction
  • Brain metastasis: steroids
  • SVC obstruction: stent insertion or radiotherapy
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21
Q

Treatment options for SCLC

A
  • Surgery: only considered in stage I-II
  • Majority treatment with chemotherapy and radiotherapy
  • In relapses SCLC consider further chemotherapy or palliative radiotherapy
  • Systemic chemotherapy includes etoposide combines with carboplatin or cisplatin: 3 weekly intervals for 4-6 cycles
  • Poor prognosis: survival is 14 months
22
Q

Lung cancer: molecular targeted therapy

A
  • EGFR tyrosine kinase inhibitors (gefitinib, erlotinib) can be offered to patients with EGFR mutations.
  • Translocation of ALK and EML4 respond to crizotinib
  • Fusions involving the ROS1 gene respond to treatment with crizotinib and entrectinib
  • NTRK gene fusion: treated with TRK inhibitors, larotrctinib and entrectinib
23
Q

Lung cancer surgery

A
  • Segmentectomyorwedge resectioninvolves taking a segment or wedge of lung (a portion of one lobe)
  • Lobectomyinvolves removing the entire lung lobe containing the tumour (the most common method)
  • Pneumonectomyinvolves removing an entire lung
  • A chest drain is left in after thoracic surgery: allows air and fluid to exit and the lungs to expand
24
Q

Palliative care for lung cancer

A
  • Palliative radiotherapy for symptom control
  • Endobronchial stenting or debulking for bronchial obstruction
  • Pleural drainage or aspiration for pleural effusion
  • Dexamethasone therapy for those with symptomatic brain metastasis
  • Opioid therapy to relievecough and breathlessness
25
Q

Disease related complications in NSCLC

A
  • Local invasion: SVC obstruction, pleural effusion
  • Distant metastasis: brain, liver, bone
  • Non-metastatic: Hypercalcaemia, Cushing’s syndrome, SIAD, Neurological syndrome
26
Q

SVC obstruction

A
  • Obstruction of blood flow through the SVC
  • Caused by compression, invasion, or thrombosis in the superior mediastinum
  • Symptoms are increased by bending forward, stooping, or by lying down
  • Treatment is at the underlying cause (mostly lung cancer)
  • Initial management: Dexamethasone
  • Symptoms: Dyspnoea, facial swelling, head fullness, venous distension of neck, facial oedema, cyanosis, cough
  • X-ray: superior mediastinal widening, pleural effusion, right hilar mass, bilateral diffuse infiltrates
27
Q

Malignant melanoma

A

skin cancer arising from the melanocytes which are responsible for producing melanin

28
Q

Risk factors for malignant melanoma

A
  • Family history or prior personal history of melanoma
  • Genetic syndromes, such as Familial Atypical Multiple Mole Melanoma Syndrome
  • Skin type prone to burning and not tanning (Fitzpatrick type I or II)
  • Immunosuppression
  • High levels of sun or UV exposure
  • Presence of atypical melanocytic naevi or multiple moles
  • Smoking
  • Advanced age and male sex
29
Q

Types of malignant melanoma

A
  • Superficial spreading
  • Nodular
  • Lentigo maligna
  • Acral Lentiginous
30
Q

Malignant melanoma- superficial spreading

A
  • 70% of cases
  • Typically affects: arms, legs, back and chest, young people. Long radial phase
  • A growing mole
31
Q

Malignant melanoma: nodular

A
  • Second most common
  • Typically affects: sun exposed skin, middle aged people. Most aggressive type, no radial phase
  • Appearance: red or black lump or lump which bleeds or oozes
32
Q

Malignant melanoma: Lentigo maligna

A
  • Less common
  • Affects: chronically sun exposed skin, older people. Very long radial phase
  • A growing mole
33
Q

Malignant melanoma: acral lentiginous

A
  • Rare form
  • Typically affects: nails, palms or soles. People with darker skin pigmentation. Short radial phase
  • Appearance: Subungal pigmentation (Hutchinson’s sign) or on palms or feet
34
Q

Malignant melanoma ABCDE

A
  • Asymmetry of the lesion
  • Border irregularity
  • Colour variation
  • Diameter >6mm
  • Elevation/evolution over time
35
Q

Clinical features of mole in malignant melanoma

A
  • Major criteria: change in size, change in shape, change in colour
  • Minor features: Diameter ≥7mm, inflammation, oozing or bleeding, altered sensation
  • Can also be itchy
36
Q

Malignant melanoma: investigations

A
  • Excisional biopsy of the lesion with a 2mm margin
  • Sentinel lymph node biopsy if the Breslow thickness is >1mm
  • PET or CT scans may be necessary in the presence of clinical suspicion for metastases
37
Q

malignant melanoma: treatment

A
  • Suspicious lesions: excision biopsy, remove the lesion completely and it undergoes histopathological assessment
  • Lymph node clearance if lymph nodes involved
  • Radiotherapy in some cases
  • Adjuvant Immunotherapy/chemotherapy in metastatic disease (Stage III/IV), such as pembrolizumab (PD-1 blocking drug)
  • Mole-mapping and lifestyle advice to prevent recurrence in those at risk
38
Q

Breslow thickness

A

determined histologically, most important prognostic indicator. Measured in mm from top of granular layer in the epidermis to the deepest point the tumour extends

39
Q

Malignant melanoma: excision clearance

A
  • Excision with a 2mm margin
  • Melanoma in situ: 5 – 10 mm
  • Melanoma < 1 mm: 10 mm
  • Melanoma 1–2 mm: 10 – 20 mm
  • Melanoma > 2 mm: 20 mm
40
Q

Brain metastasis: origins and symptoms

A
  • Origins (in order of likelihood): Lung, Breast, CUP, Melanoma, GI
  • Presenting features: Headache, Cognitive dysfunction, Neurological deficit, Seizures
41
Q

Treatment for brain metastasis

A
  • Dexamethasone IV: decreases oedema
  • Anticonvulsant IV or PO: of the patient needs, normally Phenytoin
  • Surgery: only if solitary met
  • Radiotherapy: palliative
  • Chemotherapy: little role as cant pass blood-brain barrier
42
Q

Bone metastasis

A
  • Most common tumours causing bone metastases (in descending order: breast, prostate, lung
  • Most common site (in descending order): spine, pelvis, ribs, skull, long bones
  • Features: bone pain, pathological fractures, hypercalcaemia, raised ALP
  • X-ray: sclerotic appearance
43
Q

Lung metastasis

A
  • Seen in breast, colorectal, renal cell, bladder, prostate
  • Multiple, round well-defined lung secondaries are often referred to as ‘cannonball metastases’. They are most commonly seen withrenal cell cancerbut may also occur secondary to choriocarcinoma and prostate cancer.
  • Calcification in lung metastases is uncommonexcept in the case of chondrosarcoma or osteosarcoma.
44
Q

Spinal metastasis

A
  • Can develop into metastatic spinal cord compression
  • Symptoms and findings: unrelenting lumbar back pack pain, any thoracic or cervical back pain. Worse with sneezing, coughing or straining. Nocturnal, associated with tenderness
  • If neurological features suspect spinal cord compression and act quickly
  • Without neuro symptoms a whole spine MRI within one week
45
Q

Carcinoid syndrome

A
  • Paraneoplastic syndrome due to neuroendocrine tumour
  • Investigations of carcinoid syndrome: urinary 5-HIAA (as tumour secretes serotonin)
  • Presents: flushing, diarrhoea, flushing, bronchospasm, hypotension, weight loss

Management of VTE in cancer: 6 months of DOAC

46
Q

Oesophageal cancer

A
  • Malignant neoplasm in the oesophagus
  • Poor prognosis due to late presentation and aggressive behaviour
  • Two main histological subtypes: squamous cell carcinoma and adenocarcinoma
47
Q

Risk factors for oesophageal cancer

A
  • Age, male, obesity, high fat diet, smoking, alcohol, GORD, Barett’s oesophagus, achalasia and strictures
  • H.pylori infection may reduce the risk
48
Q

Oesophageal cancer: adenocarcinoma

A
  • Most common type in the UK
  • In the lower third of the oesophagus: near the gastro-oesophageal junction
  • Risk factors: GORD, Barrett’s oesophagus, smoking, obesity
49
Q

Oesophageal cancer: squamous cell cancer

A
  • Most common type in the developing world
  • In the upper 2/3rds of the oesophagus (can occur at any level)
  • Risk factors: smoking, alcohol, achalasia, Plummer-Vinson syndrome, diets rich in nitrosamines, hot drinks
50
Q

Oesophageal cancer: clinical features

A
  • Presents at advanced stage as initially asymptomatic
  • Dysphagia: solids and progressing to liquids, is the most common presenting symptom.
  • Cough when eating can cause aspiration pneumonia (upper 1/3 of oesophagus)
  • Weight loss
  • Odynophagia: Painful swallowing
  • Hoarseness: compression of the recurrent laryngeal nerve. (upper 1/3 of oesophagus)
  • Retrosternal pain or discomfort
  • Regurgitation or vomiting: Obstruction of the oesophagus.

year 4 CDM 2 (39 decks)

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