Chest malignancy signs, causes and differentials Flashcards
What non-metastatic (paraneoplastic) manifestations of malignant lung cancer?
(The symptoms that the tumour can have on the body beyond red flag symptoms and the effects of metastases)
Fibrosis:
Finger clubbing
Bone complaints:
Hypertrophic pulmonary osteoarthropathy - pain in knees and elbows
(new bone forming in the periosteum in forearms and lower legs)
Hormone syndromes:
Hyperparathyroidism - hypercalcaemia
(secretion of PTH by an squamous tumour)
Cushing syndrome
(ACTH secretion by the small cell tumour)
Syndrome of inappropriate release of ADH
(SIADH with hyponatremia: classic cause is small cell lung carcinoma)
Neuromyopathies:
Eaton lambert syndrome (NO AcH:a neuromyopathypathy, prevents ACh release at the NMJ)
Myasthenia gravis (INSENSITIVE TO AcH: muscle weakness prevents ACh acting at the NMJ)
Peripheral neuropathy (loss of feeling)
Dementia
Cerebellar syndrome (ataxia, poor coordination)
What are the causes of bronchial carcinoma?
Tobacco smoke - biggest cause 95% (2nd hand smoking increases risk by 25%)
Ionising radiation
Asbestos - construction work
Fibrosing alveolitis
Arsenic
Chloromethyl ethers
Chromium
Nickel
Polyaromatic hydrocarbons
Vinyl chloride
What is the most common primary pleural carcinoma referred to as?
Mesothelioma
Where do secondary lung metastases originate from? (Four organs)
Breast
Kidney
Bladder
Testis
What is the primary cause of mesothelioma?
Asbestos exposure
What are the two basic categories of primary lung cancers?
- small cell lung cancers - 24%
- named because they look like small cells on their histopathology slides, very little cytoplasm and a large nucleus
2 . non-small cell lung cancers - 76%
- squamous carcinoma have a large, flattened cell type on their histopathology slides
How are small cell lung cancers different to non small cell lung cancers?
Small cell cancers are a homogenous group
Non small cell cancers are a mixture: Squamous Adenocarcinoma Large cell Other
What is the most common type of non small cell carcinoma?
Squamous cell carcinoma - 48% of all non small cell
Adenocarcinoma is 2nd most common - 13%
(Large cell is the 3rd most common - 10%)
What are the signs of bronchial cancer?
Facial swelling
Cough
Haemoptysis
Chest pain
Dyspnoea
Stridor - due to narrowing of the airways
Hoarseness - tumour invading the mediastinum left side can damage the left recurrent laryngeal nerve
Weight loss
On examination:
Finger clubbing
Lymphadenopathy - enlarged lymph nodes
Chest movement asymmetry
Consolidation
Fluid - effusion
Hepatomegaly - metastases
Neuropathy - non metastatic presentations
What is pancoast syndrome?
A supraclavicular fossa that is filled in, a tumour arising at the apex of the lung growing upwards.
This will grow in to the brachial plexus, causing:
- Pain radiating down inner arm
- Horner’s syndrome; pupil on that side will be smaller, and may have ptosis and a dry eye - sympathetic innervation to the eye comes from T1 and reaches brachial plexus before travelling up carotid artery to eye.
What is the possible presentation of a lung cancer growing in the mediastinum?
Superior vena caval obstruction:
compromises venous return from head, upper mediastinum and arms
Presents with:
- Facial and hand swellings; episodic and then constant
- Headaches
What are the neurological signs of lung cancer metastasis?
Focal/general neurological signs: Dysphagia Dysphonia Dysphasia Visual field defects Hemiparesis Decreased GCS Respiratory depression Muscle weakness
Causes:
Cerebral haemorrhage - raised ICP
Metastasis
What are the differentials for suspected bronchial carcinoma?
i.e will also cause shadowing on the lung in a cxr
TB
Pneumonia
Lung metastases from other primary
Benign lung tumor
Rare conditions like wegener’s granulomatosis
One of the paraneoplastic syndromes in lung cancer is hyperparathyroidism:
What are the signs of hypercalcaemia?
Bones, stones, groans and moans:
Bone pain
Renal stones
Abdominal groans
Psychiatric moans
What is the life expectancy of small cell lung cancer without treatment?
6 weeks
Chemotherapy generally only increases this to 12 weeks
Small-cell carcinoma is normally palliative (only 1-2% is curative)
Lung cells change in the progression to lung cancer, when are they called carcinoma in situ?
This is the stage before cancer, when the cells have severe dysplasia.
Normal cells -> Hyperplasia -> Mild dysplasia
- > Severe dysplasia (carcinoma in situ)
- > Cancer; invasive, breaks through basement membrane
How does non small cell carcinoma cause hypercalcaemia?
The tumour begins to produce and release parathyroid-related protein which acts like PTH, which acts on the kidney, gut and bones
Common causes: Squamous cell lung cancer Breast cancer Multiple myeloma Cholangiocarcinoma
What is asbestosis?
A chronic lung condition associated with lung fibrosis caused by chronic exposure to asbestos.
MOA =
1.Asbestos fibres deposit at alveolar duct bifurcations and cause macrophage-driven inflammation, with release of IL-beta and TNF
- The fibres are cleared via the lymphatic drainage and pleural cavities. However the fibres have initiated the tissue immune response and this cause fibrosis .
- Thickening and fibrosis of the visceral pleura occurs in a dose dependant manner, this leads to fusion with the parietal pleura.
(Not the same as mesothelioma or benign plaques caused by asbestos, mesothelioma isn’t dose-dependant)
What are the signs and symptoms of asbestosis?
Exertional dyspnoea
Cough
Wheeze
Chest pain
Basal crackles
Clubbing - only advanced cases
A NON-SPECIFIC INSIDIOUS PRESENTATION
What is mesothelioma?
An aggressive tumour of the mesothelial cells that most often (90%) occurs in the pleura, it has a poor prognosis.
Latency period can be to 45 years
What are the signs and symptoms of mesothelioma?
Chest pain
Dyspnoea
Weight loss
Finger clubbing
Recurrent pleural effusions
Signs of metastases: Lymphadenopathy Hepatomegaly Bone pains Abdominal pain and obstruction
