Clinical Aspects of Bronchial Carcinoma

Question 1

Characteristics of cancer?

Answer 1

Key is uncontrolled growth of tumour cells (malignant growth)
Local invasion
Metastasis - secondary cancer:
Lymphatic spread
Blood stream
Serous cavities
Non-metastatic systemic effects (paraneoplastic features)

Question 2

Describe paraneoplastic features of a cancer

Answer 2

Systemic effects from biologically active molecules released from tumour cells

Can mimic effects of naturally occurring hormones

Question 3

Describe incidence, prevalence and importance of lung cancer

Answer 3

Incidence - high

Prevalence - low, as patients fo not live long. 50% will not be alive 6 months after diagnosis

Question 4

Reasons for poor prognosis of lung cancer?

Answer 4

Tends to not cause any symptoms until disease has become too advanced for any hope of cure

Question 5

Lung cancer as a presenting complaint?

Answer 5

Symptoms due to:
Primary tumour
Local invasion
Metastases
Non-metastatic (paraneoplastic)

Question 6

Why is haemoptysis a symptoms of lung cancer?

Answer 6

Inflamed mucosa; fresh haemorrhaging can occur from tumour which is ulcerating through the endothelial surface

In other words, the haemoptysis is a direct consequence of the primary tumour

Question 7

Why is recurrent pneumonia a potential symptom of lung cancer?

Answer 7

Primary tumour can cause obstruction of an airway; thus, airway cannot be cleaned and this would be a common site for re-infection

Question 8

Which lung is normally the diseased one on a chest X-ray and why?

Answer 8

Usually, the smaller lung
When a lobe becomes obstructed, all air beyond the obstruction is absorbed and lung tissue shrinks down to a much smaller size

Question 9

Stridor as a symptom of lung cancer and how it can be used to rule out other conditions?

Answer 9

Difficulty breathing in (likened to having a rope around neck); usually accompanied by a coarse audible wheeze on inspiration (obstruction of main airways)
Asthma & COPD produce an expiratory wheeze and symptoms of difficulty breathing out

Question 10

Why are CT scans important in diagnosis of lung cancer?

Answer 10

Tumours outwith the, e.g: carina, cannot be sampled via biopsy

Question 11

Why is hoarseness a symptom of lung cancer?

Answer 11

Due to RECURRENT LARYNGEAL NERVE PALSY

In other words, primary tumour had invaded the recurrent laryngeal nerve

Question 12

Local invasion sites of a primary lung tumour and explain resulting symptoms?

Answer 12

Pericardium - can cause breathlessness, atrial fibrillation and pericardial effusion (fluid around heart - could result in cardiac tamponade)

Oesophagus - can cause dysphagia (trouble swallowing); dysphagia of solids is often a pointer to tumour

Brachial plexus - can cause neurological symptoms, like weakness (surprisingly, most of these patients do not develop chest wall pain)

Pleural space - can generate large volumes of pleural fluid, causing breathlessness

Superior vena cava - obstructs drainage of blood from arms and head ; often causes distension of superficial veins in the neck (normal pulsation is lost), puffy eyelids, headaches, plethoric face, etc; can also cause distension of veins on the abdomen and thorax (blood flow is bypassing the obstructed SVC by opening up ANASTAMOSES with the IVC tributaries)

Question 13

How is SVC obstruction (due to a primary tumour) treated?

Answer 13

Insertion of a stent to open occluded vein (must be done before the vein is permanently occluded by thrombosis)

Question 14

Describe chest wall invasion by a primary tumour

Answer 14

Can grow through intercostal spaces
Clinical presentation is localised chest wall pain (worse with movement; if there is bone erosion, it can cause pain which is worse at night

Question 15

If a tumour encases a pulmonary artery, what are the likely symptoms?

Answer 15

Could cause breathlessness and symptoms much like a pulmonary embolism

Sometimes, tumour can erode into the artery and into a major bronchus (can cause sudden death due to massive haemoptysis)

Question 16

Common sites for lung cancer metastases?

Answer 16

Liver
Brain
Bone - any bone potentially
Adrenal glands
Skin
Lung

Question 17

Clinical presentation of cerebral metastases?

Answer 17

INSIDIOUS (GRADUAL) ONSET:
Weakness
Visual disturbances
Headaches - due to raised intracranial pressure (worse in the morning, when bending down - due to pressure - and not photophobic)
Seizures/fits - if metastases involves the cortex

Question 18

Differentiation of cerebral metastases from stroke?

Answer 18

Weakness may mimic a stroke but onset in cerebral metastases can be gradual, whereas a classical stroke can develop in minutes

Question 19

Describe a contrast enhanced CT scan

Answer 19

Masses can appear as “ring enhanced” - inject contrast into the venous system

Question 20

How can symptoms of cerebral metastases be relieved?

Answer 20

High dose corticosteroid therapy, e.g: Dexamethasone, can improve symptoms in short-term by removing all oedema
However, benefit is short-lived and, within a few weeks, symptoms will return

Question 21

Describe liver metastases

Answer 21

On a CT scan, are the dark regions; in rare cases, a metastasis can obstruct the biliary drainage and present as obstructive jaundice

Live functions tests are usually ABNORMAL, particularly alkaline phosphatase; sometimes liver function tests can be normal

Question 22

Describe bone metastases

Answer 22

Common presentations are:
Localised pain which is worse at night
Pathological fracture - bone can fracture following a trivial mechanical stress

Question 23

Tests for bone metastases?

Answer 23

Isotope bone scan

Question 24

Non-metastatic (paraneoplastic) symptoms?

Answer 24

NOT INDICATIVE OF METASTATIC DISEASE (result of biochemically active products released from the primary tumour):
Finger clubbing
Hypertrophic pulmonary osteoarthropathy (HPOA) - (NOT DUE TO METASTATIC DISEASE) symptoms of pain and tenderness of long bones, near adjacent joints, is due to elevation of periosteum away from bone surface; bone scan shows increased activity, particularly in distal part of tibia and fibula
Weight loss (cachexia) - common feature of many cancers; due to metabolic activity of tumour
Thrombophlebitis - common manifestation of many cancers and is inflammation of veins (due to increased coagulability of blood in cancer patients)
Hypercalcaemia - tumour producing a substance that mimics para-thyroid hormone (PTH); causes headaches, confusion, thirst and constipation
Hyponatraemia - production of substance that mimics ADH (SIADH); confusion is main symptoms (plasma Na often less that 120 in this setting)
Weakness - Eaton Lambert syndrome (mimics myaesthenia gravis - abnormal weakness of certain muscles); resolves if primary tumour is resected

Question 25

Causes of finger clubbing?

Answer 25

LUNG CANCER IS ONE COMMON CAUSE (look out for tar staining)
Liver disease, particularly chronic hepatitis C
Congenital cyanotic heart disease
Bacterial endocarditis
Bronchiectastis (abnormal widening of bronchi/their branches

Some cases are congenital and of no significance

Question 26

Asking about productive cough in a history?

Answer 26

Almost all smokers cough up some clear sputum every morning (chronic bronchitis); cough signalling lung cancer is different (sensation which triggers close to cough is distortion of normal brochial mucosa by tumour); patient will tell you they try to cough up but nothing comes

Question 27

Asking about heamoptysis in a history?

Answer 27

Many are so frightened by this symptom and its implications that they will not mention it - think the doctor will only ask if it is relevant.
MUST ask all patients “Have you coughed up any blood ?”

Question 28

Asking about smoking in a history?

Answer 28

Many patients try to separate their smoking history from the clinical picture. If a patient says they do not smoke, ask “Have you ever smoked ?” or “When did you give up ?”

Question 29

Taking a history in lung cancer; things to consider?

Answer 29

Do they smoke/have they?
Cough
Haemoptysis
Breathlessness
Weight loss
Chest wall pain
Fatigue
Recurrent infection
Other smoking-related disease
"Is there anything you are worried about?"

Question 30

Doing an examination in lung cancer; things to consider?

Answer 30

Finger clubbing
Breathlessness
Cough
Weight loss
Bloated face
Hoarse voice
Lymphadenopathy
Tracheal deviation
Dull percussion
Stridor
Enlarged liver

Question 31

Investigation in lung cancer?

Answer 31

Full blood count
Coagulation screen
Na, K, Ca, Alk Phosphatase
Spirometry, FEV1, etc - useful in finding out health of lungs, not for finding lung cancer really
Chest X-ray
CT scan of thorax
PET scan
Bronchoscopy
Endobronchial ultrasound (EBUS)
NOT sputum cytology - results rarely influence management

Question 32

Common methods of making a tissue diagnosis of lung cancer?

Answer 32

Bronchoscopy
CT guided biopsy
Lymph node aspirate
Aspiration of pleural fluid

Question 33

Describe video bronchoscopy

Answer 33

Tip of bronchoscope can be flexed more than 90 degress (tip has two light sources, a camera and a suction channel)

Under local anaesthetic, with intravenous sedation, flexible bronchoscope is passed through nose and inspects the central part of the bronchial tree; biopsies & brush cytology often yield a diagnosis.

Useless for investigating possible tumours out in periphery of the lungs, as cannot inspect bronchial divisions which are smaller than the diameter of the bronchoscope

Question 34

Describe CT guided biopsy

Answer 34

Has a risk of pneumothorax, so patients with a very poor FEV1 would not have this done

Question 35

Describe endobronchial ultrasound

Answer 35

Bronchoscope with ultrasound tip that enables visualisation of hilar and mediastinal structures
Can target and sample lymph nodes

Question 36

Describe Positron Emission Tomography (PET)

Answer 36

Scan to assess function rather than structure
Involves analysis of tissue uptake of radiolabelled glucose; tissues with high metabolic activity appear bright (such as brain, bladder - due to glucose excretion - and TUMOURS)

Question 37

Differential diagnosis of a smoker with haemoptysis and a normal chest X-ray?

Answer 37

Lung cancer
Tuberculosis
Vasculitis
Pulmonary embolism
Secondary cancer
Lymphoma
Bronchiectasis