Clinical Aspects of Bronchial Carcinoma Flashcards
What are the general features of cancer? (5)
- Malignant growth
- Uncontrolled replication
- Local invasion
- Metastasis
- Non-metastatic systemic side effects (mimic effects of hormones - paraneoplastic features)
What are 3 ways cancer can metastasise?
- Lymphatic spread
- Blood stream
- Serous cavities e.g. via peritoneum
What are paraneoplastic features?
Molecules released from tumour can mimic the effects of naturally-occurring hormones
How many cases of lung cancer are diagnose in the UK
i) Annually?
ii) Daily?
- 45,000 new cases per year
* 120 new cases every day
Why is 90% of lung cancer incurable at the time of diagnosis?
Tends not to cause any symptoms until the disease has become too advanced
Why is lung cancer significant in Scotland?
- Most common cause of cancer death in men and women in Scotland
- Rates of lung cancer in Scotland are amongst the highest in the world
Why is prevalence of lung cancer low?
Patients do not live for long - 50% of lung cancer patients will not be alive 6 months after the diagnosis
Why is the percentage increase of lung cancer greater in females than males?
Smoking has increased in female population, decreased in male population
What are the presentations of lung cancer?
- Primary tumour
- Local invasion
- Metastases
- Non-metastatic
(paraneoplastic)
What symptoms do you look for to detect lung cancer early? (8)
- Cough for >3 weeks
- Breathless
- Chest infection that doesn’t clear up (recurrent pneumonia)
- Haemoptysis
- Weight loss
- Chest/shoulder pains
- Fatigue
- Hoarse voice
What is haemoptysis?
Coughing up blood
What causes haemoptysis with regards to cancer?
Direct consequence of primary tumour in bronchi
How does lung cancer cause pneumonia?
Lung cancer in upper lobe causes partial obstruction of upper lobe bronchus
Why does the enlarging tumour cause a shrinking lung?
- Obstruction of proximal divisions of the bronchial tree
- When a lobe becomes obstructed, all of the air beyond the obstruction is absorbed and the lung tissue shrinks down to a much smaller size
When you look at a CXR, how can you tell which lung is affected with lung cancer?
The smaller of the 2 lungs is usually the diseased one
What are the clinical signs of lung cancer?
- Haemoptysis
- Recurrent pneumonia
- Stridor
- Short of breath
- Muscle weakness (particularly in hands, etc)
- Pleural effusion
- Anastomoses to inferior vena cava
What is stridor?
A high-pitched wheezing sound caused by disrupted airflow
How does lung cancer lead to shortness of breath?
Tumour causes obstruction to the airways
Where are local sites lung cancer can invade? (6)
- Recurrent laryngeal nerve
- Pericardium
- Oesophagus
- Brachial plexus
- Pleural cavity
- Superior vena cava
How does lung cancer lead to a hoarse voice?
Tumour invades recurrent laryngeal nerve at left hilum - causes recurrent laryngeal nerve palsy
What does local invasion of the pericardium lead to? (3)
- Breathlessness
- Atrial fibrillation
- Pericardial effusion
What does local invasion of the oesophagus lead to?
Dysphagia - inability to swallow properly
How can lung cancer lead to muscle wastage in the hands? (2)
- T1 root infiltration by a primary lung cancer in the apex of the lung (pancoast tumour)
- The tumour can erode through the ribs and into the lower part of the brachial plexus
What is a pancoast tumour?
Tumour situated at the apex of the lung (pulmonary apex)
Do patients with a pancoast tumour experience pain?
Surprisingly, no - despite eroding through bone into chest wall
How does lung cancer cause pleural effusion?
When the primary tumour invades the pleural space, it often generates a large volume of pleural fluid
What is the presenting symptom of pleural effusion caused by lung cancer?
Breathlessness
What can local invasion of the superior vena cava (SVC) result in? (4)
- Obstructs drainage of blood from the arms and head - causes puffy eyelids and a headache
- Distension of superficial veins
- Loss of normal pulsation
- Anastomoses form to inferior vena cava in an attempt to bypass obstructed SVC
How are the symptoms of an obstructed SVC treated? When must this be done?
- Insertion of a stent to open up the occluded vein
* This must be done before the vein is permanently occluded by thrombosis
What are the clinical presentations of chest wall invasion by lung cancer? What if there is bone erosion?
- Localised chest pain that is worse with movement
* If there is bone erosion, patient will often describe pain that is worse at night
Why is a tumour encasing the pulmonary artery dangerous?
- The tumour can erode into the artery and into a major bronchus
- This results in sudden death due to massive haemoptysis
What are common sites for metastases of primary lung cancer? (5)
- Liver
- Brain
- Bone
- Adrenal
- Skin
What are symptoms of cerebral metastases? (5)
- Insidious onset
- Weakness
- Visual disturbance
- Headaches - worse in the morning, not photophobic
- Fits
How can you tell the difference between cerebral metastases and a stroke if they both have the same classical symptoms?
The onset of the symptoms due to a metastasis can take days or weeks, whereas a classical stroke can develop in a matter of minutes
Why does cerebral metastases cause a headache?
Due to raised intracranial pressure
What can be used to treat cerebral metastases?
- High dose corticosteroid therapy (e.g. Dexamethasone) will improve symptoms in the short term by removing all the oedema
- However, this benefit is shortlived and within a few weeks the symptoms will return
When would liver metastases produce pain?
If they are adjacent to the liver capsule
What happens if a liver metastases obstructs billiary drainage?
Obstructive jaundice
How can liver metastases be diagnosed?
- CT scan
* Liver function tests - alkaline phosphotase (ALK PHOS) levels will be abnormal
What are the clinical presentations of bone metastases?
- Localised pain which is worse at night
* Pathological fracture - the bone may fracture following a weak mechanical stress (due to weakened bone structure)
What are the clinical presentations of metastasis in left adrenal gland?
Very unlikely to get symptoms - normal hormone production
What are non-metastatic, paraneoplastic symptoms of lung cancer? (7)
- Finger clubbing
- Hypertrophic Pulmonary Osteoarthropathy - HPOA
- Weight loss
- Thrombophlebitis
- Hypercalcaemia
- Hyponatraemia - SIADH
- Weakness - Eaton Lambert syndrome
What causes paraneoplastic symptoms of lung cancer?
- Result from the effects of biochemically active products from the primary tumour
- They are NOT indicative of metastatic disease
How does lung cancer result in hypercalcaemia?
Tumour producing substance which mimics effects of parathyroid hormone
What are the symptoms of hypercalcaemia?
- Headaches,
- Confusion
- Thirst
- Constipation
How does lung cancer result in hyponatraemia?
Production of substance which mimics Anti Diuretic Hormone
What are the symptoms/clinicla presentations of hyponatraemia?
- Confusion
* Plasma sodium often less than 120
Why must anyone with a new observation of finger clubbing receive a chest x-ray?
Lung cancer is one of the commonest causes of finger clubbing
What diseases can cause finger clubbing?
- Lung cancer
- Liver disease (esp hep C)
- Congenital cyanotic heart disease
- Bacterial endocarditis
- Bronchiectasis
What are symptoms of hypertrophic pulmonary osteoarthropathy?
Pain and tenderness
What causes pain and tenderness in the long bones in hypertrophic pulmonary osteoarthropathy?
Elevation of the periosteum away from bone surface
What is thrombophlebitis?
Inflammatory process that causes blood clot to form and block one or more veins - usually in the legs
What are the symptoms of thrombophlebitis?
Appearance of painful cord-like structure - usually on the legs
Why is weight loss a common symptom of cancer?
Increased metabolic rate - tumour consuming calories
What causes hypercalcaemia?
Tumour releases free calcium
What does hypercalcaemia result in?
- Cardiac arrhythmias (important)
- Stones (renal/biliary calculi)
- Bones (bone pain)
- Groans (abdominal pain, constipation, nausea+vomiting)
- Thrones (polyuria)
- Psychiatric overtones (depression, anxiety, reduced GCS, coma)
What is the treatment for hypercalcamia?
- Initial treatment = rehydration
- If Calcium very high (>4) or does not correct with fluid then also use IV Bisphosphonate
- Treat underlying cancer – usually Squamous cell
What is SIADH?
Syndrome of inappropriate antidiuretic hormone
What causes SIADH?
Usually small cell lung cancer
What are the symptoms of SIADH?
- Low sodium concentration in blood (excreted in urine, water retention)
- Nausea/vomiting
- Myoclonus (muscle jerks)
- Lethargy/confusion
- Seizures
- Coma
What is the treatment for SIADH?
- Treat underlying cause
- Fluid restriction – 1.5L/day
- Sometimes need Demeclocycline
What should be explored when taking a history for suspected lung cancer?
- Cough
- Haemoptysis
- Cigarette smoker
- Breathless
- Weight loss
- Chest wall pain
- Tiredness
- Recurrent infection
- Other smoking related disease
- “Is there anything you are worried about ?”
What sort of examinations should be carried out for suspected lung cancer?
- Finger clubbing
- Breathless
- Cough
- Weight loss
- Bloated face
- Hoarse voice
- Lymphadenopathy
- Tracheal deviation
- Dull percussion
- Stridor
- Enlarged liver
What investigations can be carried out for suspected lung cancer?
- Full blood count
- Coagulation screen
- Na, K, Ca, Alk Phos
- Spirometry, FEV1
- Chest X-ray
- CT scan of thorax
- PET scan
- Bronchoscopy
- Endobronchial Ultrasound (EBUS)
- NOT sputum cytology
What is Positron Emission Tomography (PET scan)?
- Scan to asses function rather than structure
- Analysis of tissue uptake of radiolabelled glucose
- Tissues with high metabolic activity “light up”
e. g. increased metabolic activity in right upper lobe due to tumour
What techniques are used to make a tissue diagnosis of lung cancer?
- Bronchoscopy
- CT guided biopsy
- Lymph node aspirate
- Aspiration of pleural fluid
- Endobronchial Ultrasound
- Thoracoscopy
Explain the process of bronchoscopy
- local anaesthetic with intravenous sedation
* bronchoscope is passed through the nose to inspect the central part of the bronchial tree
What is bronchoscopy not useful for?
Investigating possible tumours out in the periphery of the lungs - you cannot inspect bronchial divisions that are smaller than the diameter of the bronchoscope
What is an endobronchial ultrasound?
Bronchoscope with ultrasound tip
What is endobronchial ultrasound used for?
- Enables visualisation of hilar and mediastinal structures
* Target and sample lymph nodes
How are lymph nodes sampled via endobronchial ultrasound scope?
Thin needle passed into the node through the scope, material aspirated from the node
Explain the medical thoracoscopy process
- Patient sedated and put under local anaesthetic
- Semi-rigid scope inserted between rib spaces
- Lung is deflated to allow visualisation of the pleural surfaces
- Biopsies can be taken from the pleura
What are differential diagnoses for a patient presenting with the following:-
- Smoker
- Haemoptysis
- Abnormal CXR
- Lung cancer
- Tuberculosis
- Vasculitis
- Pulmonary embolism
- Secondary cancer
- Lymphoma
- Bronchiectasis
