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Respiratory: Patient History, etc > Clinical Aspects of Bronchial Carcinoma > Flashcards

Clinical Aspects of Bronchial Carcinoma Flashcards

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1
Q

What are the general features of cancer? (5)

A
  • Malignant growth
  • Uncontrolled replication
  • Local invasion
  • Metastasis
  • Non-metastatic systemic side effects (mimic effects of hormones - paraneoplastic features)
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2
Q

What are 3 ways cancer can metastasise?

A
  • Lymphatic spread
  • Blood stream
  • Serous cavities e.g. via peritoneum
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3
Q

What are paraneoplastic features?

A

Molecules released from tumour can mimic the effects of naturally-occurring hormones

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4
Q

How many cases of lung cancer are diagnose in the UK

i) Annually?
ii) Daily?

A
  • 45,000 new cases per year

* 120 new cases every day

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5
Q

Why is 90% of lung cancer incurable at the time of diagnosis?

A

Tends not to cause any symptoms until the disease has become too advanced

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6
Q

Why is lung cancer significant in Scotland?

A
  • 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
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7
Q

Why is prevalence of lung cancer low?

A

Patients do not live for long - 50% of lung cancer patients will not be alive 6 months after the diagnosis

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8
Q

Why is the percentage increase of lung cancer greater in females than males?

A

Smoking has increased in female population, decreased in male population

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9
Q

What are the presentations of lung cancer?

A
  • Primary tumour
  • Local invasion
  • Metastases
  • Non-metastatic
    (paraneoplastic)
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10
Q

What symptoms do you look for to detect lung cancer early? (8)

A
  • Cough for >3 weeks
  • Breathless
  • Chest infection that doesn’t clear up (recurrent pneumonia)
  • Haemoptysis
  • Weight loss
  • Chest/shoulder pains
  • Fatigue
  • Hoarse voice
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11
Q

What is haemoptysis?

A

Coughing up blood

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12
Q

What causes haemoptysis with regards to cancer?

A

Direct consequence of primary tumour in bronchi

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13
Q

How does lung cancer cause pneumonia?

A

Lung cancer in upper lobe causes partial obstruction of upper lobe bronchus

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14
Q

Why does the enlarging tumour cause a shrinking lung?

A
  • 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
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15
Q

When you look at a CXR, how can you tell which lung is affected with lung cancer?

A

The smaller of the 2 lungs is usually the diseased one

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16
Q

What are the clinical signs of lung cancer?

A
  • Haemoptysis
  • Recurrent pneumonia
  • Stridor
  • Short of breath
  • Muscle weakness (particularly in hands, etc)
  • Pleural effusion
  • Anastomoses to inferior vena cava
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17
Q

What is stridor?

A

A high-pitched wheezing sound caused by disrupted airflow

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18
Q

How does lung cancer lead to shortness of breath?

A

Tumour causes obstruction to the airways

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19
Q

Where are local sites lung cancer can invade? (6)

A
  • Recurrent laryngeal nerve
  • Pericardium
  • Oesophagus
  • Brachial plexus
  • Pleural cavity
  • Superior vena cava
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20
Q

How does lung cancer lead to a hoarse voice?

A

Tumour invades recurrent laryngeal nerve at left hilum - causes recurrent laryngeal nerve palsy

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21
Q

What does local invasion of the pericardium lead to? (3)

A
  • Breathlessness
  • Atrial fibrillation
  • Pericardial effusion
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22
Q

What does local invasion of the oesophagus lead to?

A

Dysphagia - inability to swallow properly

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23
Q

How can lung cancer lead to muscle wastage in the hands? (2)

A
  • 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
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24
Q

What is a pancoast tumour?

A

Tumour situated at the apex of the lung (pulmonary apex)

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25
Q

Do patients with a pancoast tumour experience pain?

A

Surprisingly, no - despite eroding through bone into chest wall

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26
Q

How does lung cancer cause pleural effusion?

A

When the primary tumour invades the pleural space, it often generates a large volume of pleural fluid

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27
Q

What is the presenting symptom of pleural effusion caused by lung cancer?

A

Breathlessness

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28
Q

What can local invasion of the superior vena cava (SVC) result in? (4)

A
  • 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
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29
Q

How are the symptoms of an obstructed SVC treated? When must this be done?

A
  • Insertion of a stent to open up the occluded vein

* This must be done before the vein is permanently occluded by thrombosis

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30
Q

What are the clinical presentations of chest wall invasion by lung cancer? What if there is bone erosion?

A
  • Localised chest pain that is worse with movement

* If there is bone erosion, patient will often describe pain that is worse at night

31
Q

Why is a tumour encasing the pulmonary artery dangerous?

A
  • The tumour can erode into the artery and into a major bronchus
  • This results in sudden death due to massive haemoptysis
32
Q

What are common sites for metastases of primary lung cancer? (5)

A
  • Liver
  • Brain
  • Bone
  • Adrenal
  • Skin
33
Q

What are symptoms of cerebral metastases? (5)

A
  • Insidious onset
  • Weakness
  • Visual disturbance
  • Headaches - worse in the morning, not photophobic
  • Fits
34
Q

How can you tell the difference between cerebral metastases and a stroke if they both have the same classical symptoms?

A

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

35
Q

Why does cerebral metastases cause a headache?

A

Due to raised intracranial pressure

36
Q

What can be used to treat cerebral metastases?

A
  • 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
37
Q

When would liver metastases produce pain?

A

If they are adjacent to the liver capsule

38
Q

What happens if a liver metastases obstructs billiary drainage?

A

Obstructive jaundice

39
Q

How can liver metastases be diagnosed?

A
  • CT scan

* Liver function tests - alkaline phosphotase (ALK PHOS) levels will be abnormal

40
Q

What are the clinical presentations of bone metastases?

A
  • Localised pain which is worse at night

* Pathological fracture - the bone may fracture following a weak mechanical stress (due to weakened bone structure)

41
Q

What are the clinical presentations of metastasis in left adrenal gland?

A

Very unlikely to get symptoms - normal hormone production

42
Q

What are non-metastatic, paraneoplastic symptoms of lung cancer? (7)

A
  • Finger clubbing
  • Hypertrophic Pulmonary Osteoarthropathy - HPOA
  • Weight loss
  • Thrombophlebitis
  • Hypercalcaemia
  • Hyponatraemia - SIADH
  • Weakness - Eaton Lambert syndrome
43
Q

What causes paraneoplastic symptoms of lung cancer?

A
  • Result from the effects of biochemically active products from the primary tumour
  • They are NOT indicative of metastatic disease
44
Q

How does lung cancer result in hypercalcaemia?

A

Tumour producing substance which mimics effects of parathyroid hormone

45
Q

What are the symptoms of hypercalcaemia?

A
  • Headaches,
  • Confusion
  • Thirst
  • Constipation
46
Q

How does lung cancer result in hyponatraemia?

A

Production of substance which mimics Anti Diuretic Hormone

47
Q

What are the symptoms/clinicla presentations of hyponatraemia?

A
  • Confusion

* Plasma sodium often less than 120

48
Q

Why must anyone with a new observation of finger clubbing receive a chest x-ray?

A

Lung cancer is one of the commonest causes of finger clubbing

49
Q

What diseases can cause finger clubbing?

A
  • Lung cancer
  • Liver disease (esp hep C)
  • Congenital cyanotic heart disease
  • Bacterial endocarditis
  • Bronchiectasis
50
Q

What are symptoms of hypertrophic pulmonary osteoarthropathy?

A

Pain and tenderness

51
Q

What causes pain and tenderness in the long bones in hypertrophic pulmonary osteoarthropathy?

A

Elevation of the periosteum away from bone surface

52
Q

What is thrombophlebitis?

A

Inflammatory process that causes blood clot to form and block one or more veins - usually in the legs

53
Q

What are the symptoms of thrombophlebitis?

A

Appearance of painful cord-like structure - usually on the legs

54
Q

Why is weight loss a common symptom of cancer?

A

Increased metabolic rate - tumour consuming calories

55
Q

What causes hypercalcaemia?

A

Tumour releases free calcium

56
Q

What does hypercalcaemia result in?

A
  • 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)
57
Q

What is the treatment for hypercalcamia?

A
  • 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
58
Q

What is SIADH?

A

Syndrome of inappropriate antidiuretic hormone

59
Q

What causes SIADH?

A

Usually small cell lung cancer

60
Q

What are the symptoms of SIADH?

A
  • Low sodium concentration in blood (excreted in urine, water retention)
  • Nausea/vomiting
  • Myoclonus (muscle jerks)
  • Lethargy/confusion
  • Seizures
  • Coma
61
Q

What is the treatment for SIADH?

A
  • Treat underlying cause
  • Fluid restriction – 1.5L/day
  • Sometimes need Demeclocycline
62
Q

What should be explored when taking a history for suspected lung cancer?

A
  • Cough
  • Haemoptysis
  • Cigarette smoker
  • Breathless
  • Weight loss
  • Chest wall pain
  • Tiredness
  • Recurrent infection
  • Other smoking related disease
  • “Is there anything you are worried about ?”
63
Q

What sort of examinations should be carried out for suspected lung cancer?

A
  • Finger clubbing
  • Breathless
  • Cough
  • Weight loss
  • Bloated face
  • Hoarse voice
  • Lymphadenopathy
  • Tracheal deviation
  • Dull percussion
  • Stridor
  • Enlarged liver
64
Q

What investigations can be carried out for suspected lung cancer?

A
  • 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
65
Q

What is Positron Emission Tomography (PET scan)?

A
  • 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
66
Q

What techniques are used to make a tissue diagnosis of lung cancer?

A
  • Bronchoscopy
  • CT guided biopsy
  • Lymph node aspirate
  • Aspiration of pleural fluid
  • Endobronchial Ultrasound
  • Thoracoscopy
67
Q

Explain the process of bronchoscopy

A
  • local anaesthetic with intravenous sedation

* bronchoscope is passed through the nose to inspect the central part of the bronchial tree

68
Q

What is bronchoscopy not useful for?

A

Investigating possible tumours out in the periphery of the lungs - you cannot inspect bronchial divisions that are smaller than the diameter of the bronchoscope

69
Q

What is an endobronchial ultrasound?

A

Bronchoscope with ultrasound tip

70
Q

What is endobronchial ultrasound used for?

A
  • Enables visualisation of hilar and mediastinal structures

* Target and sample lymph nodes

71
Q

How are lymph nodes sampled via endobronchial ultrasound scope?

A

Thin needle passed into the node through the scope, material aspirated from the node

72
Q

Explain the medical thoracoscopy process

A
  • 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
73
Q

What are differential diagnoses for a patient presenting with the following:-

  • Smoker
  • Haemoptysis
  • Abnormal CXR
A
  • Lung cancer
  • Tuberculosis
  • Vasculitis
  • Pulmonary embolism
  • Secondary cancer
  • Lymphoma
  • Bronchiectasis

Respiratory: Patient History, etc (10 decks)

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