Haemoptysis & SOB

Question 1

list and discuss the differential diagnoses for patients presenting with haemoptysis, cough and shortness of breath

Answer 1

•Long standing SOB and cough
–Likely COPD/chronic bronchitis, or possible heart failure

•Recent haemoptysis with change in cough
–Likely injury to the airways or disruption of the alveolar capillary membrane
1. Chest infection such as bronchitis, pneumonia, bronchiectasis and TB
2. Lung carcinoma (no acute change of cough)
3. Pulmonary embolus (probably less likely but must not be missed)

•Other causes unlikely but need to be considered in the history
–Trauma, mitral stenosis, clotting disorder, upper airway bleeding, vasculitis

Question 2

discuss the pathophysiology of haemoptysis

Answer 2

• injury to the airways or

- disruption of the alveolar capillary membrane

Question 3

recall the different types of lung cancer and their incidence

Answer 3

Lung Carcinoma
–Adeno: Most common (40%)
–Squamous cell
–Large Cell
–Small cell

–Others (

Question 4

recall the aetiology, molecular pathogenesis and pathology of lung cancer

Answer 4

In order of most common to least common mutations:

• Unknown
• KRAS
• EGFR
• ALK
• others: BRAF, HER2, NRAS, AKT1 etc

Question 5

describe the presentation and clinical manifestations of lung cancer

Answer 5

•It is often “late” (and often by “chance”, as in this case)
•Local complications (airway and adjacent structures)
–Cough, change in voice
–SOB: Lung collapse, pleural effusion, PE, SVC obstruction
–Haemoptysis
–Chest pain (eg chest wall)
•Metastatic disease
–Bone (pain), brain (seizures, headache)
•Systemic/hormonal/paraneoplastic
–LOW, lethargy
–Hypercalcaemia, weakness

Question 6

describe the management goals and treatment options for different types of lung cancer

Answer 6

Goals:
•Cure - if localised disease
•Symptom control and comfort if locally advanced or metastatic
•Prolong life but not at any cost to the person and society
•Support: Psychosocial, nutritional

Treatment options:
• local problems require a local solution
•Surgery (best chance of cure)
•Radiotherapy
•Chemotherapy (including adjuvant treatment)
•“Targeted” agents for mutations in lung cancer: Eg Gefitinib for EGFR receptor antagonists
•Palliation (if metastatic)

Question 7

discuss the prognosis of different types of lung cancer and how this is influenced by the stage of the disease

Answer 7

5 yr survival rates for different subtypes:
ƒƒ- squamous cell carcinoma 25% (best prognosis)
-ƒƒ adenocarcinoma 12% (60% for bronchoalveolar carcinoma, a subtype of adenocarcinoma,
with a resectable solitary lesion)
-ƒƒ large cell carcinoma 13%
-ƒƒSmall Cell Lung Cancer 1% (poorest prognosis)

Higher the stage, the poorer the prognosis

5 year survival rate
Stage I: 60-80%
Stage II: 25-50%
Stage III: 5-30%
Stage IV:

Question 8

What does hypoxaemia & hyperinflation with wheezes suggest?

Answer 8

more acute airway narrowing and inflammation

Question 9

What investigations might help in trying to establish the diagnosis of a lung mass?

Answer 9

•Sputum
•Brochoscopy
–Standard
–Endobronchial ultrasound (EBUS)
•How might this sort of equipment help us?
•CT guided lung biopsy
•Surgical biopsy
•PET scan

Question 10

What is the epidemiology of lung cancer & what are the risk factors? Is there a screening program?

Answer 10

•Most common cancer worldwide and the most common cause of cancer death
–Beginning to fall in men in our community
•Smoking most common risk factor
–Also radiation therapy, second hand smoke, asbestos, radon, metals
–Pulmonary fibrosis
•Screening with low dose CT scans is still controversial and not yet common practice

Question 11

Discuss management for haemoptysis

Answer 11

depends on the cause and the amount of bleeding.

If Massive, or major, hemoptysis: a medical emergency

• Bronchial artery embolization
• surgical resection
• bronchoscopic laser therapy

If mild/moderate + chronic bronchitis/bronchiectasis/TB:

• Antibiotics
• if cancer, Rx depends on stage of cancer