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MBBS IV - Junior Clerkship WCS > JC18 (Medicine) - Pleural Effusion and Lung Cancer > Flashcards

JC18 (Medicine) - Pleural Effusion and Lung Cancer Flashcards

1
Q

Define Pleural effusion

4 types of Pleural Effusion

A

Pleural effusion: accumulation of serous fluid within pleural space

□ Empyema: accumulation of frank pus
□ Haemothorax: accumulation of blood
□ Chylothorax: accumulation of lymph
□ Hydropneumothorax: accumulation of fluid + air

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2
Q

Describe 4 factors that determine amount of fluid in pleural cavity (push and pull forces)

A

□ Hydrostatic pressure at arterial end
□ Oncotic pressure at venous end
□ Capillary permeability
□ Lymphatic drainage

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3
Q

Compare Transudative and exudative effusion causes

A
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4
Q

Symptoms of Pleural effusion

A

Dyspnoea: most common symptom, due to
□ Altered chest wall and diaphragm mechanics
□ Compression of lungs
□ Underlying lung or heart disease

Pleuritic chest pain: may not always be present, usually indicates exudative pathologies
□ Usually ↓intensity with ↑effusion size when inflamed pleural surfaces are no longer in contact

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5
Q

Signs of Pleural Effusion

A

Inspection: tachypnoea

Palpation:
□ ↓chest expansion
□ ± contralateral deviation of mediastinum

Percussion: stony dullness

Auscultation:
□ Increase transmission above effusion = bronchial breathing, ↑vocal resonance
□ Decrease transmission below effusion = ↓breath sounds, ↓vocal resonance

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6
Q

first-line investigations for pleural effusion

A

CXR

Ultrasound

CT ± PET/CT (if malignancy suspected or initial tap non-diagnostic)

Diagnostic thorcacentesis

Pleural Biopsy

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7
Q

Typical Xray appearance of pleural effusion

A

CXR: meniscus or blunted costophrenic angle seen

□ Requires ~200mL of fluid to be visible
□ May be loculated due to presence of pleural scarring or adhesions

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8
Q

Typical Ultrasound findings of pleural effusion

A

Ultrasound: more accurate than CXR

□ Transudate: clear hypoechoic space
□ Exudate: moving floating densities or septations

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9
Q

Indication for Diagnostic theracocentesis

Pleural fluid appearance for different causes of pleural effusion (4)

A

Indication: ALL effusions except bilateral effusion strongly suggestive of transudative process

Appearance:
Straw-coloured → serous (transudative)
Blood → traumatic haemothorax, malignancy, PE
Pus → empyema
Milky → chylothorax

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10
Q

Criteria for distinguishing transudative vs exudative pleural effusion

A

Light’s criteria: exudative if ≥1 positive
→ Pleural fluid:serum protein ratio > 0.5
→ Pleural fluid:serum LDH ratio > 0.6
→ Pleural fluid LDH > 2/3 of URL for serum

Pleural fluid biochemistry should be sent together with blood sample

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11
Q

List all metrics in diagnostic thoracentesis to find cause of effusion

A
  1. Appearance
  2. Glucose and pH compared to blood
  3. Cell count and WBC differentials (neutrophil vs lymphocyte predominant)
  4. Cytology for malignancy (2 taps minimum)
  5. Microbiology: Gram stain and culture, TB workup
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12
Q

Conditions that change glucose and pH level of pleural fluid

A

Glucose and pH: ↓Glc (lower than blood) and ↓pH (<7.30) in

Empyema (not in uncomplicated parapneumonic effusion)
Connective tissue disease, eg. RA, SLE
Malignant effusion
TB pleurisy → also a/w ↑adenosine deaminase (ADA) >40
Ruptured oesophagus

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13
Q

Indication for pleural biopsy

2 forms of pleural biopsy

A

Indication: exudative effusion with non-diagnostic thoracentesis (esp for TB and cancer)

1) Percutaneous:
- Blind if diffusely involved (eg. TB)
- CT- or USG-guided can be done but is inferior to thoracoscopic biopsy

2) Medical thoracoscopy (pleuroscopy) (allow therapeutic pleurodesis in the same procedure)

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14
Q

List management options for pleural effusion

A
  1. Treat underlying cause
  2. Therapeutic thoracentesis (therapeutic tap)
  3. Thoracostomy (chest tube) drainage
  4. In-dwelling pleural catheter (IDC) insertion
  5. Pleurodesis: chemical or surgical to obliterate pleural space
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15
Q

Risk factors of lung cancer

A

1) Environmental:
→ Smoking: responsible for ~90% CA lung, 40× death rate in smokers
→ Passive smoking
→ Toxin exposure: asbestos, cooking fumes
→ Radiation: thoracic RT, radon exposure
→ TB: ‘scar tumours’

2) Genetics: 1.5× risk with positive family Hx (e.g. EGFR mutation)
3) Previous lung conditions, eg. idiopathic pulmonary fibrosis (IPF)

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16
Q

Histological types of lung cancer

A
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17
Q

Prevalence of subtypes of lung cancer

A

□ Squamous cell carcinoma (SCC, 20-30%)
□ Adenocarcinoma (AD, 45-55%)
□ Large cell carcinoma (LCLC, 5-10%)
□ Small cell carcinoma (SCLC, 5-10%)

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18
Q

High-risk genetic changes asso. with lung cancer

A 
EGFR mutation (55% in local AD) 
ALK translocation (5% in local AD)
KRAS mutation (5-10% in local AD)
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19
Q

Most common presenting symptoms of Lung Cancer

A

cough (45-74%),

weight loss (46-68%),

SOB (37-58%),

chest pain (27-49%),

haemoptysis (27-29%),

bone pain (20-21%),

hoarseness (8-18%).

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20
Q

Primary lung cancer Tumor mass effects

A

Bronchial mucosa ulceration:

  • Cough (80%): usually dry, ± sputum if secondary infection
  • Haemoptysis (70%): common esp in central bronchial tumours

Partial Bronchial obstruction:

  • Monophonic, unilateral wheeze not cleared with coughing
  • Recurrent pneumonia due to poor drainage
  • Stridor

Complete Bronchial obstruction:

  • Lung Collapse
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21
Q

Primary lung cancer - List 10 structures affected in intrathoracic spread

A
  1. Lymphangitis carcinomatosis
  2. Pleural effusion
  3. Pericardial effusion and cardiac tamponade
  4. Chest wall and ribs (pain)
  5. Phrenic nerve damage and diaphragm paralysis
  6. SVC obstruction (emergency)
  7. Left RLN damage (hoarseness, bovine cough)
  8. Brachial plexus (Pancoast syndrome)
  9. Inferior cervical sympathetic chain - Horner’s syndrome
  10. Esophagus (dysphagia)
22
Q

S/S of SVC obstruction

A
  1. Dyspnoea and stridor
  2. Facial plethora, headache and conjunctiva oedema
  3. Early morning headache
  4. Dilated veins on chest wall and neck
  5. Pemberton’s sign: exaggeration of symptoms when lift both arms (narrow thoracic inlet → ↑obstruction)
23
Q

S/S of pancoast syndrome

A

pain in inner aspect of arm ± small hand muscle wasting

classically a/w NSCLC, only <5% SCLC

24
Q

S/S of Horner syndrome

A

SPAM = sunken eyeball, partial ptosis, anhidrosis, miosis

(ipsilateral partial ptosis, miosis, enophthalmos, anhidrosis)

25
Q

Anatomical location of lung cancer most likely to cause:

  • SVCO
  • Horner syndrome
  • Pancoast syndrome
  • Hoarseness
A

Rt suprahilar → SVCO

Lt upper lobe (near aortic arch) → hoarseness

Apex → Pancoast and/or Horner syndrome

26
Q

Common metastatic spread of lung cancer

A

most commonly liver, adrenals, bone, brain

Others: spinal cord, supraclavicular and cervical lymphadenopathy

27
Q

Systemic non-metastatic effects of lung cancer **

  • Haematological
  • Connective tissue
  • Endocrine
  • Neuromuscular
A

Haematological: anaemia of chronic disease, leukocytosis, thrombocytosis

Connective tissues:
→ Clubbing
→ Hypertrophic pulmonary osteoarthropathy (HPOA)

Ectopic hormones (12%):
→ SIADH (usu SCLC) → hypoNa → confusion, weakness
→ ACTH (usu SCLC) → Cushing’s syndrome (ectopic ACTH)
→ PTHrP (usu SCC) → hyperCa → polyuria, thirst, confusion

Neuromuscular:
→ Eaton-Lambert myasthenia syndrome (3% SCLC) - weakness
→ Paraneoplastic encephalitis, eg. limbic encephalitis, encephalomyelitis, cerebellar degeneration
→ Peripheral neuropathy - paraesthesia
→ Dermatomyositis and polymyositis - skin rash, weakness

28
Q

S/S of PTHrP release from lung cancer

A

hypercalcemia:

  • ‘Stones’: nephrocalcinosis, renal stones
  • ‘Bones’: bone pain, osteoporosis
  • ‘Groans’: lethargy, fatigue
  • ‘Moans’: constipation, abdominal pain, nausea, vomiting
  • ‘Thrones’: polyuria, dehydration, polydipsia
  • ‘Psychiatric overtones’: confusion, depression, anxiety, hallucinations
29
Q

2 causes of hypercalcemia due to lung cancer

A
  • Bony metastasis and bony destruction: a/w ↑PO43-
  • PTHrP production: a/w ↓PO43-
30
Q

First line investigations for Lung Cancer

A
  1. General evaluation: blood tests, cardiac and lung function assessment
  2. Radiological: CXR for screening, CT or PET for confirmation, TNM, guide biopsy
  3. Tissue biopsy: confirmation, genetic information
31
Q

8 possible radiological features of lung cancer

A
32
Q

Function of Contrast CT thorax + upper abdomen for lung cancer

A
  1. Diagnostic
  2. Guide biopsy
  3. Staging (limitations of nodal, chest wall and mediastinal invasion)
  4. Treatment: Radiotherapy planning, assess treatment response
33
Q

Function of PET/CT and MRI in Lung Cancer

A

PET/CT Whole body: Metastatic disease

MRI thorax: Pancoast tumor, assess chest wall/brachial plexus invasion\

Contrast MRI/ CT brain: Brain metastasis

34
Q

Methods of tissue sampling for dx of lung cancer (cytology)

A

For Cytology:

  • Sputum
  • Bronchial washing
  • Pleural thoracocentesis
  • FNAC

For Biopsy:

  • Conventional bronchoscopy
  • Endobronchial ultrasound transbronchial needle aspiration (EBUS- TBNA)
  • Transthoracic needle aspiration/ Biopsy (TTNA/ TTNB)
  • Mediatinoscopy
  • Video-assisted thoracic surgery (VATS)
  • Medical pleuroscopy
35
Q

Method of biopsy for lung cancer mass

A

For Biopsy:

  • Conventional bronchoscopy
  • Endobronchial ultrasound transbronchial needle aspiration (EBUS- TBNA)
  • Transthoracic needle aspiration/ Biopsy (TTNA/ TTNB)
  • Mediatinoscopy
  • Video-assisted thoracic surgery (VATS)
  • Medical pleuroscopy
36
Q

Indication for convention bronchoscopy

Modalities for lung cancer located centrally and peripherally?

A

only for directly visualized lesions in bronchi

Modalities:
Directly visualized lesions → saline washing, brushing or endobronchial forcep biopsy
Lesions close to airways → transbronchial Bx or needle aspiration
Peripheral lesions → bronchoalveolar lavage

37
Q

Indication for EBUS- TBNA

A

→ Diagnosis and staging by sampling central tumours and paratracheal/subcarinal/hilar LNs
→ Alternative dx for mediastinal lymphadenopathy (eg. TB, sarcoidosis, lymphoma)

38
Q

Indication for TTNA/ TTNB

A

Transthoracic needle aspiration/biopsy (TTNA/TTNB):
□ Indication: sample peripheral nodules (2nd line after other modalities)
□ Use: CT-guided

39
Q

List 3 minimally invasive modalities of tissue collection for Lung cancer

A

□ Sputum cytology for pt unfit for invasive biopsy

□ Endoscopic ultrasound-guided FNA (EUS-FNA) for subcarinal and paratracheal nodes

□ Electromagnetic navigation bronchoscopy for peripheral lesions (new technique for image-guidance)

40
Q

Management outline for SCLC

A

SCLC
□ All patients → chemo + RT

41
Q

Management outline for NSCLC

A
  • *Surgery: as definitive treatment (1st line)**
  • *± adjuvant chemotherapy** for pathologic stage II-III or high-risk stage IB
  • *± adjuvant RT** for +ve surgical margin or mediastinal LN involvement

Definitive RT: as alternative if medically unfit or refuse surgery

Criteria for surgery:
□ Appropriate stage: stage I, stage II, T3N1, selected T4N0-1
□ NO mediastinal involvement (N2 precludes resection)
□ Adequate cardiac and lung function

42
Q

Outline 2 pre-operative fitness tests for NSCLC surgery

A

Cardiac function: echocardiogram or cardiac catheterization

Lung function:

Spirometry: FEV1 and DLCO for predicted postop values (ppoPEV1, ppoDLCO)

Cardiopulmonary exercise test (CPET): VO2 max and threshold

43
Q

Surgical options for NSCLC resection (4)

A

1.Lobectomy: gold-standard for Ca lung ***
→ Approach: open, VATS, robotic

2.Sublobar resection, eg. segmentectomy, wedge resection
→ Indication: intolerant to full lobectomy + primary tumour ≤3cm

3.Sleeve lobectomy: alternative to pneumonectomy
→ Indication: for tumour close to main bronchus

4.Pneumonectomy: proximal tumours

± en bloc resection of chest wall invasion
+ mediastinal LN dissection

44
Q

Treatment option for non-resectable NSCLC

A
  1. Chemotherapy regimen: usually cisplatin + etoposide or weekly carboplatin + paclitaxel
  2. Radiotherapy
  3. Targeted therapy and immunotherapy (durvalumab)
45
Q

Indication for genetic testing for lung cancer

Name 3 driver mutations in NSCLC

A

Advanced NSCLC - cannot resect

All adenocarcinoma

All never-smokers with early lung CA

Genetic test on biopsy sample or plasma/ urine cell-free DNA: EGFR, ALK and ROS1

46
Q

Treatment for EGFR +ve NSCLC

S/E

A

1st/2nd generation EGFR TKIs eg. gefitinib (Iressa), erlotinib (Tarceva), afatinib (Gilotrif)

S/E: acneiform rash, radiation dermatitis, mucositis, GI disturbance, corneal erosion, pulmonary and hepatic fibrosis (drug induced pneumonitis and liver cirrhosis)

47
Q

Treatment for TKI-resistant NSCLC

A

Types: EGFR 2o mutation as exon 20 T790M (~60%), HER2 amplification (8-12%), Met activation (4-8%), conversion to SCLC (<5%)

If T790M+, then use 3rd generation TKI, i.e. osimertinib

If T790M-, then use afatinib/cetuximab or chemotherapy

48
Q

Treatment of ALK translocation or ROS1 rearrangement NSCLC

A

1st generation ALK TKIs, eg. crizotinib

Resistant to Crizotinib: start 2nd generation ALK TKIs, eg. ceritinib, alectinib, brigatinib

49
Q

Treatment of non-resectable/ end-stage NSCLC with no driver mutations

A

Check Tumour PD-L1 expression

  • *PD-L1 high (≥50%) → pembrolizumab monotherapy**
  • *PD-L1 low (<50%) or unknown → pembrolizumab + platinum-based chemotherapy**

Supportive treatment: analgesics, cough suppression, pleurodesis, end-of-life care, Palliative radiotherapy for SVCO

50
Q

Treatment for Stage 1-2 SCLC with no met.

A

Primary surgery: lobectomy + mediastinal LN dissection

Adjuvant chemotherapy: 4 cycles of cisplastin-based chemotherap ± adjuvant chemo/RT if LN involvement

51
Q

Treatment of unresectable/ advanced SCLC with met.

A

Unresectable:

  • *Chemoirradiation**: mainstay, etoposide + cisplatin (EP) + thoracic EBRT
  • *Prophylactic cranial irradiation (PCI):** prophylaxis against brain metastasis

Very late stage:

  • Induction chemotherapy: atezelizumab, PD-L1 mAb
  • Thoracic EBRT ± PCI
52
Q

Common primaries of metastatic lung cancer

A

Haematological spread:
□ Common primaries: breast, kidneys, uterus, ovary, testes, thyroid

Lymphatic spread → lymphangitis carcinomatosis
□ Common primaries:
→ Cervix, Colon, Stomach, Breast, Pancreas, Thyroid, Larynx and lungs

MBBS IV - Junior Clerkship WCS (131 decks)

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