Lung cancer

Question 1

what are the types of lung cancer

Answer 1

non small cell = squamous cell carcinoma, adenocarcinoma, large cell carcinoma

small cell (worse prognosis) = releases neuroendocrine hormones

Question 2

what are the causes of lung cancer?

Answer 2

smoking 95%
metastases
ionising radiation, asbestos

Question 3

what are the signs and symptoms of lung cancer?

Answer 3

Shortness of breath 
Cough 
Haemoptysis 
Finger clubbing
Recurrent pneumonia 
Weight loss 
Lymphadenopathy – often supraclavicular nodes first to be found !! lump in neck 
Facial swelling

Question 4

what would you see on a resp examination in someone with lung canceR?

Answer 4

stridor, consolidation and chest assymetry

may also have localised diminished breath sounds

Question 5

what investigations would you do for lung cancer

Answer 5

tCXR (may show lesion or collapse or effusion secondary to tumour)

CT if tumour possibly hidden

bloods (FBC, LFTs, calcium)

PET/FDG

bronchoscopy and biopsy

Question 6

how do you diagnose and stage lung cancer?

Answer 6

TNM staging = look at table in notes

Question 7

what is the management for lung cancer?

Answer 7

surgery = first line in NON small cell (dependant upon size, location, patient health)

if metastases = no surgery

radiotherapy (Radical = can cure non-small cell)

chemotherapy = adjuvant or palliative

for small cell, mostly radio and chemo but palliative

Question 8

what are the extrapulmonary manifestations of lung cancer?

Answer 8

• recurrent laryngeal nerve palsy (hoarse voice)
• phrenic nerve palsy = SOB
• SVC obstruction due to direct compression can lead to distended veins and facial swelling
• horners syndrome = ptosis and miosis
• SIADH and/or cushing’s bc ectopic ADH secretion by SCLC
• paraneoplastic syndrome
• stroke symptoms for brain metastases

Question 9

what is lambert-eaton syndrome

Answer 9

AB produced by IS against SCLC, damages calcium channels on motor neurones = diplopia, ptosis, muscle weakness

Question 10

what is mesothelioma

Answer 10

lung malignancy affecting mesothelial cells of pleura, linked to asbestos inhalation

very poor prognosis

Question 11

what is asbestosis

Answer 11

Lung condition caused by long-term exposure to asbestos

Symtpoms:
o	SOB
o	Persistent cough 
o	Wheezing
o	Tiredness
o	Pain in chest or shoulder
o	Clubbing
o	Takes 20-30 years before symtpoms appear 

Treatment:
o Pulmonary rehab and oxygen therapy – no cure

Question 12

what differentials should you consider for lung cancer?

Answer 12

TB, pneumonia, PE, asbestosis, benign lung tumours

Question 13

what is the normal physiology of calcium regulation?

Answer 13

• parathyroid gland regulates calcium ions
  o If falls below range, PT gland stimulated to release PTH
  o PTH released in blood to kidneys, bones and gut

In kidneys:
 Increases reabsorption

in bones:
 stimulates osteoblasts to release RANKL which stimulates osteoclasts to reproduce itself, breaks down bone tissue to release stored Ca in the blood stream

stimulates gut to increase absorption of calcium

Question 14

why is calcium affected in cancer?

Answer 14

tumour cells such as squamous lung cancer have a genetic component

production of PTH related protein which binds to PTH receptors

Question 15

what are the signs and sympotms of hypercalcaemia?

Answer 15

affects synapses and muslces = anxiety/cognitive changes, cramps, nausea, tachycardia, ventricular arrythmias

Question 16

how do you manage hypercalcaemia?

Answer 16

fluids and furosemide
treat underlying cause

severe cases: bisphosphonates and calcitonin

Question 17

what is a pleural effusion

Answer 17

collection of fluid in the pleural cavity (space between the lung and the chest wall)

Question 18

what are the 2 types of effusions

Answer 18

exudative: high protein count in the fluid (>3)
transudative: low protein count <3

Question 19

what causes exudative effusions

Answer 19

related of inflammation = protein leaks out of tissues into pleural space (disease in any organ)

includes: lung cancer, pneumonia, rheumatoid arthtiris and TB

eggs, exudate = eggs are protein

Question 20

what causes transudative effusions

Answer 20

fluid moves across into pleural space (eg from peritoneal or retroperitoneal spaces)

causes: HF, nephrotic syndrome, liver failure, hypothyroidism

Question 21

what is light’s criteria

Answer 21

if one of these = exudate:

• Pleural fluid protein/serum protein > 0.5
• Pleural fluid LDH / serum LDH >0.6
• Pleural fluid LDH >2/3 the upper limits of normal serum LDH

Question 22

how does a pleural effusion present?

Answer 22

SOB
dullness to percussion over effusion
reduced breath sounds
tracheal deviation away from effusion

Question 23

what investigations would you do for an effusion?

Answer 23

CXR

• blunting of costophrenic angle
• fluid in lung fissures
• larger effusions show meniscus
• tracheal deviation

Pleural Tap to analyse fluid

FBC, pH, glc, LDH, blood cultures, serum protein and platelet for bleeding risk

Question 24

what would you see in a pleural fluid?

Answer 24

• Bloody – malignancy, asbestos, pulmonary infarction
• White/milky – cholesterol effusion
• Black - aspergillus
• Yellow-green – rheumatoid pleurisy
• Dark green – bilothorax
• Anchovy paste like – amebic liver abscess
• Pus – empyema

Question 25

how do you treat a pleural effusion?

Answer 25

conservative: small effusions will resolve
larger: aspiration or drainage

Question 26

what is an empyema

Answer 26

infected pleural effusions (patient with improving pneumonia but new fever)

• pleural apsiration shows pus, acidic pH, low glc and high LDH

treated by chest drain