Lung Cancer Flashcards
What is this condition?
Lung cancer - 2nd most common cancer BUT, highest mortality (usually have many CXRs and GP visits prior to diagnosis)
- CT best screening technique
Where are most cancers diagnosed?
- Emergency (situations)
- GP
What is the incidence of lung cancer in the north east?
- Highest incidence and mortality from lung cancer
- DUE to strong correlation between social deprivation (smoking and asbestos exposure → from ship yard) and late presentation of disease (leads to increased mortality)
What are the clinical presentations of someone with lung cancer?
-
Cough (74%)
- Most common but least specific
- May occur on background of chronic chest disease and then be a change in quality of cough
- Failure of a cough to resolve in 2 to 3 weeks should raise suspicion
- Weight loss (70%)
-
SOB (60%)
- Common early symptom with cough and sputum
- May be related to airway obstruction (unilateral fixed wheeze)
- Often disproportionate
- May result from local spread to pleura, pericardium, mediastinum or lymphatics
-
Haemoptysis (20-50%)
- Not easily ignored
- May be sole presenting symptom
but more often with other symptoms - Typically streaking of sputum on several successive days
- But not always significant
-
Chest pain (27%)
- Persistent but often non specific ache
- Direct invasion of pleura, mediastinum or pericardium
- Metastatic to ribs or thoracic spine
- Referred from diaphragm or brachial plexus involvement
-
Hoarse voice and other features of direct intrathoracic invasion
- Hoarseness (left recurrent laryngeal)
- SVC obstruction from tumour or thrombosis
- Dysphagia from oesophageal compression
- Elevated diaphragm
- Pericardial involvement with arrhythmia or effusion
- Also consider cord compression, paraneoplastic
What are the signs of lung cancer?
- Cachexia/weight loss
- Finger clubbing
- Pleural effusion
- Lymphadenopathy
- Stridor
- Tracheal deviation (Lobar collapse/whole lung collapse)
- SVC obstruction
What are the risk factors of lung cancer?
- Smoking
- Ex-smoker
- Non-smoker → usually genetic
- Asbestos exposure
- Underlying interstitial lung disease
- COPD
How can you assess functioning status using the WHO performance scale?
What is the diagnosis and management of lung cancer?
- Confirm diagnosis of cancer: Histological/Cytology confirmation (Biopsy)
- Confirm stage of disease: Extent/Spread of disease
- Assess Patient fitness for treatment/patient wishes:
What is the treatment of lung cancer?
-
NSCLC: (75-80% cases) → non-small cell lung cancer
- Early stage disease is curable by surgery
- Radiotherapy or chemotherapy can help symptoms
- New therapies include immunotherapy and biological agents
-
SCLC: (20-25% of cases) → small cell lung cancer
- Frequently metastatic at diagnosis
- Not amenable to surgery
- Often very chemosensitive +/- radiotherapy → as divides very frequently so, MASSIVELY decreases cancer
What is the difference in the prognosis of SCLC and NSCLC?
What are the common sites for lung cancer to metastasise too?
- Breast
- Prostate
- GI tract
- Renal
- Lung
- Melanoma
What are the symptoms of spinal metastases?
- Cervical or Thoracic spine pain
- Progressive lumbar pain
- Nocturnal spinal pain
- Localised tenderness
- Spinal pain aggravated by straining
- Associated neurological symptoms and signs
- Spinal cord compression → oncological emergency
Neurological symptoms or signs
- Radicular pain
- Limb weakness
- Difficulty walking
- Sensory loss with typical sensory level
- Bladder or bowel dysfunction
- Signs of spinal cord or cauda equina compression
What are the areas of extra-thoracic spread areas for lung cancer?
- Supraclavicular lymphadenopathy
- Horner’s syndrome (cervical sympathetic trunk)
- Brain – most common cerebral tumour
- Bone typically ribs vertebrae and long bones
- Liver and adrenals also common
Can lead to SVC obstruction
What are the paraneoplastic syndromes of lung cancer?
- Finger clubbing
- SIADH
- Water retention causes cerebral oedema
- leading to confusion, drowsiness, fits etc
- Water retention causes cerebral oedema
- Hypercalcaemia
- Ectopic PTH or usually multiple bone metastases
- Nausea, constipation, dehydration and drowsiness
- Ectopic PTH or usually multiple bone metastases
- Ectopic ACTH syndrome
- Bilateral adrenal hyperplasia
- Thirst, polyuria, hypokalaemia and muscle weakness
- Bilateral adrenal hyperplasia
- Neurological Syndromes
Case 1:
Female aged 56 yrs
3 wk history cough and non specific chest pain
PH Melanoma
FH Father died lung cancer
Works local post office, smokes 20cpd
Otherwise fit and well
Investigations?
Has adenocarcinoma → what is the treatment?
Investigations
- GP Chest Xray
- Bronchoscopy
- CT Staging Scan
Treatment
- Palliative Chemotherapy with Carboplatin/Pemetrexed x 4 cycles
- Radiotherapy dependent on response and treatment field
What is the function of the pleural space?
- Lubricate visceral and parietal pleura to allow sliding as lungs inflate and deflate
- To help create a vacuum as we breath in order to suck air in
How is pleural fluid produced?
How much pleural fluid is produced, absorbed every day and how is it achieved?
- Pleural fluid production: ~15 ml/day
- Pleural fluid absorption: ~15 ml/day
- Pleural fluid drainage is achieved by the “Lymphatic pump”
How do pleural effusions develop?
When rate of production of pleural fluid exceeds the rate of re-absorbtion of the fluid → Accumulation of fluid in the pleural space
Explain the classification of pleural fluid…
-
TRANSUDATE
- Low fluid protein
- Fluid protein / serum protein < 0.5
- “protein less than 25”
- Fluid protein / serum protein < 0.5
-
Low LDH
- Fluid LDH / serum LDH > 0.6
- Low fluid protein
-
EXUDATE
- High fluid protein
- Fluid protein / serum protein > 0.5
- “protein greater than 35”
-
High LDH
- Fluid LDH / serum LDH > 0.6
- High fluid protein
What are the causes of pleural effusions → transudate?
“Fluid leaks into the pleural space from elsewhere”
- Too much fluid in body
- Heart failure
- Renal failure
- Liver cirrhosis
- Fluid leaking from elsewhere
- Hypoalbuminaemia
- Ascites / peritoneal dialysis
- Other stuff
- Hypothyroidism
- Meigs’ syndrome
- PE
What are the causes of pleural effusions → exudates?
“Too much fluid produced / failure of reabsorption due to damage to pleural surface”
- Pleural malignancy – primary or secondary
- Pneumonia
- Empyema – infection in pleural space
- Pulmonary infarction
- Connective tissue disease
- Benign asbestos pleuritis
- Pancreatitis
- Drug induced
What history would a patient with a pleural effusion give?
- Usual symptom is progressive breathlessness
- Typically develops over days to weeks
- May have pleuritic chest pain
- Often have cough – dry or white phlegm
- Symptoms of underlying cause
- Weight loss, haemoptysis
- Fever, symptoms of pneumonia
- Ankle oedema
On examination of a pleural effusion individual what would you find?
- General
- Breathless, hypoxia
- Specific
- Reduced expansion on affected side
- Dull (stony) percussion note
- Reduced / absent breath sounds
- Reduced vocal resonance
What investigations for someone with a pleural effusion would you do?
- History and exam
- Bloods
- U+E, LFT, FBC, CRP
- ESR, autoantibodies
- Amylase
- CXR
- Pleural ultrasound
- Consider CT chest
How would you treat someone with a pleural effusion?
PLEURAL ASPIRATION
- Ultrasound guided
- Pass needle in to pleural fluid
- Aspirate sample
- Investigations
- Colour, viscosity, smell
- Biochemistry: protein, LDH, glucose
- Fluid pH
- Microbiology
- Cytology
What can the cause of benign pleural disease?
Indicator of asbestos exposure
What is mesothelioma?
- Malignant tumour of serosal surfaces (most commonly the pleura)
- Usually resulting from asbestos exposure
- Median survival is 9-12 months from diagnosis
- Identification of asbestos exposure is essential for the patient to be able to claim compensation
- On CT shows ROUGH border
