Lung Cancer Flashcards
What are the red flag symptoms in a respiratory examination?
Haemoptysis, weight loss, persistent cough, breathlessness, pain, changes in fingers suggesting clubbing or pain in the limbs indicating Hypertrophic osteoarthropathy.
What do you understand by Skill mix?
This is the use of different grades of staff trying to use skilled personnel at the right level. For doctors this originally meant trying to avoid clerical duties but now includes training non medics to do work to keep costs down and provide a resilient workforce.
What do you think happens in your trust when something seems to have gone wrong?
Case report, duty of candor
There are a number of non metastatic manifestations of malignant disease how many can you give?
These are commonest with small cell lung cancer but clubbing and the closely related hypertrophic arthropathy occur with other types of cancer.
Eaton lambert (Lambert Eaton) syndrome and myasthenia gravis happen due to autoantibodies but behave differently in the muscle synapses. The former prevents Acetyl choline being released while the latter blocks ACh acting. Myasthenia is closely linked to the thymus and a tumour is seen in 15% of patients with the condition but half of patients with a thymoma have myasthenia.
SIADH has a long list of causes but one classic one is small cell cancer and this should be excluded with a scan if the sodium is very low.
Hypertrophic osteoarthropathy results in new bone forming in the periostium in the forearms and lower legs. the patient will have pain and also marked clubbing. Treatment of the primary cancer (or any other cause for severe clubbing) will result in resolution of the disease unlike metastases.
Cushings syndrome due to secretion of ACTH by the tumour or hyperparathyroidism also by hormone secretion.
Other rare causes include acanthosis, polymyositis, dermatomyosistis, cerebellar syndrome, thrombophlebitis, fits, confusion and neuopathy.
Describe the SPIKES framework used to break bad news
S = Setting P = Patients Perception I = Invitation to continue with the explanation K = Knowledge in small chunks. E = Empathy for the shock or other emotions S = Strategy what you and the patient are going to do
What is illuminated on a PET scan?
The scan shows up anything that’s using glucose and that includes your vocal cords and brown fat
What are the causes of bronchial carcinoma?
- Tobacco smoking
- Ionising radiation
- Asbestos
- Fibrosing alveolitis
- Industrial chemicals
- Arsenic
- Chloromethyl ethers
- Chromium
- Nickel
- Polyaromatic hydrocarbons
- Vinyl chloride
What are the types of bronchial carcinoma?
- Lung
- Primary (76% non-small cell = squamous, adenocarcinoma)
- Secondary (breast, kidney, bladder, testes) - Pleura
- Primary (mesothelioma)
- Secondary
Other cell types (sarcoma, lymphoma)
What is the clinical presentation of bronchial carcinoma?
?- Cough
- Hemoptysis
- Chest pain
- Breathlessness
- Stridor
- Hoarse voice
- Weight loss
- Facial swelling
- Finger clubbing
- Lymphadenopathy
- Chest asymmetry
- Focal chest signs (consolidation/fluid)
- Hepatomegaly
- Neuropathy
Weeks/months
What are the complications of a bronchial carcinoma?
- Pancoast syndrome (superior sulcus tumors along with ipsilateral shoulder and arm pain, paresthesias, paresis and atrophy of the thenar muscles of the hand and Horners syndrome (ptosis, miosis, and anhidrosis).)
- SVC Obstruction
- Facial/hand swelling worst in mornings
- Headache - Cutaneous metastasis
- Shoulder
- Hard palate
Name the non-metastatic manifestations of bronchial carcinoma
- Finger clubbing
- Hypertrophic pulmonary osteoarthropathy
Hormone syndromes:
- Hypercalcemia
- Inappropriate ADH
- Ectopic ACTH
Neuromyopathies:
- Eaton-Lambert syndrome
- Peripheral neuropathy
- Dementia
- Cerebellar syndrome
What is the treatment for small cell/non-small cell carcinoma?
Small cell = chemotherapy
Non-small cell:
- Surgery
- Radical radiotherapy (usually 20 daily treatments)
- Palliation (symptomatic, radiotherapy, chemotherapy)
What are the possible differentials for bronchial carcinoma?
- TB
- Pneumonia
- Lung metastases from other primary (ie. breast)
- Benign lung tumours
- Rarities (Wegener’s granulomatosis - inflammation of respiratory tract and kidneys)
What investigations are done in bronchial carcinoma?
- Chest xray/CT scan
- Bloods (FBC, LFTs, Calcium)
- Fibreoptic bronchoscopy (60%)
- Percutaneous needle biopsy
- Node biopsy
- Mediastinoscopy/mediastinotomy
- Thoracotomy
What is the macroscopic appearance of bronchial carcinoma seen at thoracoscopy?
Visceral + parietal pleural deposits of mesothelioma
In what situations would a non-small cel bronchial carcinoma not be operable?
- Distant metastasis
- Mediastinal spread (i.e. recurrent laryngeal nerve palsy, phrenic nerve palsy)
- Poor pulmonary function
- Frequent angina/heart failure
- Psychological failure
What is a FDG-PET scan?
A PET scan uses a small amount of a radioactive drug, or tracer, to show differences between healthy tissue and diseased tissue. The most commonly used tracer is called FDG (fluorodeoxyglucose), so the test is sometimes called an FDG-PET scan. Before the PET scan, a small amount of FDG is injected into the patient.
How are bronchial carcinomas staged?
Primary tumour (T0-T4)
Regional lymph nodes (N0-N3)
Distant metastasis (M0-M1b)
What is the importance of EGFR positive lung cancer cells?
EGFR is a protein found in abnormally high levels on the surface of many types of cancer cells, particularly non-small cell lung cancer cells.
EGFR mutation positive cells predict response to specific chemotherapy - GEFITINIB
What are multiple pleural plaques on X-ray an indicator of?
Asbestos exposure
As far as we can tell these plaques are benign and very slow growing. They are not the cancer called mesothelioma. As far as we know these plaques do not change into mesothelioma. They do however suggest significant past exposure to asbestos and that in itself increases your risk of mesothelioma.
What is asbestosis?
Asbestosis refers to a very specific chronic lung condition associated with lung fibrosis that follows chronic exposure to asbestos
What is the difference between asbestos exposure and asbestosis?
Pathological changes in severe asbestosis: note the extensive thickening and plaque formation in the pleura.
Diffuse pleural thickening is less specific for asbestos exposure because other causes of exudative effusions can lead to it. It results from thickening and fibrosis of the visceral pleura, which leads to fusion with the parietal pleura, and is preceded by benign pleural effusion. Histologically, there is similarity between pleural thickening and plaques, except that fusion of the pleural layers is suggestive of more intense inflammation. The underlying process is thought to be inflammation and fibrosis of lymphatic vessels and may be a direct extension of lung fibrosis.
What causes multiple cough fractures on chest x-ray?
Chronic cough
When is a meniscus seen on chest x-ray? Silhouette?
Meniscus = effusion Silhouette = pneumothorax (no lung markings)
What does a bats wing appearance look like on chest x-ray, and what does it signify?
Radiating out from the hilum
Indicates fluid in the interstitium
List some complications of lung cancer
- Growing mass of cells compress nearby structures (i.e. wheeze)
- Pancoast’s tumour, recurrent laryngeal nerve palsy (hoarseness of voice), Horner’s syndrome, SVC obstruction - Spread of cancer to liver (jaundice), adrenal gland (alters hormone secretion, diabetes), lymph nodes around mediastinum, pleural walls = increased inflammation
- Immune response = muscle weakness, decreased ability of nerves to signal to muscles
What are the main differences between non-small cell and small cell carcinoma of the lung?
- Non-small cell = more at the apex of the lung
Small cell = more at the centre of the lung - Non-small cell = parathyroid hormone related protein released -> Ca2+ removed from bones + increased amounts in blood = weakening of bone
Small cell = increased ADH secretion = decreased urine volume = bloating + increased BP, Na+ excretion + H2O retention
Small cell = increased adrenocorticotropic hormone = ectopic Cushing’s syndrome (from adrenal gland = decrease immune function + immunosuppression)
Where does PTH have its effect?
kidney
bone
gut
What are the signs and symptoms of increased PTH?
- Anxiety
- Depression
- Cognitive changes
- Lethargy -> coma
- Cramping
- Nausea/vomiting
- Anorexia
What is the treatment for elevated Ca2+ levels?
- Furosemide with fluid which will get rid of excess Ca2+ (calciuresis)
- Treatment of underlying disease (tumour)
- Bisphosphonates ± calcitonin
What is the point of staging a tumour and what system is used for lung cancer?
The staging systems used are based on assessing the primary tumour (T), the lymph Nodes (N), metastases(M). The survival curves (Kaplan Meyer)for T2 are worse than T1, T3 than T2 and so on. Non small cell cancer that has not spread has a median survival of approximately 2 years if treated but only 10% if there is significant spread.
How does one evaluated pleural effusion?
Thoracentesis: needle + catheter into thorax to drain fluid
What are the indications of a pleural effusion?
New findings of pleural effusion
What does a thoracentesis diagnose?
- Malignancy
- Empyema
- TB
- Pleuritis
- Fungal infection
- Lupus pruritis
- Chylothorax
- Urinothorax
- Esophageal rupture
- Hemothorax
- Peritoneal dialysis
What blood tests should you order to evaluate a pleural effusion?
- FBC
- Cytology
- Amylase
- pH
- Glucose
- Adenosine deaminase
- LDH
- Total protein
- Cultures
What are the possible gross appearances of pleural effusion fluids?
Bloody = malignancy, asbestosis, pulmonary infarction, postcardiac injury syndrome
White = chylothorax, cholesterol effusion
Black = aspergillus
Yellow-Green = Rheumatoid pleurisy
Dark Green = Bilothorax
Anchovy Paste-Like = Amebic liver abscess
Pus = Empyema
What is the difference between transudate and exudate?
Transudate: Imbalance in hydrostatic + oncotic pressures
- Fluid moves from peritoneal or retroperitoneal spaces
- i.e. CHF, cirrhosis, nephrosis (“the big 3”)
Exudate: Disease in virtually any organ can cause exudates
What is Light’s Criteria?
If at least 1 of these is met = exudate
- Pleural fluid protein/serum protein > 0.5
- Pleural fluid LDH/serum LDH > 0.6
- Pleural fluid LDH > 2/3 upper limits of normal serum LDH
What are the levels of protein, LDH, cholesterol, glucose, pH, amylase, and adenosine deamylase in pleural effusion diagnoses indicating?
Protein:
- Most transudates have total protein > 3.0
- TB pleural effusion > 4.0g/dl
- if > 7-8 = Walderstorm’s macroglobinemia or Multiple Myeloma
LDH:
- > 1000 = empyema, rheumatoid pleurisy, malignancy
- Pneumocystitis jirovecci pleural effusion:
1. Fluid/serum LDH > 1
2. Fluid protein/serum protein < 0.5 (also in urinothorax)
Cholesterol:
- Indicates vascular leakage + degeneration of cells
- > 45mg/dl = exudate
Glucose:
- < 60 or fluid/serum < 0.5 =
1. Rheumatoid pleurisy
2. Parapneumonic effusion/empyema
3. Malignant effusion
4. Lupus pleuritis
5. Esophageal rupture
pH:
Low = increased acid production by pleural fluid cells (empyema)
OR
Decreased H+ ion efflux (malignancy, rheumatoid pleurisy, TB pleurisy)
Amylase:
- Fluid > ULN serum
- Fluid/serum > 1 =
1. Acute pancreatitis
2. Esophageal rupture
3. Chronic pancreatic pleural effusion
4. Malignancy
Adenosine Deamylase:
- > 50 = TB
Practice prescribing a high strength nicotine patch for a patient that smokes on average 20 cigarettes a day. The pharmacy stock Nicotinell Patches. The patient has no known drug allergies.
Nicotinell “30” patch, 1 patch, topical
A middle aged patient presents with tiredness. Nothing is found in the history or examination but bloods reveal:
Serum Sodium 119mmol
Serum Potassium 4.6 mmol
Serum Urea 6.4 mmol
Serum Creatinine 84 micromol/l
Blood glucose 5.2mmol
The first test to do is?
Urinary sodium
In a patient who is neither fluid deficient or overloaded the urinary sodium value if less than 40mmol suggests a recent excess water load or psychogenic over drinking. If higher ie >40mmol then this suggests the syndrome of inappropriate ADH secretion.
The patient in 1 above has further results urinary Sodium 62mmol, Urinary osmolality 319 mosm/kg . Which is the most likely diagnosis?
Small cell cancer of the lung
Small cell cancer characteristically causes SIADH often quite severe and may be the cause of the presenting symptom(s). In SIADH the urine osmolality is greater than the serum osmolality.
A middle aged lady presents with mild dizziness due to vertigo and examination reveals grade 2 nystagmus. She is otherwise well and brain scanning is normal. Anti Hu antibodies are present. The most likely cause is:
Small cell carcinoma of the lung
Antigens released by the tumour cause an immune response that attacks neurones.
A female patient from East Asia who has never smoked develops an adenocarcinoma of the lung which tests positive for a mutation in the epidermal growth factor receptor. Which of the following best describes the situation?
She has a better prognosis than if she had EGFR wild type
A mutation in this gene allows treatment with drugs such as gefitinib or erlotinib which roughly doubles her likely survival with relatively little toxicity. This is a classic clinical presentation of a patient with egfr mutation. Each pack year smoked makes a mutation less likely.
A 55 year old lady has developed a large pleural effusion with chest pain and soft tissue extending through the chest wall. The percutaneous biopsy shows mesothelial cells invading fat. Which statement is most accurate?
Talc pleurodesis is useful in controlling symptoms
Talc which is a mineral which causes intense inflammation is the best material to stick the layers of pleura together and prevent pleural effusions
List possible differentials for a well demarcated consolidation in the middle zone of the lung, near the hilum
- Vascular (PE) -> D-dimer to investigate
- Infection (TB, Aspergillus) -> FBC
- Neoplasm (Tumour) -> Bronchoscopy, PET scan
- Metabolic (Rheumatoid nodules, sarcoidosis)
- Churg Strauss/Wegeners vasculitis (ANCA screen)
- Kaposi’s sarcoma -> KS usually occurs in immunocompromised hosts such as patients with HIV.
- Trauma hematoma
What is Churg Strauss/Wegeners vasculitis?
Churg Strauss:
- Churg-Strauss syndrome, in particular, occurs in patients with a history of asthma or allergy and features inflammation of blood vessels (also referred to as angiitis) in the lungs, skin, nerves, and abdomen. The blood vessels involved in Churg-Strauss syndrome are small arteries and veins.
Wegeners:
- Wegener’s granulomatosis is a systemic necrotising granulomatous inflammatory condition that may be accompanied by vasculitis, classically involving the upper respiratory tract, lungs, and kidneys
How can you distinguish a contrast CT from non-contrast CT?
Contrast = blood vessels and bone are same colour (white)
What is the treatment for PE?
- LMWH (S/C) -> IV not as well controlled
Warfarin is not licensed in patients with active cancer
What are some investigations performed for lung cancers?
- Endobronchial US (EBUS)
- Bronchoscopy
- Biopsy
- PET scan
- EGFR, ROS, ALK, PDLs proteins (if positive offer monoclonal antibodies as treatment!)
What should be asked to a patient with suspected pleural effusion?
- Any symptoms of heart failure (swelling of legs, waking at night (PND)
- Symptoms of pneumonia/infection (fever)
- History of RA/SLE (predispose to pleural effusion)
- Alcohol use/abuse (liver failure/heart failure increase risk of pleural effusion)
When performing a pleural tap what should the fluid be sent off for?
- Biochemistry (determine if its transudate/exudate)
- Cytology
- Culture
What are the 3 causes of increased calcium levels?
- Sarcoidosis
- Hyperparathyroidism
- Bone metastases
What is the management plan for someone with metastatic cancer?
- Pleurodesis (medical procedure in which the pleural space is artificially obliterated. It involves the adhesion of the two pleurae.)
- Pleurex catheter (long-term drainage)
