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Respiratory: Patient History, etc > Pleural Malignancy > Flashcards

Pleural Malignancy Flashcards

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1
Q

What are pleura?

A

Serous membranes

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2
Q

What does the visceral pleura cover?

A

Lungs

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3
Q

What do visceral pleura form?

A

Interlobar fissures

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4
Q

What do parietal pleura cover (4 types of parietal pleura)?

A

* Mediastinum * Diaphragm * Cervical pleura * Costal pleura

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5
Q

Where are the pleura considerably lower than the corresponding border of the lung?

A

Inferior margins

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6
Q

How much pleural fluid does the pleural cavity normally contain?

A

Usually contains around 4ml (depends on weight)

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7
Q

How much pleural fluid must be present in the pleural cavity in order for it to be detected via CXR?

A

200 ml

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8
Q

What is the function of pleural fluid?

A

* Lubricates the 2 pleural surfaces * Allows the pleura to slide smoothly during respiration

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9
Q

What allows lung surface to stay touching thoracic wall?

A

Surface tension

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10
Q

Which part of the lung has no pleural coverage?

A

The hila

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11
Q

What is formed by the combination of the 2 pleural layers?

A

Pulmonary ligament

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12
Q

What is the pulmonary ligament?

A

Runs inferiorly and attaches the root of the lung to the diaphragm

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13
Q

What is pleural effusion?

A

Abnormal collection of fluid in pleural space?

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14
Q

What common techniques are used to make a diagnosis of pleural effusion? (6)

A

* History and examination
* PA CXR
* Pleural aspirate
* Biochemistry (is it a transudate or an exudate?)
* Cytology
* Culture

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15
Q

What other tests can be carried out if cause of pleural effusion is still unclear?

A

* Contrast enhanced CT chest
* Repeat pleural tap (thoacentesis)
* Pleural biopsy (blind or thoracoscopy)

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16
Q

What problem is seen on this CXR?

A

Right lower lobe pleural effusion - as there is no mediastinal shift, which could indicate tumour instead

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17
Q

What is often indicative of pleural effusion on CXR?

A

Meniscus sign

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18
Q

What is often indicative of both fluid and air in lung tissue on CXR?

A

Flat line rather than meniscus

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19
Q

What can straw-coloured pleural fluid indicate?

A

* Cardiac failure
* Hypoalbuminaemia

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20
Q

What can bloody pleural fluid indicate?

A

* Trauma
* Malignancy
* Infection
* Infarction

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21
Q

What can turbid/milky pleural fluid indicate?

A

* Empyema
* Chylothorax

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22
Q

What can foul-smelling pleural fluid indicate?

A

Anaerobic empyema

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23
Q

What can food particles in pleural fluid indicate?

A

Oesophageal rupture

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24
Q

What can cause a bilateral pleural effusion?

A

* Left ventricle failure
* Pulmonary thromboembolism
* Drugs

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25
Q

What is the purpose of biochemical tests in pleural effusion?

A

To determine whether fluid is transudate or exudate

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26
Q

In biochemical tests, what is indicative of transudate?

A

Protein <30g/l

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27
Q

In biochemical tests, what is indicative of exudate?

A

Protein >30g/l

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28
Q

What is transudate fluid indicative of?

A

* Heart failure
* Liver cirrhosis *
Hypoalbuminaemia
* Atelectasis (ITU or post surgery)
* Peritoneal dialysis

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29
Q

What is exudate fluid indicative of?

A

* Malignancy - cancer
* Infection inc TB
* Pulmonary infarct
* Asbestos

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30
Q

What should be done if fluid is found to be exudate?

A

Always look for serious pathology

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31
Q

What can fluid pH tell us in biochemical testing?

A

* Normal 7.6 (only valid if plasma pH normal)
* < 7.3 suggests pleural inflammation (malignancy/rheumatoid arthritis)
* < 7.2 requires drainage in the setting of infection

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32
Q

What can glucose levels in biochemical testing tell us?

A

Glucose levels are low in:-
* infection
* TB
* Rheumatoid arthritis
* Malignancy
* oesophageal rupture
* Systemic lupus erythematosus (SLE)

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33
Q

What are cytology and cell counts used for in regards to pleural effusion?

A

* Mostly looking for malignant cells
* Also lymphocytes
* Neutrophils

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34
Q

What does the presence of lymphocytes in cytology of pleural effusion suggest?

A

* Tuberculosis
* Malignancy
* However, any long-standing infection will eventually become lymphocytic

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35
Q

What does the presence of neutrophils in cytology of pleural effusion suggest?

A

An acute inflammatory process

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36
Q

What are the tests for Tuberculosis?

A

* PCR
* Ziehl-Neelsen stain (acid-fast stain)
* Culture

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37
Q

What microbiology techniques are used in the diagnosis of pleural effusion?

A

* Gram stain and microscopy
* Culture
* PCR, AFB stain and liquid culture

38
Q

How can the liquid culture produce higher diagnostic yield?

A

Placing in blood culture bottles

39
Q

What is repeat pleural tap/thoracentesis the same as?

A

Pleural aspiration

40
Q

Is thoracentesis/pleural aspiration useful diagnosing malignant pleural effusion?

A

Pleural aspiration will diagnose malignancy in approx. 60% of patients with malignant pleural effusion

41
Q

What can be done to increase the diagnostic yield of a pleural tap?

A

* A second sample may increase the yield slightly, third and subsequent samples are non-contributory * Increasing the volume of the aspirate does not increase yield

42
Q

What has a very poor chance of being diagnosed via Pleural fluid cytology?

A

Mesothelioma - a positive result is obtained in less than a third of cases

43
Q

What are types of tissue biopsy?

A

* Blind percutaneous pleural biopsy - Abrams
* CT guided pleural biopsy
* Thoracoscopy
* Thoracotomy

44
Q

How is a blind percutaneous pleural biopsy carried out?

A

Pleural aspiration using a needle with a special head - when it is pulled back, it takes a section of pleural membrane with it

45
Q

Why are biopsies so often negative?

A

* Wrong technique - biopsy doesn’t contain pleura
* The involvement of pleural disease is discontinuous (biopsies section of pleura not affected by disease)
* The effusion is ancillary to malignancy but not malignant

46
Q

What is the advantage of using CT imaging to guide needle pleural biopsy?

A

Increases diagnostic sensitivity of Abrams needle biopsy from 47% to 87%

47
Q

What is a mesothelioma?

A

Uncommon malignant tumour of the lining of the lung or very occasionally of the lining of the abdominal cavity

48
Q

What increases the chance of developing mesothelioma?

A

Likelihood of developing mesothelioma increases with the degree and the length of time exposed to asbestos (may occur in people who have not worked with asbestos but have been associated with people who have)

49
Q

How often does mesothelioma take to develop?

A

Often takes 30–40 years to develop

50
Q

What are symptoms of mesothelioma?

A

May cause breathlessness, chest pain, weight loss, fever, sweating and cough

51
Q

What investigations are involved in diagnosis of mesothelioma?

A

* Imaging * Pleural fluid aspiration * Biopsy

52
Q

What does imaging for mesothelioma involve?

A

Looking at:- * Pleural nodularity * Circumferential pleural thickening * Local invasion * Lung entrapment

53
Q

What does pleural fluid aspiration for mesothelioma involve?

A

* Low cytological diagnostic yield (larger with biopsy) * Avoid repeated aspiration

54
Q

What does biopsy for mesothelioma involve?

A

Thoracoscopy or CT/US guided

55
Q

What are the treatment options for mesothelioma?

A

* Pleurodesis (adhesion of pleural layers to obliterate pleural cavity)
* Radiotherapy
* Surgery
* Chemotherapy
* Palliative care
* Report deaths to fiscal (compensation, asbestos etc)

56
Q

What cancers can metastasise to the pleura?

A

Virtually all cancers but especially:-
* lung cancer
* breast cancer
* Upper GI
* lymphoma
* melanoma
* ovary

57
Q

What is the medial survival rate of mesothelioma sufferers?

A

3-12 months

58
Q

What is a TALC slurry used for?

A

Pleurodesis

59
Q

What is pleurodesis?

A

Procedure to obliterate the space between the pleura (the pleural cavity) so that fluid (water, blood, or pus) can no longer build up between the layers

60
Q

What is TALC?

A

A sclerosing agent

61
Q

What is a Talc slurry?

A

TALC in suspension

62
Q

What is the success rate of TALC slurry in plerodesis?

A

60% success

63
Q

What are complications of TALC?

A

* Minor pleuritic pain and fever (Common)
* Pneumonia (Rare)
* Respiratory failure (Rare)
* Talc pneumonitis/ARDS ( Rare)
* Secondary empyema (Rare)
* Local tumor implantation at port site in mesothelioma

64
Q

What are long term pleural catheters?

A

Designed to allow patients control their effusion and therefore symptoms

65
Q

When are long term pleural catheters used?

A

Inserted mostly in patients with malignant effusions

66
Q

Is long term pleural catheter eventually removed?

A

Drain is designed to remain in place for life though some people will stop producing pleural fluid

67
Q

In long term pleural catheters, what provides the suction to drain pleural fluid?

A

Vacuum in drainage bottle

68
Q

How much fluid is drained by long term pleural catheter per day?

A

Never drain more than 1 litre a day

69
Q

What are the complications of long term pleural catheters?

A

* Incorrect placement
* Bleeding
* Infection
* Flying can be tricky

70
Q

What are the advantages of long term pleural catheters?

A

* Controls symptoms of pleural effusion
* Patients can shower
* Some will even bathe or swim though this is not really recommended

71
Q

What is used to predict survival in malignant pleural effusion?

A

LENT score

72
Q

What is a LENT score?

A

L - LDH level in pleural fluid
E - ECOG performance status
N - neutrophil to lymphocyte ratio
T - Tumour type

73
Q

What does treatment of malignant pleural effusion involve?

A

* LVF – diuretics
* Infection – drain, antibiotics, may require surgery
* Malignancy – drain, pleurodesis, long term pleural catheter

74
Q

What does treatment of malignant pleural effusion depend on?

A

Depends on the underlying cause

75
Q

When is pneumothorax more common?

A

* Tall thin men
* Smokers
* Cannabis
* Underlying lung disease

76
Q

What is primary pneumothorax?

A

* Initially normal lungs
* Apical bullae rupture

77
Q

What is secondary pneumothorax?

A

Underlying lung disease (e.g. COPD)

78
Q

What are the presentations primary pneumothorax?

A

May be asymptomatic even if moderately sized

79
Q

What are the presentations of secondary pneumothorax?

A

Usually symptomatic even if small

80
Q

What are the symptoms of secondary pneumothorax?

A

* Acute onset pleuritic chest pain
* SOB
* Hypoxia

81
Q

What are the clinical signs of pneumothorax?

A

* Tachycardia
* Hyper-resonant percussion note
* Reduced expansion
* Quiet breath sounds on auscultation
* Hamman’s sign (‘Click’ on auscultation left side)

82
Q

What investigation techniques are used for pneumothorax?

A

* Chest X-ray usually sufficient
* CT chest

83
Q

What is a small pneumothorax?

A

<2cm rim of air (measured at hilar level, not apex)

84
Q

What is a large pneumothorax?

A

>2cm rim of air (measured at hilar level, not apex)

85
Q

What is a CT scan of the chest used for in pneumothorax?

A

Used to differentiate between bullous lung disease and small pneumothoraces

86
Q

How is pneumothorax managed?

A

* Oxygen even if no drain
* No treatment if asymptomatic and small
* Aspiration 1st line treatment in primary pneumothorax
* Chest drain
* May need suction (air leak >48 hours)
* Surgical intervention

87
Q

What are the advantages and disadvantages of aspiration for pneumothorax?

A

* Advantages - avoids chest drain
* Disadvantages - Time consuming May fail esp if age >50 or secondary pneumothorax

88
Q

What does the follow-up for a pneumothorax involve?

A

* CXR until resolution
* Discuss flying and diving after pneumothorax
* Risk of recurrence
* Smoking cessation

89
Q

Why is tension pneumothorax an emergency?

A

Can lead to cardiac arrest

90
Q

What are clinical signs of tension pneumothorax?

A

* Trachea deviated to opposite side
* Hypotension
* Raised JVP
* Reduced air entry on affected side

91
Q

What can cause tension pneumothorax?

A

* Over-ventilation of patient
* Trauma
* CPR
* Blocked, kinked, misplaced drain
* Pre-existing airway disease
* Patients undergoing hyperbaric treatment

92
Q

What is the treatment for tension pneumothorax?

A

Needle decompression
* Usually with large bore venflon
* Second intercostal space anteriorly, mid-clavicular line

Respiratory: Patient History, etc (10 decks)

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