Respiratory Malignancies (WATCH VIDEOS) Flashcards
Respiratory malignancies include:
Lung cancer
Mesothelioma (cancer of lung pleura)
what does knowledge of anatomy help with when looking at malignancies?
helps diagnosis and treatment of cancer
define Mid-clavicular and Mid-axially line
Mid-clavicular line (halfway between clavicle)
Mid-axially line vertical: line from the middle of axilla
what is the Angle of Louis?
explain the positioning
Formed by junction between manubrium and sternal body
Level of T4-T5 intervertebral disc
Marks the level of the 2nd rib
Marks level of the bifurcation of trachea (carina)
Marks the start of aortic arch
Marks where azygous vein enters superior vena cava
what is the pleura?
explain the positioning
2 layers: Visceral and Parietal pleura
Pleura Meet at 2nd rib
Pleura diverge at 4th rib (accommodate for heart)
Line up to the midclavicular line at 8th rib
Pleural lines travel posteriorly around the chest wall at 12th rib
explain the positioning of the heart
Sits at the 3rd to 6th rib
Lies to the left of sternum
Apex of heart located at 5th intercostal space (on left)
In lung disease or lung collapse: heart can be moved
explain what each lung is made up of
how do you listen to all the lobes?
The right lung is made up of 3 lobes
The left lung is made up of 2 lobes
Must move stethoscope to listen to all the lobes.
what is the location of the lobes of the lungs?
label the parts of the lung
when listening to the chest anteriorly what might happen?
The righter lower lob is very small – clips the bottom
So, when you listen to the chest anteriorly you may think you are listening to right lower lobe but you are probably listening to right middle lower
what are clinical features (taken from history) that you look for when diagnosing lung cancer?
Cough
Chest pain (40%) - if cancer is peripheral and sitting near nerves or parietal pleura, common in mesothelioma
Hoarse voice (22%) - if it’s a big central tumour pressing on recurrent laryngeal nerve and therefore affects voice
Dyspnoea - breathlessness due to lack of lung function
Weight loss (7%) - displayed later when cancer is more advanced
Smoker
Haemoptysis - coughing up blood
Not massively common, only if tumour is present in main airways
Finger clubbing
what does this radiograph suggest?
Large tumour present in the right upper lobe
This may present with any of the symptoms above.
what is the epidemiology of lung cancer?
40,000 new cases of lung cancer every year in UK
Survival rates not improved as much as other cancers
It is now more important than ever to identify patients with lung cancer as soon so we can to cure e.g. through surgery which is more difficult if cancer is picked up later
what are the causes (aetiology) of lung cancer?
Smoking: biggest factor
Asbestos: building material that was used in plumbing and insulation in 1980s
When taking a history, you must ask the patient about previous jobs/determine possibility of contact with Asbestos; those who have are viable for government compensation
Peak of incidence will be in 2020
Radiation: causes change in cell proliferation and cell cycle pathway.
All work by a mechanism which triggers abnormal and uncontrolled cell proliferation
We now target treatment at the receptor or pathway that has been implicated.
what are some important statistics regarding lung cancer?
Only 30% of lung cancer patients survive 1 year from time of diagnosis (due to signs presenting late or ignoring symptoms)
8% lung cancer patients survive past 5 years
Contrast to: 94% breast cancer patients and 96% prostrate cancer patients surviving 1 year
Screening could ↑ this prognosis, but controversial
explain the diagnosis pathway for lung cancer?
Suspect lung cancer in patient due to common symptoms –> Chest Xray
1. If abnormality is seen in X-ray - do a CT scan of chest (tell you location of
tumour)
- Staging and typing of cancer (determine how to manage it best). This is done via:
Bronchoscopy is done if there is a central tumour that can be seen through airways -> Take a biopsy. The Bronchoscopy can be done with or without endobronchial ultrasound (EBUS) - this allows us to what lymph nodes are involved (changes staging)
Biopsy => usually CT guided if the tumour is peripheral.
PET scan (radioactive scan)
- Glucose is labelled and given to patient either through IV or orally.
- The glucose is then taken up by highly metabolically active cells (cancer cells).
- These then light up which tells you if there is distant spread of cancer and what lymph glands are involved (important information in staging)
Neck USS (biopsy)
The tests above work out:
Which lobe is involved?
Local spread?
Metastatic spread? (has cancer spread beyond the diaphragm)
Tissue Diagnosis (what type of cancer)
what is the tissue diagnosis of Non-Small Cell Carcinomas?
Non-Small Cell Carcinomas
- Squamous cell carcinoma
- Cancer arises from squamous cells
Adenocarcinomas:
- Rarer
- Due to mutation in acinar cells – those that produce mucus.
what is the tissue diagnosis of Small cell carcinomas?
Carcinoids:
Derived from neuroendocrine tissue
Neuroendocrine tumours - Can produce endocrine hormones e.g. ADH or produce PTH causing hypercalcaemia (Bones, moans and stone)
what is Bronchoscopy and when is it done?
visualising inside of airways
Done with patient awake using a local anaesthetic
Insert through nose or mouth, pass through larynx into trachea and into lungs.
If you see cancer take some clippers to perform biopsy.
Visualisation and sampling via bronchoscopy is limited by anatomy (cannot reach/visualise narrow further bronchioles)
If tumour is very peripheral (beyond the bronchioles and main airways) you cant see them and pass a needle into them.
to stage the cancer, what do you use?
Using a PET scan you can see if a cancer has spread (not easy to see in CT scan)
Use radio-labelled glucose → given to patient –> glucose is taken up by highly metabolic active tumour cells –> these cells will then light up in a PET scan (yellow flash)
In the image below you can see how a PET clearly confirms suspicions created by a CT scan.
how can you manage by stage for NSCLC?
Things that limit being offered surgery are that if the patient has COPD or emphysema – taking out big portion of lung may result in no viable lungs left to breathe with.
White boxes (T3/T4) patient not suitable for surgery so palliative treatment with chemotherapy or immunomodulator drugs.
how can you manage lung cancer?
Staging determines management
what are local complications of large tumour sat at upper lobe?
Superior Vena cava obstruction (via compression due to tumour)
Causing back flow causing pressure effect in head
Fixed + raised jugular venous pressure (JVP)
Lips cyanosed
Collateral vasculature forming on chest (blood trying to find route around tumour)
what is horners syndrome?
Damage to sympathetic nerve fibres by tumour
Signs: partial ptosis (drooping of eyelid), enophthalmos (sinking in of eye), miosis (pupil constricted), anhidrosis (loss of sweating)
what is Recurrent laryngeal nerve palsy?
Recurrent laryngeal nerve palsy → hoarse voice
See normal vocal cords on left and on right you can see palsy of vocal cords
what is pleural effusion?
Clinical features?
Pleural cells create excess plural fluid which when in the pleural space will compress the lung causing breathlessness and pain.
Clinical features of pleural effusion:
Dyspnoea
Pain
Symptoms of underlying cause (e.g., those for lung cancer)
Reduced expansion of affected side of chest
Dull percussion notes
reduced vocal resonance
Occurs due to 3 reasons:
↑ leakage into pleural space
Produced by Pathology in pleural space
↓ removal from pleural space
what are the causes of pleural effusion?
How we look at pleural effusion is that we take sample of fluid by using a needle and see protein content.
Causes:
what does this image show?
See asbestos fibres
These fibres enter pleura via airways and enter pleura and cause mutation in cells there leading to mesothelioma.
