S11: lung cancer & clinical signs and symptoms of lung disease Flashcards
Describe the incidence of lung cancer
One of the most frequently diagnosed cancers and the leading cause of cancer-related deaths worldwide
In UK: rate is three times higher in the lower socio-economic group compared with the highest
List aetiological factors involved in lung cancers
Smoking
Exposure to asbestos and radon
Genetic
Dietary factors
Describe the common methods used to obtain material for histological diagnosis
Usually obtained by bronchoscopy & needle biopsy of the lung or pleura
Making a histological diagnosis essential -> confirm lung cancer & decide the cell type, which is important both in terms of the prognosis & treatment
Describe what imaging is used for suspected lung cancer
All: chest x-ray & staging chest CT
Some: PET-CT, head CT, pelvic CT, MRI, bone scan & ultrasound
Central to both the diagnosis and assessment of the extent of disease – this is known as staging
Describe treatments for lung cancer
Surgery, chemotherapy, radiotherapy & palliative therapy
Often used in combination and are tailored to each individual patient
Management is provided by an expert MDT
Surgery is the treatment most likely to result in long-term survival, if this is not possible, other treatments can increase life expectancy & provide significant relief from their symptoms
Describe screening for lung cancer
Not currently, but there is hope that as screening is adopted, survival to improve
Barriers – stigma of smoking, lack of awareness of screening recommendations among healthcare professionals
Describe the different types of lung cancer
Divided broadly into non-small cell lung cancer (85%) or small cell lung cancer (15%)
For NSCLC, adenocarcinomas are the most common subtype, followed by squamous-cell carcinomas
Standard care for stage 1, 2 & 3A is surgical resection
SCLC is characterised by its rapid growth, tendency to metastasise and poor survival rates
List common symptoms of lung cancer
Cough
Dyspnoea – central tumours may occlude airways resulting in lung collapse
Haemoptysis
Recurrent lung infections
Wheeze
Hoarse voice – compression of the recurrent laryngeal nerve (left more than right)
Brachial plexus and/or sympathetic nerve chain compression
SVC obstruction
What is a Pancoast tumour?
Tumours occurring in the lung apex
May invade the brachial plexus causing C8/T1 palsy with small muscle wasting in the head & weakness
If sympathetic chain compressed -> Horner’s syndrome may occur with miosis, ptosis & anhidrosis
Define paraneoplastic syndromes
A group of clinical disorders that are associated with malignant diseases and are not directly related to the physical effects of the primary or metastatic tumours
These conditions arise from secretions of functional peptides/hormones from the tumour or inappropriate immune cross-reaction between normal host cells & tumour cells
Describe paraneoplastic syndromes related to lung cancer
Most associated with lung cancers – 10% of people with lung cancer will have a paraneoplastic syndrome
Humoral hypercalcaemia of malignancy – squamous cell carcinoma
Syndrome of inappropriate antidiuretic hormone secretion (SIADH) – small cell lung cancer
Lung cancer associated paraneoplastic neurological syndromes – body makes antibodies to the tumour, but those antibodies then attack other organs (RARE)
Describe humoral hypercalcaemia of malignancy
Caused by:
1) Parathyroid hormone-related protein – most common
2) Ectopic parathyroid hormone production
Hypercalcaemia in lung cancer can also be seen from osteolytic activity at the sites of skeletal metastases -> not considered a paraneoplastic syndrome as it results from metastasis eroding bone & releasing calcium
List key signs and symptoms of respiratory disease
Breathlessness Chest pain Cough Productive cough (sputum) Haemoptysis Wheeze/stridor
Describe breathlessness (dyspnoea)
Subjective awareness of increased effort of breathing
Symptom rather than a sign
Very common, but not specific to respiratory conditions eg. anaemia, heart failure, obesity
Describe things to ask a patient about breathlessness
Onset, timing and duration – acute onset, duration of symptoms, continuous/intermittent
Progression – has it got worse over time?
Exacerbating factors – lying flat, cold weather, pets or pollen
Severity – walking upstairs, walking on flat, whilst speaking or housebound
List different causes of chest pain
Mediastinal structures – ACS, pericarditis, oesophagitis/GORD & aortic dissection
Pleura – infection, pneumothorax, pulmonary embolism
Chest wall – rib fracture, costochondritis, shingles (varicella zoster)
Compare cardiac and pleuritic pain
Cardiac – crushing, dull, poorly localised, radiates to neck, jaw & arm
Pleuritic – thoracic wall/shoulder tip, sharp, well localised & worse when coughing and breathing in
Describe the cough mechanism
Triggered by stimulation of mechano and/or chemoreceptors within airway
After initial inhalation, a cough includes:
1) Adduction of VCs with contraction of internal ICs and abdominal muscles increasing intrathoracic pressure
2) Followed by abduction of VCs
Describe things to ask a patient about cough
Dry or productive – what colour, how much, blood
Character – bovine, croup
Timing – night, seasons
List conditions which could cause a productive cough
Chronic bronchitis & COPD – clear sputum (no active infection)
Yellow-green sputum (live/dead neutrophils) – infection
Large volumes (yellow/green) – could suggest bronchiectasis
Haemoptysis – red flag
List respiratory and non-respiratory causes of a cough
Any irritation of airways, lung parenchyma or pleura
Non-respiratory causes: LV heart failure, GORD & drugs (eg. ACE-inhibitors)
Describe a wheeze
High pitched, musical Mostly on expiration Narrowing in intrathoracic airways eg. bronchial smooth muscle contraction, oedema, mucous Narrowing exacerbated during expiration May only be audible with stethoscope
Describe a stridor
High pitched, constant, loud
Mostly on inspiration
Indicates narrowing in extrathoracic airway – supraglottis, glottis, infraglottis or trachea
Narrowing exacerbated during inspiration
Often audible without stethoscope
Describe inspection in respiratory examination
General inspection – patient comfortable, breathlessness at rest and/or speaking, elevated RR
Closer inspection – hands, face, chest
Compare central and peripheral cyanosis
Bluish discolouration
Peripheral – cold exposure/decreased cardiac output
-slowing of blood to peripheries, increased oxygen extraction, more deoxy blood in that area
Central – significant cardiac or respiratory cause
-caused by increase in amount of deoxy Hb in blood arriving at tissues
Describe pursed lip breathing
Breathing out slowly through mouth with pursed lips – commonly seen in COPD
Pursing lips increases resistance to outflow on expiration
Maintains intrathoracic airway pressures allowing for small airways to remain open for longer:
1) Prolonging period for gas exchange to occur
2) Allow more air to empty (rather than trap)
Describe barrel shaped chest
Increased AP diameter
Associated with lung hyperinflation – seen in severe COPD (especially emphysema)
AP diameter > lateral diameter
Chronic over-inflation of lungs (due to air trapping)
Hyperexpands the chest wall over time
Describe palpation in respiratory examination
Tracheal position
Chest expansion – symmetrical?
Describe percussion in respiratory examination
Resonant – normal
Hyper-resonant – increased air
Dull – consolidation
Stony-dull – fluid
Describe auscultation in respiratory examination
Normal (vesicular) – ‘rustling leaves’, inspiration & first part of expiration, no gap between inspiration & expiration
Bronchial – ‘blowing’ harsh sound, inspiration and expiration, gap between them
Reduced or absent
Added sounds
List the different added sounds which can be seen in a respiratory examination
Wheeze/stridor
Crackles – snapping open of alveoli/small bronchi
-fine: pulmonary fibrosis
-coarse: COPD, bronchiectasis (air bubbling through mucous secretions)
Pleural rub – scratching, coarse sound
-inflammation of pleura
Describe examination findings for pleural effusion
Tracheal deviation – if very large, possible
Chest wall movement – reduced on affected side
Percussion note – stony dull
Breath sounds – absent over fluid
Added sounds – possible rub
Describe examination findings for consolidation
Tracheal deviation – none Chest wall movement – reduced on affected side Percussion note – dull Breath sounds – bronchial Added sounds – crackles
Describe examination findings for asthma
Tracheal deviation – none Chest wall movement – decreased symmetrically Percussion note – resonant Breath sounds – normal or reduced Added sounds – wheeze
Describe examination findings for a pneumothorax
Tracheal deviation – if tension, possible
Chest wall movement – reduced on affected side
Percussion note – hyper-resonant
Breath sounds – absent
Added sounds – none
