S11: lung cancer & clinical signs and symptoms of lung disease

Question 1

Describe the incidence of lung cancer

Answer 1

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

Question 2

List aetiological factors involved in lung cancers

Answer 2

Smoking
Exposure to asbestos and radon
Genetic
Dietary factors

Question 3

Describe the common methods used to obtain material for histological diagnosis

Answer 3

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

Question 4

Describe what imaging is used for suspected lung cancer

Answer 4

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

Question 5

Describe treatments for lung cancer

Answer 5

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

Question 6

Describe screening for lung cancer

Answer 6

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

Question 7

Describe the different types of lung cancer

Answer 7

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

Question 8

List common symptoms of lung cancer

Answer 8

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

Question 9

What is a Pancoast tumour?

Answer 9

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

Question 10

Define paraneoplastic syndromes

Answer 10

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

Question 11

Describe paraneoplastic syndromes related to lung cancer

Answer 11

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)

Question 12

Describe humoral hypercalcaemia of malignancy

Answer 12

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

Question 13

List key signs and symptoms of respiratory disease

Answer 13

Breathlessness 
Chest pain
Cough
Productive cough (sputum)
Haemoptysis 
Wheeze/stridor

Question 14

Describe breathlessness (dyspnoea)

Answer 14

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

Question 15

Describe things to ask a patient about breathlessness

Answer 15

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

Question 16

List different causes of chest pain

Answer 16

Mediastinal structures – ACS, pericarditis, oesophagitis/GORD & aortic dissection
Pleura – infection, pneumothorax, pulmonary embolism
Chest wall – rib fracture, costochondritis, shingles (varicella zoster)

Question 17

Compare cardiac and pleuritic pain

Answer 17

Cardiac – crushing, dull, poorly localised, radiates to neck, jaw & arm
Pleuritic – thoracic wall/shoulder tip, sharp, well localised & worse when coughing and breathing in

Question 18

Describe the cough mechanism

Answer 18

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

Question 19

Describe things to ask a patient about cough

Answer 19

Dry or productive – what colour, how much, blood
Character – bovine, croup
Timing – night, seasons

Question 20

List conditions which could cause a productive cough

Answer 20

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

Question 21

List respiratory and non-respiratory causes of a cough

Answer 21

Any irritation of airways, lung parenchyma or pleura

Non-respiratory causes: LV heart failure, GORD & drugs (eg. ACE-inhibitors)

Question 22

Describe a wheeze

Answer 22

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

Question 23

Describe a stridor

Answer 23

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

Question 24

Describe inspection in respiratory examination

Answer 24

General inspection – patient comfortable, breathlessness at rest and/or speaking, elevated RR
Closer inspection – hands, face, chest

Question 25

Compare central and peripheral cyanosis

Answer 25

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

Question 26

Describe pursed lip breathing

Answer 26

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)

Question 27

Describe barrel shaped chest

Answer 27

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

Question 28

Describe palpation in respiratory examination

Answer 28

Tracheal position

Chest expansion – symmetrical?

Question 29

Describe percussion in respiratory examination

Answer 29

Resonant – normal
Hyper-resonant – increased air
Dull – consolidation
Stony-dull – fluid

Question 30

Describe auscultation in respiratory examination

Answer 30

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

Question 31

List the different added sounds which can be seen in a respiratory examination

Answer 31

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

Question 32

Describe examination findings for pleural effusion

Answer 32

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

Question 33

Describe examination findings for consolidation

Answer 33

Tracheal deviation – none
Chest wall movement – reduced on affected side 
Percussion note – dull 
Breath sounds – bronchial 
Added sounds – crackles

Question 34

Describe examination findings for asthma

Answer 34

Tracheal deviation – none 
Chest wall movement – decreased symmetrically 
Percussion note – resonant 
Breath sounds – normal or reduced 
Added sounds – wheeze

Question 35

Describe examination findings for a pneumothorax

Answer 35

Tracheal deviation – if tension, possible
Chest wall movement – reduced on affected side
Percussion note – hyper-resonant
Breath sounds – absent
Added sounds – none