Station 1.11: Lung cancer

Question 1

Clinical signs

What are the clinical signs of Lung Cancer? 1/3

Lung cancer

Please examine this patient who has had a 3‐month history of chronic cough, malaise and weight loss.

Answer 1

• Cachectic
• Clubbing and tar‐stained fingers
• Lymphadenopthy: cervical and axillary
• Tracheal deviation: towards (collapse) or away (effusion) from the lesion
• Reduced expansion
• Percussion note dull (collapse/consolidation) or stony dull (effusion)
• Absent tactile vocal fremitus (effusion); increased vocal resonance (collapse/
  consolidation)
• Auscultation:
  ⚬ Crackles and bronchial breathing (consolidation/collapse)
  ⚬ Reduced breath sounds; absent tactile fremitus (effusion
• Hepatomegaly or bony tenderness: metastasis

Question 2

Clinical signs

What are the clinical treatment signs of Lung Cancer? 2/3

Lung cancer

Please examine this patient who has had a 3‐month history of chronic cough, malaise and weight loss.

Answer 2

• Treatment:
  ⚬ Lobectomy scar
  ⚬ Radiotherapy: square burn and tattoo

Question 3

Clinical signs

What are the clinical complication signs of Lung Cancer? 3/3

Lung cancer

Please examine this patient who has had a 3‐month history of chronic cough, malaise and weight loss.

Answer 3

• Complications:
  ⚬ Superior vena cava obstruction: suffused and oedematous face and upper limbs,
  dilated superficial chest veins and stridor
  ⚬ Recurrent laryngeal nerve palsy: hoarse with a ‘bovine’ cough
  ⚬ Horner’s sign and wasted small muscles of the hand (T1): Pancoast’s tumour
  ⚬ Endocrine: gynaecomastia (ectopic βHCG)
  ⚬ Neurological: Lambert–Eaton myasthenia syndrome, peripheral neuropathy,
  proximal myopathy and paraneoplastic cerebellar degeneration
  ⚬ Dermatological: dermatomyositis (heliotrope rash on eye lids and purple papules on
  knuckles (Gottron’s papules associated with a raised CK) and acanthosis nigricans

Question 4

Disscussion

What are the clinical types of Lung Cancer?

Lung cancer

Please examine this patient who has had a 3‐month history of chronic cough, malaise and weight loss.

Answer 4

• Squamous 35%
• small (oat) 24%
• adeno 21%
• large 19%
• alveolar 1%

Question 5

Discussion Management

Diagnosis of mass methods of management for Lung Cancer? 1/3

Lung cancer

Please examine this patient who has had a 3‐month history of chronic cough, malaise and weight loss.

Answer 5

1. Diagnosis of a mass:
   * CXR: collapse, mass and hilar lymphadenopathy
   * Volume acquisition CT thorax (so small tumours are not lost between slices) with
   contrast

Question 6

Disscussion - Management

Determining cell type methods of management for Lung Cancer? 2/3

Lung cancer

Please examine this patient who has had a 3‐month history of chronic cough, malaise and weight loss.

Answer 6

2.. Determine cell type:
* Induced sputum cytology
* Biopsy by bronchoscopy (central lesion and collapse) or percutaneous needle
CT guided (peripheral lesion; FEV1 >1L))

Question 7

Disscussion - Management

Stages methods of management for Lung Cancer?

Lung cancer

Please examine this patient who has had a 3‐month history of chronic cough, malaise and weight loss.

Answer 7

3… Stage (CT/bronchoscopy/endobronchial ultrasound guided biopsy/
mediastinoscopy/thoracoscopy/PET):
* **Non‐small cell carcinoma (NSCLC): **TNM staging to assess operability
* Small cell carcinoma (SCLC): limited or extensive disease
4. Lung function tests for operability assessment:
* Pneumonectomy contraindicated if FEV1 < 1.2L
5. Complications of the tumour:
* Metastasis: ↑ LFTs, ↑ Ca++, ↓ Hb
* NSCLC: ↑ PTHrP → ↑ Ca++
* SCLC: ↑ ACTH, SIADH → Na+ ↓

Question 8

Disscussion - Treatment

What treatments are there for Lung Cancer?

Lung cancer

Please examine this patient who has had a 3‐month history of chronic cough, malaise and weight loss.

Answer 8

• NSCLC:
  ⚬ Surgery: lobectomy or pneumonectomy
  ⚬ Radiotherapy: single fractionation (weekly) versus hyper‐fractionation (daily for
  10 days)
  ⚬ Chemotherapy: benefit unknown; EGFR Positive – erlotinib
• SCLC:
  ⚬ Chemotherapy: benefit with six courses

Question 9

Disscussion - Multidisciplinary approach

Multidisciplinary approach and palliative care methods for Lung Cancer?

Lung cancer

Please examine this patient who has had a 3‐month history of chronic cough, malaise and weight loss.

Answer 9

• Dexamethasone and radiotherapy for brain metastasis
• SVCO: dexamethasone plus radiotherapy or intravascular stent
• Radiotherapy for haemoptysis, bone pain and cough
• Chemical pleurodesis for effusion – talc; tetracycline no longer used
• Opiates for cough and pain