Troublesome Cough Flashcards
1
Q
What are the red flag symptoms for lung cancer?
A
- Cough (dry/productive): if productive then send sputum for microscopy, sensitivity and cytology
- Haemoptysis: remember to clarify amount, many lung cancers do not present with this but it is very worrying if present
- Dyspnoea: check if this has changed recently
- Hoarse voice: could be a symptom of recurrent laryngeal nerve involvement which would imply mediastinal involvement with cancer
- Chest pain: character important
- Fatigue
- Weight loss: how much over how long, intentional? Proportion of usual weight
- Appetite loss
2
Q
What are para-neoplastic syndromes?
A
Rare disorders caused by an immune response to cancer. They are non-metastatic systemic effects. They include hypercalcaemia in squamous cell lung cancer due to PTrH, HPOA.
3
Q
What do radiologists need to know before a CT scan?
A
- Previous contrast reaction
- Renal function - if eGFR <40ml/min then increased risk of contrast-induced AKI
- Diabetes mellitus - metformin therapy (may need to be stopped pre-contrast if renal impairment)
4
Q
What are the investigations for suspected lung cancer?
A
- FBC: anaemia (can signal more advanced disease/co-morbidities)
- U+Es: fitness for chemotherapy (most is platinum based and excreted in the kidneys so require good renal function)
- Bone profile: increased calcium could indicated bone metastases or paraneoplastic syndrome due to secretion of PTrH in squamous cell cancer
- LFTs: if abnormal may not tolerate chemotherapy or indicate liver metastases
- Pulmonary Function Tests: essential before surgery and radical radiotherapy to measure lung reserve
- CT scan thorax and abdomen: for staging. Should be done prior to bronchoscopy so can see where to biopsy
- Bronchoscopy/biopsy: histological diagnosis and staging
- PET/CT: for metastases
- Other tests: only if indicated by symptoms i.e. if bony pain then bone scan and if headaches then brain CT/MRI
5
Q
What are important factors in deciding treatment?
A
- The stage of disease i.e. is it operable or localised for radiotherapy
- Patient’s fitness or performance status
- Co-morbidities
- Histology and other characteristics of the tumour that may mean it would respond to specific systemic anti-cancer treatments
- Patient’s preferences for treatments
- Patient’s local support networks
6
Q
What are important parts to find out about the SH and FH?
A
- Smoking hx: causation and opportunity to improve prognosis by stopping. If a never smoker then increased likelihood of eGFR mutation and response to tyrosine kinase inhibitors
- Alcohol intake: poorer ability to tolerate chemotherapy
- Occupation: asbestos exposure, compensation, inability to work and loss of income
- Who is at home i.e. who are they supporting and who will support them through treatment and SEs of therapy
- FH of cancer. Patients may have pre-conceived ideas about their diagnosis that can be either positive or negative
7
Q
What are the side effects of radiotherapy on the lungs?
A
- Oesophagitis: usually occurs within 2 weeks of commencement of radiotherapy and can require admission for nutritional support but is usually short-lived and settles within 2-4 wks of completion of treatment
- Dyspnoea: due to lung damage, occurs within 2-3 weeks of starting radiotherapy but can progress several months after treatment finishes and can be life-threatening. Pneumonitis (lung toxicity) is treated with high dose steroids if severe but may be irreversible.
8
Q
What are the features of Small Cell Lung Cancer?
A
15% frequency, small cell lung cancer is typically centrally located and infiltrative on CT scan. Histologically:
- Usually disseminated, smoking related
- Rapid growth, doubling time is approx 29 days
- Very chemo/radiosensitive but rarely cured (NSLC not chemosensitive)
- Without treatment median survival is 2-4 months
- With treatment median survival is 6-12 months for extensive (metastatic) disease and 16-24 months for localised disease
9
Q
What are the features of Squamous Cell Carcinoma?
A
- 30%
- Smoking related
- Best survival to potential operability
- Doubling time 90 days
10
Q
What are the features of Adenocarcinoma?
A
- 30-40%
- Typically peripheral location and often slower growth with typical doubling time of 160 days
- However metastasise early
- Can occur in non-smokers
- Can respond to newer systemic agents e.g. tyrosine kinase inhibitors - large cell carcinoma (10%) and mixed unknown (<10%)
11
Q
What is the T staging in lung cancer?
A
- T1 tumour = <3cm
- T2 = 3-5cm or involves main bronchus but not carina
- T3 = 5-7cm or invades chest wall or separate nodule, same lobe
- T4 = >7cm or invading local structures e.g. mediastinum/heart/trachea - inoperable
12
Q
What is the N staging in lung cancer?
A
- N0 = no nodes
- N1 = local ipsilateral nodes
- N2 = ipsilateral mediastinal node(s)
- N3 = contralateral mediastinal nodes
13
Q
What is the M staging in lung cancer?
A
- M1a = separate tumour nodule(s) in a C/L lobe
- M1b = single extra-thoracic metastases in a single organ
- M1c = multiple extra-thoracic metastases
14
Q
What is a common site of metastases in lung cancer?
A
It is thought that 1/3 of lung cancer patients will develop brain metastases. This is particularly common in advanced disease and adenocarcinoma. Patients often present with headache and increasing confusion.
- Most brain secondaries will show on contrast enhanced brain MRI
- If there is a brain metastases with oedema, give dexamethasone 8mg BD PO. Also check baseline blood sugars as steroids can exacerbate diabetes and also give a PPI e.g. lansoprazole 30mg OD.
15
Q
What is supportive care that is available for cancer patients?
A
- Macmillan nurse referral
- Symptom control e.g. steroids can cause side effects that may need addressing. For more complex problems referral to palliative care team is recommended.
- Benefits: if someone has a probable life expectancy of 12 months, they are eligible for the top rate of Disability Living Allowance - can be referred by GP, Macmillan nurse or social worker
- Discussion regarding life expectancy and place of death
- Hospice: day hospice or inpatient stay can be helpful for support, symptom control or end of life care
- DNAR/AaND (allow a natural death): important if patient admitted to hospital
- Family/social concerns: some patients can benefit from referral to a social worker
