Week 6 - Haemoptysis Flashcards
What routes can cancer metastasise through?
- lymphatics
- blood
- transcoelomic (seen in peritoneal and tumours)
- along epithelial-lined surfaces
- within epithelium (e.g Paget’s disease of nipple)
What other symptoms can be mistaken for haemoptysis?
- oral bleeding when brushing teeth
- haematemesis - vomiting blood
- epistaxis - further back in the nose can affect phlegm/snot
What are some vascular causes of haemoptysis?
- PE leading to pulmonary infarction
- rupture of telangiectatic vessels
What are some infectious causes of haemoptysis?
- TB
- necrotising pneumonia
- lung abscess
What are some autoimmune causes of haemoptysis ?
inflammation to pulmonary vessels leading to rupture and bleeding (via conditions like SLE and Wegeners granulomatosis)
What are some iatrogenic causes of haemoptysis ?
- drugs (e.g crack cocaine)
- prescription drugs (e.g anti platelets/coags)
- endobronchial procedures
- lung biopsy
- pulmonary artery catheterisation
What are some neoplastic causes of haemoptysis?
lung cancer / metastases
What are some congenital causes of haemoptysis?
Cystic fibrosis
What are some degenerative causes of haemoptysis?
- COPD
- Bronchiectasis
What are the 2 main (broad) categories of lung cancer?
- small cell (15-20%)
- non-small cell (80-85%)
What are the main subtypes of non-small cell lung cancer?
- adenocarcinoma
- squamous cell
- large cell
What type of lung cancer can resemble pneumonia on imaging?
Adenocarcinoma
Which type of cell do adenocarcinomas originate in?
Glandular cells in the small airways/peripheries
Are adenocarcinomas fast or slow to become invasive?
Often slow (years)
What is the most common subtype of lung cancer to develop in non-smokers ?
Adenocarcinomas
Which cell type does squamous cell cancer develop in?
The squamous cells lining the central airways
Are squamous cell carcinomas smoking related cancers ?
Yes
Which type of non-small cell cancer is often seen in the periferal lung fields ?
Adenocarcinoma
And large cell - seen anywhere within lung
Which type of non-small cell cancer is often seen in the central lung fields ?
Squamous cell
And large cell - seen anywhere within lung
Which type of non-small cell cancer can be seen anywhere in the lungs ?
Large cell
Which is the fastest growing/spreading type of non-small cell lung cancer ?
Large cell
Which type of non-small cell cancer often form a cavity ?
Squamous cell
Which type of lung cancer is the fastest to grow and spread ?
Small cell
What stage do small cell cancers often present at ?
Stage 4
Which type of lung cancer is most responsive to chemo ?
Small cell
What do the NICE guidelines recommend the indications are for a suspected lung cancer referral ?
- chest x-ray findings that suggest lung cancer, or
- aged 40 and over with unexplained haemoptysis
What is the first line investigation following a lung cancer referral?
CT scan
What are 4 examples of paraneoplastic manifestations of (typically small cell) lung cancer ?
- lambert-Eaton syndrome
- SIADH
- Hypertrophic osteoarthropathy
- Cushing syndrome
What is the MOA of lambert-Eaton syndrome ?
Autoantibodies that block acetylecholine being released
What is a symptom of lambert-Eaton syndrome ?
Muscle weakness
What is the MOA of SIADH ?
Release of ADH causing low sodium
What are the symptoms of SIADH ?
- nausea
- vomiting
- confusion
- seizures (in severe cases)
What is the MOA of hypertrophic osteoarthropathy ?
New bone forming in periosteum in the forearms and lower legs
What are the symptoms of hypertrophic osteoarthropathy ?
- pain
- marked clubbing
What is the MOA of Cushings syndrome ?
Ectopic secretion of ACTH (adrenocorticotropic hormone) by small cell tumour
What are the symptoms of Cushings syndrome ?
- hypertension
- weight gain
What are the different ‘T’ stages of cancer staging and what does each mean ?
- T0 = no primary tumour
- Tis = carcinoma in situ (adeno or squamous)
- T1 = tumour </= 3cm
- T1mi = minimally invasive adenocarcinoma
- T1a = superficial spreading tumour in central airways, tumour </= 1cm
- T1b = tumour >1 cm but </= 2cm
- T1c = tumour >2cm but </= 3cm
- T2 = tumour >3cm but </= 5cm, or tumour with visceral pleura, main bronchus (not carina) or atelectasis to hilum
- T2a = tumour >3cm but </= 4cm
- T2b = tumour >4cm but </= 5cm
- T3 tumour >5cm but </= 7cm, or invading chest wall/pericardium/phrenic nerve, or separate nodules in the same lobe
- T4 = tumour >7cm or, invading mediastinum/diaphragm/heart/great vessels/recurrent laryngeal nerve/carina/trachea/oesophagus/spine, or tumour nodules in different ipsilateral lobe
What are the different ‘N’ stages of cancer staging and what does each mean ?
- N0 = no regional lymph node metastases
- N1 = metastases in ipsilateral pulmonary or hilar nodes
- N2 = metastases in ipsilateral mediastinal or subcarinal nodes
- N3 = metastases in contra lateral mediastinal, hilar or supraclavicular nodes
What are the different ‘M’ stages of cancer staging and what does each mean ?
- M0 = no distant metastases
- M1 = Malignant pleural or pericardial effusion or pleural or pericardial nodules or separate tumor nodule(s) in a contralateral lobe
- M1a = single extrathoracic metastases
- M1b = multiple extrathoracic metastases in one or more organs
What does the stage TNM stage T0 mean ?
No primary tumour
What does the TNM stage Tis mean ?
Carcinoma in situ
adenocarcinoma or squamous cell cancer
What does the TNM stage T1 mean ?
Tumour is 3cm or smaller
What does the TNM a stage T1mi mean ?
Minimally invasive adenocarcinoma
What does the TNM a stage T1a mean ?
Superficial spreading tumour in central airways
Tumour is 1cm or less
What does the TNM a stage T1b mean ?
Tumour is >1cm but ≤ 2cm
What does the TNM a stage T1c mean ?
Tumour is >2cm but ≤ 3cm
What does the TNM stage T2 mean ?
Tumor >3 cm but ≤5 cm or tumor with any of the following features:
- Visceral pleura
- Main bronchus (not carina)
- Atelectasis to hilum
What does the TNM stage T2a mean ?
Tumor >3 cm but ≤4 cm
What does the TNM stage T2b mean ?
Tumor >4 cm but ≤5 cm
What does the TNM stage T3 mean ?
Tumor >5 cm but ≤7 cm or:
- Invading chest wall, pericardium, phrenic nerve
- Separate tumor nodule(s) in the same lobe
What does the TNM stage T4 mean ?
Tumor >7 cm or:
- Invading mediastinum, diaphragm, heart, great vessels, recurrent laryngeal nerve, carina, trachea, esophagus, spine
- Tumor nodule(s) in a different ipsilateral lobe
What does the TNM stage N0 mean?
No regional lymph node metastasis
What does the TNM stage N1 mean?
Metastasis in ipsilateral pulmonary or hilar nodes
What does the TNM stage N2 mean?
Metastasis in the ipsilateral mediastinal or subcarinal nodes
What does the TNM stage N3 mean?
Metastasis in contralateral mediastinal, hilar or supraclavicular nodes
What does the TNM stage M0 mean?
No distant metastasis
What does the TNM stage M1a mean?
Malignant pleural or pericardial effusion or nodules, or separate tumour nodules in a contralateral lobe
What does the TNM stage M1b mean?
Single extra thoracic metastasis
What does the TNM stage M1c mean?
Multiple extrathoracic metastases in one or more organs
What does the ECOG performance status scale measure ?
The patients ability to look after themselves, daily activity and physical ability
How many levels are there on the ECOG performance status scale ?
0-5
What does the ECOG grade 0 mean?
Patient is fully active and capable of pre-disease activities without restriction
What does the ECOG grade 1 mean?
Patient is
- able to walk around (ambulatory)
- able to carry out work of a light or sedentary nature
- restricted in physically strenuous activity
What does the ECOG grade 2 mean?
Patient is
- able to walk around (ambulatory)
- capable of all self care
- unable to carry out any work activities
- up and about >50% waking hours
What does the ECOG grade 3 mean?
Patient is
- confined to bed or chair >50% waking hours
- capable of only limited self care
What does the ECOG grade 4 mean?
Patient is
- totally confined to bed or chair
- completely disabled
- cannot carry out any self care
What does the ECOG grade 5 mean?
Patient is dead
How long before a PET scan must he patient stop eating ?
6 hours before the scan
How long before a PET scan must he patient stop doing strenuous exercise ?
24 hrs before the scan
What is the injected radiotracer called that’s used in a PET scan ?
Fluorodeoxyglucose (FDG)
it’s similar to naturally occurring glucose so the body treats it in a similar manner
How do PET scans work ?
- inject FDG radiotracer
- body takes FDG up in a similar way to natural glucose
- scan analyses where the FDG does/doesn’t build up in the body
cancers use glucose at a faster rate to normal cells, so will light up on the scan
What ‘normal’ structures will also show up brighter on a PET scan, other than a cancer ?
- kidneys
- vocal cords
- brown fat
Which other type of scan is often paired with a PET scan ?
CT scan
How is a lung biopsy performed ?
- guided by CT scan
- local anaesthetic to the area
- insert needle between ribs
- take biopsy
When is a CT lung biopsy performed instead of a biopsy guided by specialist imaging e.g EBUS ?
When the cancer is too peripheral to be accessed via bronchoscopy or endobronchial ultrasound (EBUS)
What’s re the 2 most common complications of a CT guided biopsy ?
- pneumothorax
- haemoptysis
What are the long term harms of nicotine ?
Addiction
Other than that, nicotine is relatively harmless. The harm comes when it is paired with other chemicals in a cigarette as they are what cause the cancer, strokes, CVD etc
How many chemicals are released when cigarettes burn ?
Around 5000
What proportion of smokers will die early due to a smoking related illness ?
1 in 2
What is a good oral drug to help smokers stop ?
Varenicline
What is the MOA of varenicline ?
Nicotine receptor agonist and antagonist
Releases domain via agonist action
Prevents dopamine release from cigarettes
What is a good immunotherapy option to treat small cell lung cancers with a high PDL-1 levels ?
Pembrolizumab
When does immunotherapy related pneumonitis classically present ?
Within the first 3 months after starting immunotherapy
How does immunotherapy related pneumonitis classically present ?
- Cough
- SOB
On investigation:
- mildly raised inflammatory markers
- reticular shadowing on CXR
- innumerable, centrilobular micronodules throughout both lugs on CT
How is immunotherapy related pneumonitis treated ?
- steroids
- IV methylprednisolone (in severe cases)
- oral prednisolone (in milder cases)
What respiratory examination findings are consistent with pleural effusion ?
- reduced chest expansion
- reduced breath sounds
- reduced vocal resonance
- dull percussion
- finger clubbing
What are the clinical signs of pneumothorax?
- absent breath sounds
- hyper resonant percussion
- no/reduced vocal resonance
What respiratory examination findings are consistent with pneumonia ?
- dull percussion
- bronchial breathing
- increased vocal resonance
Is transudative effusion
A) high in protein?
B) low in protein?
Transudative = LOW in protein (less than 30)
plus low/normal LDH
Is exudative effusion
A) high in protein?
B) low in protein?
Exudative = HIGH in protein (more than 30)
plus raised LDH
What causes transudative effusion ?
High hydrosTatic pressure pushing fluid out of vessels into pleural space
What causes exudative effusion ?
InfEction causing leaky vessels, letting fluid and cellular substances into pleural space
Is transudative effusion usually
A) bilateral ?
B) unilateral ?
Transudative = Bilateral
way to remember: transition between 2 different things
Is exudative effusion usually
A) bilateral ?
B) unilateral ?
Ex**udative = Unilateral
way to remember: your ex is 1 person
What are pleural effusions broadly categorised into, and what is this based on ?
Transudative and exudates
Based on pleural fluid protein and LDH content
