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Y4 Respiratory Medicine > 4. Lung Cancer and Pleural Disease > Flashcards

4. Lung Cancer and Pleural Disease Flashcards

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1
Q

Invasive Sx of lung cancer

A

Chest wall pain ( may be pleuritic or central and tight, or insidious ache) , hoarse voice ( left recurrent laryngeal nerve), vasc invasion eg. SVC, dysphagia as mediastinal LN invades into oeso, Horner’s syndrome, shoulder pain and arm weakness/ wasting

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2
Q

Metastatic Sx of lung ca

A

Headches, seizures

Pleural and pericardial effusion, airway compression or SVC/RLN invasion

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3
Q

Sx of SVCO

A

Facial and upper limb oedemaa
Venous distention of upper body
Headaches
Pemberton’s sign- facial plethora and distress, stridor after lifting arms above head

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4
Q

Most common cause of SVCO

A

Small cell lung cancer or lymphoma

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5
Q

Tx of SVCO

A

Dexa to reduce oedema assoc with lymphadenopathy
Anticoag to tx acute ep where thrombosis is likely pri cause
Radio and chemo to treat underlying cause
SVC stenting to relief Sc

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6
Q

Common sites of lung ca spread

A

Supraclavicular, mediastinal and hilar lymph node,
Brain, bone, liver,adrenal glands,
pleura, lung, skin,

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7
Q

Paraneoplastic syndrome of squamous cell carcinoma

A

Ectopic PTH like hormone - hypercal , May be assoc w/ bone metastases and bone invasion

Hypertrophic pulmonary osteoarthropathy assoc with Finger clubbing and periostits

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8
Q

Paraneoplastic syndrome of SCLC

A

SIADH: MOST COMMON, hyponatraemia (pts may look euvolaemic)
Ectopic ACTH, hypoK
Cerebellar Sx
Eaton lambert Sx
Limbic encephalitis

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9
Q

Pathology of SIADH

A

Inappropriately concentrated urine in SIADH

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10
Q

Hypercal Sx

A

Confusion, constipation, thirst, fatigue

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11
Q

Tx of hypercal and hypoNa

A

IV fluid first step, add diuretic to increase excretion, then IV bisphosphonate to prevent rebound

Fluid restriction for hypona and salt supplemments

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12
Q

What is carcinoid syndrome

A

Usually due to liver metastasis from a carcinoid tumour. Diarrheoa, dry skin, flushing, palpitations

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13
Q

What scale tests pts abilityy to tolerate chemo

A

ECOG PS

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14
Q

What is V/Q scan done for

A
  • For borderline pts
  • Usually due to coexisting emphysema → check if removing damaged part would have adverse effect on lung fx
  • Also if pt has high risk of dyspnoea
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15
Q

What tests should be done before Ix of cancer

A

ECOG, PFT, ET, check pt’s daily fitness

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16
Q

What is Ix of choice for staging lung cancer

A

CT Chest Abdomen w/ contrast - early indication of stage
If CT shows lymphadenopathy can use EBUS

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17
Q

When is CT PET used in lung cnacer

A

When not stage 4- gives more accurate picture of such ca, can identify metastases, and high sensitivitty for N and M staging. May show uptake even if no other findings elsewhere

or can be used if doubt over incurable disease ( 3B vs 4) if tissue confirmation is not available

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18
Q

False +ve and -ve in PET-CT scan

A

TB, sarcoid, other inflammatory lesions
low uptake in primary lesion (carcinoid, lipidic adenocarcinoma), uncontrolled diabetes and lesions

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19
Q

What can mediastinocopy be useful for in lung cancer Ix

A

For mediastinal LN before surgery
Indications include:
- PET pos MLC
- N1 disease
- Central tumor
- Tumor >3cm with high FDG uptake

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20
Q

Downsides of PET

A

Doesn’t diff between tumour and infxn

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21
Q

N staging for lung cancer

A

0- no spread
1- on same side
2- hilar/ central (mediastinal) lymph gland spread ( surgery only if N2a or below i.e. singular station in mediastinum only)
3 - opp side of tumour/up to neck

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22
Q

M staging for lung ca

A

1a - intrathoracic
1b - extrathoracic
1c - multiple

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23
Q

marker for lung adenocarcinoma

A

TTF1, cK7, p63

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24
Q

markers for squamous cell carcinoma

A

CK5/6, p63, -ve for CK7, TTF1

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25
Contraindications for bronchoscopy
FEV1 unacceptable compared to predicted values, coagulopathy eg. liver disease, anti coag, SpO2 <92
26
How to obtain tissue in lung for pathology: 1. For tumours visible in airway 2. For main lesions in lung, esp peripheral of larger lesions 3.To stage mediastinum and hilum LNs 4. For those with poorer resp reserve 5. For biopsy for excluding lymphoma 6. To stage cancer, also for small lesions that are difficult to get to 7. For pleural effusion
1. Bronchoscopy 2. CT guided biopsy (LA applied to skin and radiological guided needle passed through skin and lung to mass) 3. Endobronchial ultrasound 4. EBUS FNA 5. EBUS biopsy 6. CT PET, may need lobectomy to prove ( following resection) 7. pleural aspiration
27
Why can't CTGBx be done for central lesions
risk hitting impt structures, incr. risk of pneumothorax
28
What is Mx for pt with LN spread
Chemo and radio, usually won't do surgery due to node spread
29
First test for lung ca
CXR
30
What could reduced transfer factor and early drop in sats in pt with significant COPD be due to
Emphysema
31
Local Sx of lung cancer
Cough ( may be clear mucus?), wheeze/ stridor, HAEMOPTYSIS, dyspnoea, chest pain,
32
Mx of SVCO
Steroids and stent consider anticoag based on rapidity of Sx
33
Tissue Dx for SVCO
Sample peripheral lymph node to confirm Small cell Lung Cancer - non invasive
34
Tx for cerebal mets
Dexa to reduce oedema Consider pophylatic anti epileptics
35
What mutation is important to consider in lung cancer and when. What does presence of this EGFR mean
EGFR, in non-smokers with sever cancer EGFR mutation allows for targeted therapy, use tyrosine kinase inhibitors rather than systemic chemo
36
Risk factors for pri spontaneous pneumo
- Young males - Tall, thin - Smoking - Cannabis
37
Pathology of PSP
Apical blebs/ emphysema like changes that rupture and create air leak
38
What famillial gene disorder can increase risk of PSP
Folliculin
39
CXR signs of PSP
Loss of lung markings and lung edge moves medially
40
What can cause SSP
TB, PCP , any CLD, emphysema, asthma, ILD,CF MARFAN'S is associated with it
41
Signs of tension pneumoT
- Airway deviated to the other site on CXR - Could be palpated - B→ Only blood? on side with TP, no lung tissue Vasc appearance may not be obv due to pneumoT - C→ Heart also deviated to other side - D→ diaphragm should be higher on right, but is higher on left instead due to tension pneumothroax pushing to the other side (may have blunted CPA if hv haemothorax) - E→ Larger ICSt
42
Pneumothorax Mx algorithm
Bilateral/ haemodynamically unstable/ hypoxic/>50 yo with sig smoking history then chest drain Pri pneumo: If size >2 and or breathless, then aspirate with cannula. Otherwise discharge and review Sec pneumo: If size >2 or breathless, chest drain, if not then aspirate with cannula, unless less than 1 cm then admit and high flow oxygen, observe
43
Mx of open pneumoT
COver wound over 3 sites to allow air to escape from chest cavity
44
Where should therapeutic acspiration with needle take place
ICS2 MCL
45
Possible complication of chest drain insertion and px
Surgical emphysema- Air leaks out of tube and accumulates around skin --- Re expansion P oedema if drain more than 1.5l w/o hrs break - collapsed lung is allowed to expand suddenly - If pressure is released very quickly, shifting of fluid from intravascular to interstitial space may occur → PO PX includes - Cough, chest discomfort, hypoxemia - Shock and death if sever
46
When should thoracic surgery be done for penumothorax
VATS done where chest drainage not successful or for pt with recurrent PTX or bilat PTX Bleb removal, apical stapling, talc pleurodesis to prevent recurring
47
What should not be done after PTX
No scuba divinf, no flying for 2 weeks, no heavy lifting for one month
48
What are the main diseases that can cause pleural fluid accumulation
LVSD, CAP, PTE SVCO, RVF-- due to increased intravascular pressure in pleura and systemic vasc pressure Atelctasis due to decreased pleural pressure ascites
49
What is massive haemothorax and its mx
Blood drainage >1.5 l after closed thoracostomy/ chest drain and continuous bleeding at 0.2 L/hrs for at least 4 hrs Usually surgical mx
50
Ligth's criteria
Exudate is P to s protein ratio > 0.5 LDH ratio >0.6 P LDH >2/3 upper limit normal (>145)
51
Causes of exudates
Infxn ( esp pneumonia) , cancer, inflm diseases, amiodarone and methothrexate
52
Causes of transudates
Heart failure, liver failure, fluid overload, hypoALB, nephrotic Sx, hypothyroidism
53
How to Ix pleural effusion
Early- CXR (homogenous shadowing) , USS if contemplsting prognosis, CT for ant potential causes eg. pleural ca Pleural asp for culture and sensitivity etc. Medial throacoscopy or VATS if biopsy needed
54
Are transudates more likely to be bilateral or unilateral
BIlatersl
55
Main tx for transudative Pleural effusion
Diuretic
56
When should pleural thoracic USS be done for pleural effusion. If diff to assess on USS, or if complicated or innoculated, what should be done instead?
before procedures CT CAP
57
what do these appearances in pleural fluid suggest frank pus blood stain frank blood Milky bile
Empyema malignamcy, pulm infarction, infxn, TBetc. haemothorax chylothorax biliary fistyla
58
When is pH low in pleural fluid
In pleural infx, malignancy
59
when is glucose very low
In empyema
60
What does haematocrit suggest in pleural fluid
Separates blood stained effusions from haemothorax
61
What does high amylase suggest in pleural fluid
Oesophagus rupture to pancreatis
62
Main treatment for pleural effusion
Therapeutic thoracocentesis (pleural aspiration)
63
Vitals in massive pleural effusion
May be tachycardic with low BP
64
Possible blood test results for malignant pleural effusion
Hyopna, hyperca, anaemia, deranged LFT
65
CXR position of heart in massive Pleural Effusion
Pushed away from location of PE cross midline
66
Risk factors for Lung Ca
Smoking, asbestos
67
Most common lung cancer
Non-Small cell lung cancer - Adenocarcinoma most common,followed by squamous cell
68
paraneoplastic features of adenocarcinoma
Gynaecomastia, hypertrophic pulmonary osteoarthropathy
69
What is the most aggressive lung cancer that usually presents at stage 4
SCLC
70
Lung cancer Tx
Anatomical resectn - may remove bronchus - Segmentectomy accepted for early stage lung cancer, not inferior to lobectomy Non-anatomical resection→ doesn’t affect bronchus, used foer samll tumours now
71
Complication of lung surgery'
- Long thoracic innervates seratus anterior, should spare during resection or will cause winged scapular
72
IF ICD is done for pleural effusion and it is bubbling, should it be removed or left in What does continuous bubbling mean
Left in, as air is leaking Continuous- may have subcutaneous emphysema ( air outside chest cavity but beow soft tissue)
73
What is the function of the interstitium
For gas exchange
74
When is the pt more likely to get empyema
If pleural fluid is acidotic
75
How to diff parapneumonic effusion from other kinds of pleural effusion
Can see air bronchodgram
76
What can cause whiteout of lung ( complete opacification of one hemithorax) and how to differentiate these causes
- pneumonectomy, huge **pleural effusion** or complete collapse of the lung - Mediastinum pushed away in pleural effusion, pulled in collapse
77
Sx and txof cardiac tamponade
- 1/3 of pts may have pulsus paradooxuss, Kussmaul’s sign, beck’s triad → hypotension, JV distension, muffled heart sound - Due to cardiac fluid surrounding the heart - Venous return to heart is low as surrounded by fluid around heart -Tx is pericardial window (surgery)to evacuate fluid from heart
78
what is the safe triangle for chest drain
oirders are Pec major, latissimus dorsi and 5th ICS ( nipple)
79
Px of malignant pleural effusion
SOB, slow or rapid detioriation in breathing Chest pain may be plejuritic or central and tight, my keep pt awake overnight Cough may produce clear mucus Weight loss, night sweats
80
How to manage malignant PE
Thoracocentesis to reduce breathlessness, OR can insert chest drain and talc slurry once pleural fluid has been drained to seal pleural space for trapped lung. Good for old pts who cannot be cured of cancer
81
What can be done if solid pleural disease on chest wall
Cardiothoracic surgery
82
What is empyema
Accumulation of pus in pleural space, can be organised from a parapneumonic effusion
83
What does whiteout of lung on CXR show
Huge pleural effusion
84
Is mediastinum pushed away or pulled in pleural effusion and collapse respectively
Pushed in PE, pulled in collapse
85
Presentation of mesothelioma
Dyspnoea, weight loss, chest wall pain Clubbing 30% present as painless pleural effusion Only 20% have pre-existing asbestosis History of asbestos exposure in 85-90%, latent period of 30-40 years
86
What is related to Mesothelioma
Asbestos
87
Ix of mesothelioma
Suspicion raised by a CXR showing either pleural effusion or pleural thickening Next step is normally a pleural CT If a pleural effusion is present fluid should be sent for MC&S, biochemistry and cytology Then can do thoracoscopy or CT guided pleural biopsy
88
Fx of PE
Chest pain typically pleuritic Dyspnoea Haemoptysis Tachycardia Tachypnoea Respiratory examination Classically the chest will be clear
89

Y4 Respiratory Medicine (6 decks)

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