Lung cancer

Question 1

5yr survival

Answer 1

7% still alive 5 years after diagnosis
more people are diagnosed every year than there are people with lung cancer due to the high number of patients that don’t survive 12 months

Question 2

invasion

Answer 2

hoarse voice suggest involvement of the recurrent laryngeal nerve.
this means that the patient is now inoperable

Question 3

T1 nerve

Answer 3

pancoast tumours will lead to pain in the T1 dermatome - in the forearm
T1 is the level if the thoracic vertebra at which the sympathetic nerve leaves the spinal cord, which can lead to horner’s syndrome

Question 4

horner’s

Answer 4

T1 is a favoured site of mets in NSCLC

pancoast tumours can also grow upwards

Question 5

pleural effusion

Answer 5

investigation of drained fluid
ie cytology

breast cancer can cause pleural effusion

Question 6

skin lesions

Answer 6

indicate stage IV disease

Question 7

investigations

Answer 7

sputum cytology
bronchoscopy
transthoracic needle biopsy

try and use investigations that also allow for a biopsy

Question 8

squamous cell cancer

Answer 8

much more commonly associated with finger clubbing

more likely in smokers vs non smokers

Question 9

small cell

Answer 9

neuroendocrine tumour
very short doubling time

image the upper abdomen due to metastasis to liver and adrenal glands

Question 10

mesothelioma

Answer 10

arises from the pleura

possibly involving mediastinal structures or the heart

Question 11

NSCLC

Answer 11

other considerations eg pulmonary function tests, MRI etc to determine how far the cancer has spread, and whether surgical excision will be effective

Question 12

LDH

Answer 12

intracellular enzyme
released after necrosis of cells, haemolysis of RBCs
high LDH indicates cell death
suggest empyema rather than simple effusion
acts as cardiac enzyme if cell death is around heart
elevated in SCLC
indicative if large tumour bulk, and at risk of tumour lysis syndrome
if raised in NSC:C indicates the tumour is growing rapidly and has a worse prognosis

Question 13

adenocarcinoma

Answer 13

much more common than squamous cell cancer in non smokers

Question 14

complications

Answer 14

SVC obstruction - JVP waveform absent
pleural effusion - inflammatory process after involvement of the pleura.
exudate - inflammation
transudate - (organ) failure

distant mets - brain, liver, bone

non-metastatic effects:
hypercalcaemia
cushing syndrome
SIADH

Question 15

SVC obstruction

Answer 15

blocks drainage back to right atrium
demarcated below the nipple line
needs stenting, or treatment of the underlying cause

Sx:
most common:
dyspnoea
facial swelling
less common:
head fullness
cough
arm swelling
chest pain

CXR:
widening if mediastinum
pleural effusion
may be normal (16%)

Question 16

melanoma

Answer 16

heavily haemorrhagic brain mets

Question 17

brain mets

Answer 17

50% are due to lung cancer

present:
headaches
seizures (most common)

Tx:
supportive - steroids, anticonvulsants (valproate)
surgery -solitary vs multiple sites
radiotherapy
chemo - doesn’t cross BBB unless it is disrupted by mets. more of a role in germ cell and small cell tumours

patients with minimal involvement outside of the bran have much better outcomes

resection of brain tumour much more effective than just biopsy

Question 18

hypercalcaemia

Answer 18

can have insidious presentation
PTH-rP is way stringer than PTH
more associated with squamous cell lung cancer
Tx is to rehydrate the patient with IV saline - dehydration will kill the patient first
follow with a bisphosphonate

therefore IV saline is the most appropriate initial intervention

Question 19

ectopic ACTH

Answer 19

50% due to SCLC
leads to cushing’s syndrome
7% of SCLC patients will have ectopic ACTH production

Question 20

SIAD

Answer 20

most common endocrine paraneoplastic syndrome
SCLC
many chemotherapy drugs cause it
fluid restrict patient, then assess serum/plasma osmolarity as well as urine

need to have:
hyponatraemia
normal albumin/glucose
serum hypo-osmolality

Question 21

gynaecomastia

Answer 21

gonadotrophins can be released from SCLCs, or lung mets after a gonadal primary
b-hCG will be raised
can lead to thyrotoxicosis - b-hCG increased thyroxine production

Question 22

lambert-eaton myasthenic syndrome

Answer 22

non-metastatic manifestation of SCLC (60-70%)

often confused for myasthenia gravis

Question 23

ABx in chemo patients

Answer 23

a small delay can massively increase mortality

eg if no ABx after 48h mortality is 80%