Case 4 - Lung cancer and pleural effusion

Question 1

How common of a cancer is lung cancer?

Answer 1

• Biggest cause of cancer related deaths worldwide and UK

Question 2

5 year survival rate lung cancer

Answer 2

16%

Question 3

What are most lung cancers caused by in UK?

Answer 3

76% is from smoking

Question 4

Lung cancer presentation features

Answer 4

• Asymptomatic - incidental finding
• Respiratory symptoms/deterioration
• SVC obstruction - tortuous veins on chest and distended veins in upper limbs and head/neck
• Horners syndrome
• Mets disease - liver, adrenals (addisons), bone, pleural, CNS
• Paraneoplastic - hypercalcaemia (PTHrp), SIADH, Cushings (ACTH), Lambert Eaton mysathenic syndrome
• Increased risk of thrombo-embolic disease

Question 5

Horners syndrome

Answer 5

• Miosis - small pupil
• Anhidrosis
• Ptosis

Caused often by Pancoast apical lung cancer compressing sympathetic chain - interupted

Question 6

Risk factors for lung cancer

Answer 6

• Large number of smoking pack years
• Airflow obstruction
• Increasing age
• FH of lung cancer
• Exposure to other carcinogens eg asbestos

Question 7

What is performance status?

Answer 7

WHO scale - is used to assess fitness of patient and how likely they are to cope with certain treatments and disease

Question 8

Perfomance status stages

Answer 8

0. Normal - fully active with no restriction
1. Restricted in physical strenuous activity but ok with light work
2. Ambulatory and able to self care but unable to carry out work activities, up and about >50% waking hours
3. Capable of limited sellf care, confined to bed or chair >50% waking hours
4. Completely disabled
5. Dead

Question 9

Blood diagnostic tests for lung cancer

Answer 9

• FBC
• U&E
• Calcium
• LFTs
• INR

Question 10

Imaging for lung cancer

Answer 10

• CXR
• Staging CT - spinal CT thorax and upper abdo - for TNM staging
• PET scan - MDT decision if patient is surgical candidate and CT suggests low stage, helps detect small mets not seen in staging CT

Question 11

Histology options for biopsying lung cancer

Answer 11

• US guided neck node for cytology via fine needle aspiration if lymphadenopathy
• Bronchoscopy - endobronchial, transbronchial, endobronchial US (if mediastinal lymphadenopathy)
• CT biopsy
• Thoracoscopy if pleural effusion present

Question 12

Histological classification of lung cancer

Answer 12

• Small cell lung cancer (SLCL, oat cell)
• Non-small cell lung cancer (NSCLC)

Question 13

Examples of non-small cell lung cancer

Answer 13

• Squamous cell
• Adenocarcinoma
• Large cell carcinoma
• Bronchoalveolar cancer

Question 14

Lung cancer treatment options

Answer 14

• Curative surgery - for stages I and II - if fit
• Surgery and adjuvant chemotherapy for stage IIIa
• Chemotherapy - stage III/IV and PS0-2
• Radiotherapy - curative if not fit for surgery or palliative
• Palliative care
• Do nothing - watch and wait

Question 15

What is curative radiotherapy?

Answer 15

CHART - continious hyperfractionated accelerated radiotherapy

Question 16

NSCLC survival rates at 5 years

Answer 16

• All - 15-23%
• I - 65-80%
• II - 50-60%
  (these are both following surgical resection)
• III - 20%
• IV - 1-5%

Question 17

Treatment for SCLC

Answer 17

• Rapid growth rate and almost always too extensive for surgery
• Chemotherapy = main treatment
• Palliative radiotherapy too

Question 18

Prognosis for SCLC

Answer 18

• Untreated - median survival 8-16 weeks
• Combo chemotherapy median survival is 7-15 months

Question 19

Approach to a suspected pleural effusion

Answer 19

• History and examination is MAIN PART

Question 20

Bloods for pleural effusion

Answer 20

• FBC
• U&Es
• LFTs
• CRP
• Bone profile
• LDH
• Clotting - in case procedure

Question 21

Imaging for pleural effusion

Answer 21

• ECHO - if suspect HF
• Staging CT with contrast if suspect exudative cause

Question 22

Pleural effusion definitive diagnosis

Answer 22

• Ultrasound guided pleural aspiration

Question 23

What do we test pleural aspirate for?

Answer 23

• Biochemistry - protein, pH, LDH
• Cytology
• Microbiology

Question 24

When to insert chest drain for pleural effusion?

Answer 24

• Never unless diagnosis is well established (eg known mets cancer)
• Otherwise draining all fluid off may hinder opportunity to obtain pleural biopsies
• ONLY INDICATION for urgent chest drain is if empyema - pH <7.2 or visble pus in aspirate

Question 25

Other methods to consider for pleural effusion diagnosis

Answer 25

* Thoracoscopy * CT pleural biopsy

Question 26

Transudate protein level

Answer 26

Is <25g/L

Question 27

Common causes of transudate effusions

Answer 27

* Heart failure * Cirrhosis * Hypoalbuminaemia Problems with Starling Forces

Question 28

Less common causes of transudate effusions

Answer 28

* Hypothyroidism * Mitral stenosis * PE

Question 29

Rare causes of transudate effusions

Answer 29

* Constrictive pericarditis * SVC obstruction * Meigs syndrome (benign ovarian tumour --> ascites and pleural effusion)

Question 30

Treatment for transudate

Answer 30

* Often no diagnostic tap needed * TREAT UNDERLYING CAUSE * If effusion resolves, stop/reduce treatment * If persists then therapeutic drainage is required

Question 31

Protein level for exudates

Answer 31

Is >35g/L

Question 32

Common causes of exudate effusions

Answer 32

* Malignancy * Infections - TB, paraneumonic, HIV (Kaposi)

Question 33

Less common causes of exudative effusions

Answer 33

Inflammatory problems eg: * RA * Pancreatitis * Asbestos effusion (benign) * PE/infarction * Lymphatic disorders * Connective tissue disease

Question 34

Rare causes of exudative effusions

Answer 34

* Yellow nail syndrome * Fungal infection * Drugs

Question 35

Light criteria - when to apply

Answer 35

If protein is between 25-35 g/L - ie if borderline

Question 36

Lights criteria for exudative effusion

Answer 36

* If pleural protein/serum protein >0.5 * If pleural LDH/serum LDH >0.6 * Pleural LDH >2/3 upper limit of normal

Question 37

SPIKES framework for breaking bad news

Answer 37

* Setting up -sit down, space, have someone with you * Perception - what do they already know * Ice breaker - set up for bad news * Knowledge - be direct, use plain language * Emotions and empathy - * Summary - check patients wishes

Question 38

Problem with screening for lung cancer

Answer 38

May find incidental nodules on CT scan These are benign but can turn into cancer Need then regular CT monitoring

Question 39

Problem with lung cancer presentation

Answer 39

* present late in disease prgression * maximise QOL * so increased palliative care input

Question 40

Sites lung cancer often metastasizes to

Answer 40

* Lymph nodes * Brain * Liver * Adrenal glands

Question 41

Which lung cancer is most common in non-smokers?

Answer 41

Adenocarcinoma

Question 42

Problem with previous radiotherapy for breast cancer

Answer 42

Increases risk of future lung cancer

Question 43

What paraneoplastic syndrome is often seen in Squamous cell carcinoma?

Answer 43

* PTHrP = hyperclalcaemia Hypertrophuc pulmonary osteoarthropathy - inflammation of bones and joints in wrists and ankles

Question 44

Which paraneoplastic syndromes are seen in SCLC?

Answer 44

* ACTH - Cushings syndrome * SIADH * Lambert Eaton myasthenic sydrome

Question 45

Carcinoid syndrome test

Answer 45

Urinary 5-HIAA - metabolite of serotonin