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Respiratory YR3 > Case 4 - Lung cancer and pleural effusion > Flashcards

Case 4 - Lung cancer and pleural effusion Flashcards

1
Q

How common of a cancer is lung cancer?

A
  • Biggest cause of cancer related deaths worldwide and UK
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2
Q

5 year survival rate lung cancer

A

16%

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3
Q

What are most lung cancers caused by in UK?

A

76% is from smoking

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4
Q

Lung cancer presentation features

A
  • 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
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5
Q

Horners syndrome

A
  • Miosis - small pupil
  • Anhidrosis
  • Ptosis

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

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6
Q

Risk factors for lung cancer

A
  • Large number of smoking pack years
  • Airflow obstruction
  • Increasing age
  • FH of lung cancer
  • Exposure to other carcinogens eg asbestos
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7
Q

What is performance status?

A

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

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8
Q

Perfomance status stages

A
  1. Normal - fully active with no restriction
  2. Restricted in physical strenuous activity but ok with light work
  3. Ambulatory and able to self care but unable to carry out work activities, up and about >50% waking hours
  4. Capable of limited sellf care, confined to bed or chair >50% waking hours
  5. Completely disabled
  6. Dead
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9
Q

Blood diagnostic tests for lung cancer

A
  • FBC
  • U&E
  • Calcium
  • LFTs
  • INR
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10
Q

Imaging for lung cancer

A
  • 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
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11
Q

Histology options for biopsying lung cancer

A
  • 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
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12
Q

Histological classification of lung cancer

A
  • Small cell lung cancer (SLCL, oat cell)
  • Non-small cell lung cancer (NSCLC)
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13
Q

Examples of non-small cell lung cancer

A
  • Squamous cell
  • Adenocarcinoma
  • Large cell carcinoma
  • Bronchoalveolar cancer
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14
Q

Lung cancer treatment options

A
  • 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
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15
Q

What is curative radiotherapy?

A

CHART - continious hyperfractionated accelerated radiotherapy

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16
Q

NSCLC survival rates at 5 years

A
  • All - 15-23%
  • I - 65-80%
  • II - 50-60%
    (these are both following surgical resection)
  • III - 20%
  • IV - 1-5%
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17
Q

Treatment for SCLC

A
  • Rapid growth rate and almost always too extensive for surgery
  • Chemotherapy = main treatment
  • Palliative radiotherapy too
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18
Q

Prognosis for SCLC

A
  • Untreated - median survival 8-16 weeks
  • Combo chemotherapy median survival is 7-15 months
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19
Q

Approach to a suspected pleural effusion

A
  • History and examination is MAIN PART
20
Q

Bloods for pleural effusion

A
  • FBC
  • U&Es
  • LFTs
  • CRP
  • Bone profile
  • LDH
  • Clotting - in case procedure
21
Q

Imaging for pleural effusion

A
  • ECHO - if suspect HF
  • Staging CT with contrast if suspect exudative cause
22
Q

Pleural effusion definitive diagnosis

A
  • Ultrasound guided pleural aspiration
23
Q

What do we test pleural aspirate for?

A
  • Biochemistry - protein, pH, LDH
  • Cytology
  • Microbiology
24
Q

When to insert chest drain for pleural effusion?

A
  • 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
25
Q

Other methods to consider for pleural effusion diagnosis

A
  • Thoracoscopy
  • CT pleural biopsy
26
Q

Transudate protein level

A

Is <25g/L

27
Q

Common causes of transudate effusions

A
  • Heart failure
  • Cirrhosis
  • Hypoalbuminaemia

Problems with Starling Forces

28
Q

Less common causes of transudate effusions

A
  • Hypothyroidism
  • Mitral stenosis
  • PE
29
Q

Rare causes of transudate effusions

A
  • Constrictive pericarditis
  • SVC obstruction
  • Meigs syndrome (benign ovarian tumour –> ascites and pleural effusion)
30
Q

Treatment for transudate

A
  • Often no diagnostic tap needed
  • TREAT UNDERLYING CAUSE
  • If effusion resolves, stop/reduce treatment
  • If persists then therapeutic drainage is required
31
Q

Protein level for exudates

A

Is >35g/L

32
Q

Common causes of exudate effusions

A
  • Malignancy
  • Infections - TB, paraneumonic, HIV (Kaposi)
33
Q

Less common causes of exudative effusions

A

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

34
Q

Rare causes of exudative effusions

A
  • Yellow nail syndrome
  • Fungal infection
  • Drugs
35
Q

Light criteria - when to apply

A

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

36
Q

Lights criteria for exudative effusion

A
  • If pleural protein/serum protein >0.5
  • If pleural LDH/serum LDH >0.6
  • Pleural LDH >2/3 upper limit of normal
37
Q

SPIKES framework for breaking bad news

A
  • 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
38
Q

Problem with screening for lung cancer

A

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

39
Q

Problem with lung cancer presentation

A
  • present late in disease prgression
  • maximise QOL
  • so increased palliative care input
40
Q

Sites lung cancer often metastasizes to

A
  • Lymph nodes
  • Brain
  • Liver
  • Adrenal glands
41
Q

Which lung cancer is most common in non-smokers?

A

Adenocarcinoma

42
Q

Problem with previous radiotherapy for breast cancer

A

Increases risk of future lung cancer

43
Q

What paraneoplastic syndrome is often seen in Squamous cell carcinoma?

A
  • PTHrP = hyperclalcaemia
    Hypertrophuc pulmonary osteoarthropathy - inflammation of bones and joints in wrists and ankles
44
Q

Which paraneoplastic syndromes are seen in SCLC?

A
  • ACTH - Cushings syndrome
  • SIADH
  • Lambert Eaton myasthenic sydrome
45
Q

Carcinoid syndrome test

A

Urinary 5-HIAA - metabolite of serotonin

46
Q
A

Respiratory YR3 (14 decks)

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