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Respiratory: Patient History, etc > Clinical Aspects of Bronchial Carcinoma > Flashcards

Clinical Aspects of Bronchial Carcinoma Flashcards

(73 cards)

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1
Q

What are the general features of cancer? (5)

A
  • Malignant growth
  • Uncontrolled replication
  • Local invasion
  • Metastasis
  • Non-metastatic systemic side effects (mimic effects of hormones - paraneoplastic features)
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2
Q

What are 3 ways cancer can metastasise?

A
  • Lymphatic spread
  • Blood stream
  • Serous cavities e.g. via peritoneum
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3
Q

What are paraneoplastic features?

A

Molecules released from tumour can mimic the effects of naturally-occurring hormones

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4
Q

How many cases of lung cancer are diagnose in the UK

i) Annually?
ii) Daily?

A
  • 45,000 new cases per year

* 120 new cases every day

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5
Q

Why is 90% of lung cancer incurable at the time of diagnosis?

A

Tends not to cause any symptoms until the disease has become too advanced

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6
Q

Why is lung cancer significant in Scotland?

A
  • Most common cause of cancer death in men and women in Scotland
  • Rates of lung cancer in Scotland are amongst the highest in the world
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7
Q

Why is prevalence of lung cancer low?

A

Patients do not live for long - 50% of lung cancer patients will not be alive 6 months after the diagnosis

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8
Q

Why is the percentage increase of lung cancer greater in females than males?

A

Smoking has increased in female population, decreased in male population

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9
Q

What are the presentations of lung cancer?

A
  • Primary tumour
  • Local invasion
  • Metastases
  • Non-metastatic
    (paraneoplastic)
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10
Q

What symptoms do you look for to detect lung cancer early? (8)

A
  • Cough for >3 weeks
  • Breathless
  • Chest infection that doesn’t clear up (recurrent pneumonia)
  • Haemoptysis
  • Weight loss
  • Chest/shoulder pains
  • Fatigue
  • Hoarse voice
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11
Q

What is haemoptysis?

A

Coughing up blood

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12
Q

What causes haemoptysis with regards to cancer?

A

Direct consequence of primary tumour in bronchi

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13
Q

How does lung cancer cause pneumonia?

A

Lung cancer in upper lobe causes partial obstruction of upper lobe bronchus

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14
Q

Why does the enlarging tumour cause a shrinking lung?

A
  • Obstruction of proximal divisions of the bronchial tree
  • When a lobe becomes obstructed, all of the air beyond the obstruction is absorbed and the lung tissue shrinks down to a much smaller size
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15
Q

When you look at a CXR, how can you tell which lung is affected with lung cancer?

A

The smaller of the 2 lungs is usually the diseased one

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16
Q

What are the clinical signs of lung cancer?

A
  • Haemoptysis
  • Recurrent pneumonia
  • Stridor
  • Short of breath
  • Muscle weakness (particularly in hands, etc)
  • Pleural effusion
  • Anastomoses to inferior vena cava
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17
Q

What is stridor?

A

A high-pitched wheezing sound caused by disrupted airflow

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18
Q

How does lung cancer lead to shortness of breath?

A

Tumour causes obstruction to the airways

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19
Q

Where are local sites lung cancer can invade? (6)

A
  • Recurrent laryngeal nerve
  • Pericardium
  • Oesophagus
  • Brachial plexus
  • Pleural cavity
  • Superior vena cava
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20
Q

How does lung cancer lead to a hoarse voice?

A

Tumour invades recurrent laryngeal nerve at left hilum - causes recurrent laryngeal nerve palsy

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21
Q

What does local invasion of the pericardium lead to? (3)

A
  • Breathlessness
  • Atrial fibrillation
  • Pericardial effusion
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22
Q

What does local invasion of the oesophagus lead to?

A

Dysphagia - inability to swallow properly

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23
Q

How can lung cancer lead to muscle wastage in the hands? (2)

A
  • T1 root infiltration by a primary lung cancer in the apex of the lung (pancoast tumour)
  • The tumour can erode through the ribs and into the lower part of the brachial plexus
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24
Q

What is a pancoast tumour?

A

Tumour situated at the apex of the lung (pulmonary apex)

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25
Do patients with a pancoast tumour experience pain?
Surprisingly, no - despite eroding through bone into chest wall
26
How does lung cancer cause pleural effusion?
When the primary tumour invades the pleural space, it often generates a large volume of pleural fluid
27
What is the presenting symptom of pleural effusion caused by lung cancer?
Breathlessness
28
What can local invasion of the superior vena cava (SVC) result in? (4)
* Obstructs drainage of blood from the arms and head - causes puffy eyelids and a headache * Distension of superficial veins * Loss of normal pulsation * Anastomoses form to inferior vena cava in an attempt to bypass obstructed SVC
29
How are the symptoms of an obstructed SVC treated? When must this be done?
* Insertion of a stent to open up the occluded vein | * This must be done before the vein is permanently occluded by thrombosis
30
What are the clinical presentations of chest wall invasion by lung cancer? What if there is bone erosion?
* Localised chest pain that is worse with movement | * If there is bone erosion, patient will often describe pain that is worse at night
31
Why is a tumour encasing the pulmonary artery dangerous?
* The tumour can erode into the artery and into a major bronchus * This results in sudden death due to massive haemoptysis
32
What are common sites for metastases of primary lung cancer? (5)
* Liver * Brain * Bone * Adrenal * Skin
33
What are symptoms of cerebral metastases? (5)
* Insidious onset * Weakness * Visual disturbance * Headaches - worse in the morning, not photophobic * Fits
34
How can you tell the difference between cerebral metastases and a stroke if they both have the same classical symptoms?
The onset of the symptoms due to a metastasis can take days or weeks, whereas a classical stroke can develop in a matter of minutes
35
Why does cerebral metastases cause a headache?
Due to raised intracranial pressure
36
What can be used to treat cerebral metastases?
* High dose corticosteroid therapy (e.g. Dexamethasone) will improve symptoms in the short term by removing all the oedema * However, this benefit is shortlived and within a few weeks the symptoms will return
37
When would liver metastases produce pain?
If they are adjacent to the liver capsule
38
What happens if a liver metastases obstructs billiary drainage?
Obstructive jaundice
39
How can liver metastases be diagnosed?
* CT scan | * Liver function tests - alkaline phosphotase (ALK PHOS) levels will be abnormal
40
What are the clinical presentations of bone metastases?
* Localised pain which is worse at night | * Pathological fracture - the bone may fracture following a weak mechanical stress (due to weakened bone structure)
41
What are the clinical presentations of metastasis in left adrenal gland?
Very unlikely to get symptoms - normal hormone production
42
What are non-metastatic, paraneoplastic symptoms of lung cancer? (7)
* Finger clubbing * Hypertrophic Pulmonary Osteoarthropathy - HPOA * Weight loss * Thrombophlebitis * Hypercalcaemia * Hyponatraemia - SIADH * Weakness - Eaton Lambert syndrome
43
What causes paraneoplastic symptoms of lung cancer?
* Result from the effects of biochemically active products from the primary tumour * They are NOT indicative of metastatic disease
44
How does lung cancer result in hypercalcaemia?
Tumour producing substance which mimics effects of parathyroid hormone
45
What are the symptoms of hypercalcaemia?
* Headaches, * Confusion * Thirst * Constipation
46
How does lung cancer result in hyponatraemia?
Production of substance which mimics Anti Diuretic Hormone
47
What are the symptoms/clinicla presentations of hyponatraemia?
* Confusion | * Plasma sodium often less than 120
48
Why must anyone with a new observation of finger clubbing receive a chest x-ray?
Lung cancer is one of the commonest causes of finger clubbing
49
What diseases can cause finger clubbing?
* Lung cancer * Liver disease (esp hep C) * Congenital cyanotic heart disease * Bacterial endocarditis * Bronchiectasis
50
What are symptoms of hypertrophic pulmonary osteoarthropathy?
Pain and tenderness
51
What causes pain and tenderness in the long bones in hypertrophic pulmonary osteoarthropathy?
Elevation of the periosteum away from bone surface
52
What is thrombophlebitis?
Inflammatory process that causes blood clot to form and block one or more veins - usually in the legs
53
What are the symptoms of thrombophlebitis?
Appearance of painful cord-like structure - usually on the legs
54
Why is weight loss a common symptom of cancer?
Increased metabolic rate - tumour consuming calories
55
What causes hypercalcaemia?
Tumour releases free calcium
56
What does hypercalcaemia result in?
* Cardiac arrhythmias (important) * Stones (renal/biliary calculi) * Bones (bone pain) * Groans (abdominal pain, constipation, nausea+vomiting) * Thrones (polyuria) * Psychiatric overtones (depression, anxiety, reduced GCS, coma)
57
What is the treatment for hypercalcamia?
* Initial treatment = rehydration * If Calcium very high (>4) or does not correct with fluid then also use IV Bisphosphonate * Treat underlying cancer – usually Squamous cell
58
What is SIADH?
Syndrome of inappropriate antidiuretic hormone
59
What causes SIADH?
Usually small cell lung cancer
60
What are the symptoms of SIADH?
* Low sodium concentration in blood (excreted in urine, water retention) * Nausea/vomiting * Myoclonus (muscle jerks) * Lethargy/confusion * Seizures * Coma
61
What is the treatment for SIADH?
* Treat underlying cause * Fluid restriction – 1.5L/day * Sometimes need Demeclocycline
62
What should be explored when taking a history for suspected lung cancer?
* Cough * Haemoptysis * Cigarette smoker * Breathless * Weight loss * Chest wall pain * Tiredness * Recurrent infection * Other smoking related disease * “Is there anything you are worried about ?”
63
What sort of examinations should be carried out for suspected lung cancer?
* Finger clubbing * Breathless * Cough * Weight loss * Bloated face * Hoarse voice * Lymphadenopathy * Tracheal deviation * Dull percussion * Stridor * Enlarged liver
64
What investigations can be carried out for suspected lung cancer?
* Full blood count * Coagulation screen * Na, K, Ca, Alk Phos * Spirometry, FEV1 * Chest X-ray * CT scan of thorax * PET scan * Bronchoscopy * Endobronchial Ultrasound (EBUS) * NOT sputum cytology
65
What is Positron Emission Tomography (PET scan)?
* Scan to asses function rather than structure * Analysis of tissue uptake of radiolabelled glucose * Tissues with high metabolic activity “light up” e. g. increased metabolic activity in right upper lobe due to tumour
66
What techniques are used to make a tissue diagnosis of lung cancer?
* Bronchoscopy * CT guided biopsy * Lymph node aspirate * Aspiration of pleural fluid * Endobronchial Ultrasound * Thoracoscopy
67
Explain the process of bronchoscopy
* local anaesthetic with intravenous sedation | * bronchoscope is passed through the nose to inspect the central part of the bronchial tree
68
What is bronchoscopy not useful for?
Investigating possible tumours out in the periphery of the lungs - you cannot inspect bronchial divisions that are smaller than the diameter of the bronchoscope
69
What is an endobronchial ultrasound?
Bronchoscope with ultrasound tip
70
What is endobronchial ultrasound used for?
* Enables visualisation of hilar and mediastinal structures | * Target and sample lymph nodes
71
How are lymph nodes sampled via endobronchial ultrasound scope?
Thin needle passed into the node through the scope, material aspirated from the node
72
Explain the medical thoracoscopy process
* Patient sedated and put under local anaesthetic * Semi-rigid scope inserted between rib spaces * Lung is deflated to allow visualisation of the pleural surfaces * Biopsies can be taken from the pleura
73
What are differential diagnoses for a patient presenting with the following:- * Smoker * Haemoptysis * Abnormal CXR
* Lung cancer * Tuberculosis * Vasculitis * Pulmonary embolism * Secondary cancer * Lymphoma * Bronchiectasis

Respiratory: Patient History, etc (10 decks)

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