Oncological Presentations - SOB

Question 1

What is lymphangitis carcinomatosis

Presentation

Answer 1

Diffuse infiltration of lymphatics by tumour => obstruction and interstitial edema

SOB out of proportion to physical findings

Question 2

Investigation findings for LC

Answer 2

CXR - can be normal in 50% of cases

• diffuse bilateral reticulonodular opacification
• Kerley B lines

CT

• thickening of interlobar septa
• thickening of central bronchovascular structures
• reticular alveolar pattern
• lung and lobular architecture ok

Question 3

Management for LC

Answer 3

Dexmeth
Symptomatic management of SOB - opiates, lorazepam
Manage underlying primary

Question 4

Presentation of SVCO

Answer 4

Head, neck, arm edema
Cyanosis, facial plethora
Distended SC vessels on arms, neck, upper chest, back - collateral superficial vessels having to be used
SOB, cough, chest pain
Hoarse voice - compression of recurrent laryngeal
Blurred vision, strider, headache

Question 5

Causes of SVCO

• general
• malignant
• non malignant

Answer 5

Luminal obstruction by infiltration, stenosis, thrombosis
Extrinsic compression => obstruction

Malignant - most common reason
- mainly lung cancer

Non malignant

• mediastinal fibrosis from RT or infection
• IV devices causing thrombosis/stenosis
• goitre

Question 6

Management of SVCO

Answer 6

Elevation of bed head
O2

Tissue diagnosis of cancer
-chemotherapy if cancer v chemo sensitive

Percutaneous stenting + prophylactic AC (or if thrombus found)

Question 7

Presentation of malignant pleural effusion

What are you assessing for

Answer 7

Worsening SOB, chest pain

Symptoms of acute on chronic resp disease, malignancy
Baseline and current resp function
Occupational, smoking exposures

Question 8

What are the potential differentials for increased SOB

Answer 8

Pneumonia, bronchitis, pneumonitis
COPD, asthma exacerbation
ACS, HF
PE, pleural effusion, PT
SVCO
Anemia

Question 9

Initial management for SOB

Answer 9

A-E assessment

ABG
Blood tests -
-FBC - anemia, signs of malignancy affecting BM
-U&E - renal function, may affect medication given
-clotting - PE, DVT
-CRP - inflammation?

ECG - rule out cardiac causes
CXR

Question 10

Investigations for pleural effusions

Answer 10

US guided pleural aspiration

• cytology
• protein
• LDH
• pH
• gram stain, MC&S

Exudate - protein 30g+
Transudate - protein U30g
Lights Criteria

Contrast enhanced CT CA if cancer suspected
If cancer likely
-peripheral => CT, US transthoracic biopsy
-central => bronchoscopy, EBUS, transbronchial needle aspiration
-likely mediastinal node involvement => US neck + biopsy

Question 11

Common causes of exudate and transudate

Answer 11

Common causes of exudates

• malignancy
• parapneumonic effusion
• TB

Common causes of transudates

• LVF
• cirrhosis

Question 12

Management of malignant pleural effusion

Answer 12

Observe

Therapeutic US thoracocentesis

Insertion of IC chest drain via US + pleurodesis

May need pleural indwelling catheter