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TCD 6 - Lung Cancer Maria Chewingcurryinahurryand@scrubbedup_ECGs @manchesterisoc *Disclaimer* The content of this presentation was created by med students for med students. This session isn’t intended to replace any formal education provided by the uni of mani, so make sure to review all the cases on 1Med and read your ILOs and attend at least 40 hours/week of clinical experience ;)Admin Stuff - Checkyourjunkmail - Checktheemailaddressthatyouregisteredwithtoday - Pleasedon’tDMme/robyn/maria-wedon’thavephonesxxx - YouwilleventuallygettheslidesIpromise(ifyoufilledout feedbackformsthatislol) - BEPATIENTWITHUS(PLEASEEEEEvbizzyrn5thyrispeak) - Don’tworryaboutthenittygrittystuff,justtryandabsorbas muchasyoucan - ZAKrecommendation-don’ttakelotsofnotesitsvsillyimobut - STOPbeingsomeaninyourfeedbackas🥺f-wevalueitbutweare hoomansattheendofthedaytryingourbestxxxSo what is this teaching exactly? Covers the main pathologies mentioned in each week’s TCD Progress Test, CCA/OSCE, DDx, top notch medics basically NOT HERE TO HOLD YOUR HAND THROUGH THE 1MED CASES SUCCINCT, HIGH YIELD, SHARP and ACTIVE KEYWORD IS نﺎﺳﺣإHow to benefit from this session Contribute & Input (LEGIT most important thing) Ask questions Ask more questions If i don’t know something (most likely so, i will find out for u) Don’t be afraid to get something wrong ! Don’t be mean ! I WILL PICK ON PPL (but nicely I promise dw) SMILE, HAVE FUN, (cry), GET INVOLVED Offer me food (not compulsory but highly encouraged) Contents 1. Lung Cancer Essentials (types, features, diagnosis, management) 2. Cancer and its complications 3. Pleural Effusions 4. Hypercalcaemia 5. Covering CXR 6. Practise Progress Questions 7. Potential OSCE StationsLung Cancer EssentialsLung Cancer Whenwetalkaboutlungcancer,wearegenerallyreferringtotumourofthebronchusorlung parenchyma. ➔ Thirdmostcommoncancer(breast&prostate) ➔ Smokingisahugeriskfactor(?80%preventable) ➔ Histologicaltypes-determinetreatment ◆ Non-smallcelllungcancer(NSLC)-80% ● SCC25% ● Adenocarcinoma38%-mostcommontypeinUK ● Largecellcarcinoma-5%-metastasiseearly ● Mesothelioma ◆ SCLC20%-affectsAPUDcells ● Releaseneuroendocrinehormones=>paraneoplasticsyndromes Namemesomecausesofhaemoptysis? Presentation tuberculosis,emboli(pulmonary),aspergilloma,lungabscess, coagulopathy,pneumonia,mitralstenosis,goodpasture’s? ➔ Asymptomatic,SOB,cough,haemoptysis,clubbing,recurrentpneumonias, weightloss,lymphadenopathy,pneumonianotrespondingtotreatment ➔ Redflagsrespiratoryhistory: ◆ Haemoptysis,weightloss,persistentcough,pain,clubbing,paraneoplasticsymptoms,malaise,night sweats ➔ Riskfactors: ◆ Smoking!,occupational(e.g.asbestos,arsenic) ➔ Signs:Lymphadenopathy,Stridor,Wheeze,Clubbing,PleuralEffusion PresentstoGPwiththeabove→ 2wwreferraltorespiratory Whatdoyoudonextifsomeone department hasthesesymptoms? Incidentalfindingonscan→2wwreferralReferral Criteria - NG 12 ‘not-so’ NICE guidelines ➔2wwRespConsultantReferral ◆ SusCXR ◆ Unexplainedhaemoptysisin>40y/o ➔2wwCXR+>40y/o ◆ Persistent/recurrentLRTI,clubbing,supraclavic/persistentcervical lymphadenopathy,thrombocytosis,lungcancerchestsigns ➔ 2wwCXR+<40y/o+eversmoked ◆ Cough,SOB,fatigue,SOB,C/P,Weight/appetitelossInvestigations ➔FBC-anaemiaetc ➔U&Es-SIADHetc ➔LFTs-livermets ➔Boneprofile-hypercalcaemia ➔ChestX-Ray ◆ Hilarenlargement,focalopacity,unilateralpleuraleffusion,lung collapse ➔CTTAP(whatisthat?)–staging+spiculation ➔PET-CT–metabolicactivity-FGD18 ➔BronchoscopywithEBUS-biopsyforpTstaging ◆ Airwaycancers!Histologyisneededfortreatment-canbe donewithEBUSorpercutaneously(throughtheskin) ◆ Offerthoracoscopyw/biopsyfordistanttumours ➔BTS’sBROCKCalculator–likelihoodapulmonary nodulewillbediagnosedascancerin2-4years ➔ CT/MRIheadformets ➔ LFTsforpre-oplungreductionsurgeriesetc.Lung CancerTypes Non-small Cell Carcinomas: Squamous cell ➔ SecondmostcommontypeoflungcancerinUK-highsmokingassociation ➔ UsuallypresentsasCENTRALobstructivelesionsofthebronchusleadingto infection ◆ Pneumonia-6/wfollowupCXR ➔ Occasionallycavitates(10%atpresentation-moresothanothercancers ◆ CXR-?abscessorcancer(poorlydefinedborders) ➔ Aggressivelocalspreadbutmetastasizeslate-thereforesurgeryispossible ➔ Oftencauseshypercalcaemia-ectopicPTHanalogueproduction/bonedestruction ◆ SecretesPTHrH ➔ AssociatedwithclubbingandHPOA(hypertrophicpulmonaryosteoarthropathy) ◆ Periostealreaction(noactualbonylesions)→“onionskin”XR Hypercalcaemia-eitherfrombonemetsorSquamousCellCaPTHrH Symptomsofhypercalcemia-bones,stones,groans,thronesandpsychiatricmoansAdenocarcinoma ➔ MostcommonLungCa ➔ Arisesfromglandular,secretorybronchialepithelium ➔ Doesnotusuallycavitate-METSVEARLY→BRAIN ➔ Morecommoninnonsmokers ◆ Womenfromfareast-leastlikelytoberelatedtosmoking ➔ Lesionsusuallyinperipherallungnotcentral ➔ Paraneoplastics? ◆ Gynaecomastia,HPOA,TrousseauSyndrome Mesothelioma ➔ CancerofthepleuraNOTLUNGPARENCHYMA ➔ Relatedwithasbestosexposure(hugelatentperiod-cantake45yrstodevelop) ➔ Poorprognosis-chemoispalliativeSmall Cell Lung Carcinoma - SCLC ➔ Arisefromneuro-endocrine,APUDcells→LOCATEDveryCENTRALLY-SMOKING ◆ Mostassociatedwithendocrineparaneoplasticsyndromes ● Excepthypercalcemia/PTH/HPOA-squamous ◆ S-SIADH-excessiveADHproduction→euvolaemichyponatremia ◆ C-Cushing’ssyndrome→ectopicACTHrelease ◆ L-Lambert-EatonMyasthenicSyndrome→antibodiestovoltage-gatedCa2+channels→ proximal/ocularweaknessandhyporeflexiawhichimproveWITHmovement ◆ C-CerebellarDegeneration-DANISH ➔ Mostcommoncauseofpancoasttumor(apical) ◆ Invadesbrachialplexus- Anti-HuDandAnti-Yo ◆ Horner'ssyndrome-ptosis,miosis,anhidrosis ➔ Metastasisesearly-inoperable(poorprognosis) ➔ VERYChemosensitiveInvestigations NB:VALSGstagingforSCLC - Limiteddisease - ExtensivediseaseManagement ➔ SMOKINGCESSATION ➔ ResultsandtreatmentdiscussedatMDT ➔ Curativetreatment ◆ SurgeryisfirstlineinNSCLC–lobectomy/segmentectomy/wedgeresection ● Radiotherapysecondline,curativeifveryearlystage ● Adjuvantchemotherapy ◆ ChemoradiotherapyforSCLC–verypoorprognosis ◆ SACT-SystemicAnti-cancerTherapy(non-squamousNSCLC-genespecificonly) ➔ Palliativetreatment ◆ Chemotherapy ◆ Endobronchialtreatment–stentordebulkingtorelievebronchialobstruction ◆ OncologicalEmergenciesRxWho’s involved in care? ➔ GP ➔ Respiratoryphysicians ➔ MDT–pathology,oncology,surgeons,nurses,radiology ➔ Referraltosurgeonsoroncologists ➔ Macmillanspecialistnurses ◆ Givethemaphonenumberforeasycontact ◆ Tellingthefamily ◆ Decisionmaking ◆ Financial/occupationalsupport ➔ “Prehab”–exercise,nutrition,wellbeing ➔ “CURE”–SmokingcessationprogrammeatWythenshaweOncological ComplicationsCategorising Complication ➔ 1.Masseffect- affectinglocalregionsandcompressingstructures ◆ Airwaycompression,pneumonia,SVCO,sympatheticchain(Horner’s),phrenicnerve (diaphragmatichemiparesis),recurrentlaryngealnerve(hoarseness) ➔ 2.Spread ◆ Hilar/mediastinalnodes,chestwall,liver,brain,bone,adrenals ➔ ParaneoplasticSyndromes: ◆ 3.Immuneresponse ■ Inflammation,B-symptoms,Lambert-Eatonsyndrome, anti-HuAb(limbic encephalitis),anti-Jo(dermatomyositis/polymyositis) ◆ 4.Hormones ■ PTHrH(hyperparathyroidism)/Hypercalcaemia–NSLC(alsoGyno,HPOA), ■ ADH(SIADH)-SCLC ■ eACTH(Cushing’s)-SCLC Mass Effect & Spread -Pancoast tumour (in lung apex) --> -SOB. SVCO - Superior Vena Cava Obstruction -Recurrent laryngeal nerve palsy (hoarse voice).ung cancer causes this the most? -Facial swelling. - SCLC -Phrenic nerve palsy (difficulty breathing).t line → dexamethasone (↓↓ -Headache. inflammation/swelling). -Visual disturbance.e. - Definitive → stenting/balloon venoplasty. -Damage to sympathetic chain --> ipsilateral -↑↑ non-pulsptosis/miosis/anhidrosis/enophthalmos. → chemo/radio. -Pemberton’s +ve gottron’spapules Immune Response ➔ Lambert-Eatonsyndrome-SCLC 2+ ◆ AutoantibodiesactonpresynapticCa channel heliotroperash ◆ Proximalmuscleweakness ➔ Polymyositis-ConnectiveTissueDisease ◆ Affectsextra-ocular,eyelidandpharyngealmuscles causingdiplopia,ptosis,slurredspeechand ◆ Muscleinflammation,raisedcreatininekinase dysphagia ◆ Pain,fatigue,weakness,bilaterally,proximal ◆ Improvesslightlywithrepetitivemovement muscles,overweeks ◆ Alsoassociatedwithothercancers ◆ >SCLC ◆ Anti-Joantibodies ➔ Dermatomyositis=Polymyositis+skininvolved ➔ LimbicEncephalitis ◆ Gottron’spapules,heliotroperash,shawl ◆ SCLCmakesimmunesystemproduceAntiHu rash,photosensitiverash,periorbital antibodieswhichattacklimbicsystem oedema ◆ Causesmemoryloss,hallucinations,confusion, ◆ Anti-Mi-2antibodies seizuresHormonesHormones Cancer Hormone Effect Squamous Parathyroidrelatedprotein(PTHrP) Hypercalcemia,weakbones SCLC Antidiuretichormone(ADH) SIADH SCLC Adrenocorticotropichormone(ACTH) Cushing’s ➔ SCLCCushing’s-ilikemypegstobeflat?Flatpeg?Wthuonaboutzik? ◆ BothACTHandcortisoldon’t↓withlowdosetest(1mg)andhighdosetest(8mg) ● thissuggestsectopicrelease ➔ SCLCSIADH + ◆ Excessivewaterreabsorptionincollectingducts->waterretention->hypoNa ● Waterretentionnotsignificantsoeuvolemichyponatremia ◆ LowserumNa ,highurineNa ,lowK+andH+(hypokalaemicalkalosis),highurineosmolality ◆ Vaguesymptoms:headache,fatigue,aches,confusion,?seizure,↓GCS ◆ Correcthyponatremiaslowlytopreventcentralpontinemyelinolysis ● Waterrapidlyshiftsfromcells->saltyblood;spasticquadriparesis,behavioursympt.,death; cantbecured(onlyprevented!) ➔ Adeno-HPOA(HypertrophicPulmonaryOsteoarthropathy) ◆ Clubbingandpainfulwrist/ankleswellingHormones Cancer Hormone Effect Hormones Squamous Parathyroidrelatedprotein(PTHrP) Hypercalcemia,weakbones SCLC Antidiuretichormone(ADH) SIADH SCLC Adrenocorticotropichormone(ACTH) Cushing’s ➔ SquamousCell ◆ PTH-rP-->↑↑Ca2+. ◆ HPOA(clubbing+painfulwrist/ankleswelling)Pleural EffusionsPleural Effusions Pleurabecomeinflamed,whichcanresultinexcessfluidproduction ○ Maynotrequiretreatment ○ Mayrequiredrainage ○ Iffluidbecomesinfected->empyema DxwithPleuralAspiration(thoracocentesis)underUSS/CTguidance Signs: +/-chestdrain? ● CXR:costophrenicblunting ○ Sendoffforprotein,glucose,MCS,cytology(?),pH,LDH,Acid <500ml,clearfluidlevel >500mlw/meniscus FastBacilli(?) ● decreasedchestexpansion, ○ Classifiedbyproteincontent: ■ Transudate<30g/L ● dullness, ■ Exudate>30g/L ● reducedbreath ■ 25g/L<x>35g/L?? sounds/reducedvocal ● UseLight’sCriteria resonance ● ItisExudateif: ● trachealdeviation(awayif largeenough) ○ Pleuralp:Serump>0.5 ● pleuralrub ○ PleuralLDH:SerumLDH>0.6 ○ PleuralLDH>200Exudate AlltheI's (↑Permeability--> Infection-->pneumonia(mostcommon)/TB. proteinleak) Inflammation(e.g.RA/SLE). (>30g/Lprotein) InfiltrationCancer(lung/mesothelioma/mets) Infarction(PE). -PE. -Pancreatitis. -Dressler'ssyndrome. -Yellownailsyndrome.Transudate -Heartfailure(mostcommon). (↑Hydrostatic/↓oncotic) -↓↓Albumin(liverfailure/nephroticsyndrome/malnutrition…). (<30}}g/Lprotein) -Hypothyroidism. -Meig'ssyndrome. -(Benignovariantumour--(resection)-->ascites+rightpleuraleffusion). Light'scriteria Anexudatehas1of: -Effusion:serumprotein>0.5. 25<x>35g/dL -Effusion:serumLDH>0.6. -EffusionLDH>2/3sofUNLofnormalserumLDH.Pleural EffusionsPleural Effusions Cont’d… ● Transudate:duetooncoticissue ○ Heartfailure,hyopalbuminaemia,cirrhosis,nephrotic,Meig’sSyndrome ● Exudate: ○ Inflammation:cancer,pneumonia,rheumatoidarthritis,TB,PE ○ Highproteinfluids:blood(haemothorax) ○ Infections(+empyema) ● Mx: ○ Fluidshouldberemovedslowly–2Levery24hrmax. ■ Why? ■ Large,fastfluidremoval→pulmonaryoedema. ○ InMalignancy–mostcaseswilloccurwithinamonth,andso pleurodesisorlong-termin-dwellingchestdrainsmaybeconsidered. ○ Pleurodesis– twolayersofthepleuraarestucktogether,either chemicallyorsurgically,topreventtheaccumulationoffluid. ○ Pleurodesistalcismostusefulforeffusionscausedbymalignancy CXR - White Lung Lesions MassivePleuralEffusion- RightUpperLobeCollapse Pneumonectomy-Tracheapulled TracheapushedAWAYfrom TOWARDwhiteout whiteoutQuick Quiz ➔ WhatisthemostcommontypeoflungcancerinUK? ➔ Whichlungcancerisassociatedwithnon-smokers? ➔ CavitatinglesionseenonCXR,howwouldyoudifferentiatebetweenacancerand abscess? ➔ Whichhormoneisectopicallyreleasedfromsquamouscellcarcinomas? ➔ LimbicEncephalitisisassociatedwithwhichtypeofcancer? ➔ Whichtypeoflungcancerinvolvessurgeryasfirstlinemanagement? ➔ Name3causesofhighproteininapleuraltapsample? ➔ Pneumonectomy-Towardsorawayfromwhiteout? ➔ WhatisthetriadseeninMeig’sSyndrome?HypercalcaemiaHypercalcaemia and Hypocalcaemia Hyper Hypo "Bones,stones,groans,thrones, • Spasms psychicmoans" • Perioral pins and needles ● Bonepain-patho#fracs • Seizures ● Kidneystones ● Abdominalpain • Confusion • Cataracts ● Lowmoodandconfusion Also:thirst,vomiting,anda • Long QT interval shortenedQTinterval Give calcium Givefluidsandbisphosphonates Phosphate not really as consequential but if low enough it can be fatal via cardiac arrest.Hypercalcaemia Rx -1stline→ angry/aggressiveIVfluids(0.9%saline). -~IVBisphosphonates(pamidronate/zoledronate)→ 5-7daystowork. -~Calcitonin→ worksfaster. -Treatif: ->3. ->2.6+symptoms. Trousseau's sign: inflation Hypocalcemia signs of a cuff causes the wrist and fingers to flex (carpopedal spasm) (hypocalcaemia) Chvostek's sign: tapping the facial nerve over the parotid causes a facial twitch (hypocalcaemia)Progressionally Progressive Depressive Mentally Supressive Progress Test Questiones Slido.com 3687337 Z et ROSCEs (the stuffyou’ve been waiting for)Data Interpretation ➔ Basicclinicalinfo ◆ Knowsymptoms,redflags,riskfactors,paraneoplasticeffectsoflungcancer ◆ Give3differentials,saywhylungcancerisyourfavouredone ◆ Whattestswouldyourequest? ● Bloods,CXR,CTTAP,biopsy;toruleoutdifferentials,tolookforandstagetumour,biopsyto guidetreatment ➔ X-ray-ABCDEapproach ➔ Bloodsandurineosmolality ◆ SIADH–cameupinourmockOSCEwithanX-rayofanobviousPancoasttumour ➔ Pleurodesis ◆ Transudateorexudate?HistoryTaking ➔ PC,HPCw.redflags,ICE,Meds,smoking/alcohol,S/FH,ICE,summary ➔ WhenexploringHPCaskexplicitlyforredflagsymptoms ➔ Smoking ◆ Enoughinformationtocalculatepackyears(butdon’twastetimecalculating) ◆ Everthoughtaboutstoppingsmoking?Ifinterested,wecanreferyoutooursmokingcessationservice ➔ Differentials:pneumonia,haematologicalmalignancye.g.Hodgkin’s lymphoma,TB,metastasise.g.frombreast,hyperthyroidism,anaemia ◆ ILD,benigntumoure.g.fibroma,raritiese.g.ChurgStrauss,AspergillusFocused Respiratory Examination Dothenormalresp.exambutworkthefollowingfindingsintoit: ➔ Inspection: ◆ Cigarettes,Looselyfittingclothes,hoarseness,cough ➔ Hands: ◆ Hypertrophicpulmonaryosteoarthropathy,tarstaining ➔ Head&Neck: ◆ Cushingoidfeatures(ACTH-SCLC),Supraclavicularlymphadenopathy,SVCS–?Pemberton’s, Horner’ssyndrome ➔ Chest: ◆ Chestwallabnormalities–swelling,tenderness“To complete my examination…” ➔ “TocompletemyexaminationIwouldliketotakeadetailedhistory, lookatthepatientsobservationalcharts,requestsomebloods includingFBC,CRP,TFTsandrequestaCXR. ◆ FBC:anaemia,infection ◆ CRP:infection,inflammation(?vasculitis) ◆ TFTs:ifweightlossorneckmass?hyperthyroid ◆ CXR:pneumonia,lungcancer,othere.g.TB,vasculitis ➔ AsIamconcernedaboutlungcancer,Iwouldreferthispatientonthe 2wwHSCpathwayforfurtherimaging,biopsyandstaging.” ➔ Celltype,TNMstage,fitnessforsurgery(PFTs,shuttlewalk,echo), patientpreference NORMALEXAMINATIONPRESENTATION→Thepatientisalertandspeakinginfull sentences.Therearenoperipheralsignsofrespiratorydisease.Chestexpansionwasequal andcricosternaldistancewasinrange.Percussionwasresonantinallzonesandtherewas equalairentrytobothlungbases.TocompletemyexaminationIwouldliketo….
