Post on 24-Feb-2016
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Respiratory Malignancy
Charlotte Miller
Contents
DefinitionClassificationsClinical PresentationManagementPrognosisClinical ScenarioEmergency
Definition
Neoplasia Abnormal growth of cells which persists
after initial stimulus has been removedBenign
Compact mass that remains at the site of origin
Malignant Uncontrolled growth, not organised,
necrotic centre, illmargined
Classification Primary
Small Cell Non Small Cell▪ Squamous▪ Large cell▪ Adenocarcinoma
Secondary Breast Bone Kidney Prostate thyroid
Bronchial Carcinoma • 95% of primary
tumours• 3:1 M:F
Pathophysiology
GeneticEnvironmental
The British Doctors Study
MAGNIFICENT SEVEN• Self Sufficiency in Growth
Signals• Insensitivity to negative
signals• Defects in DNA repair• Evasion of Apoptosis• Limitless replication potential• Angiogenesis• Invasion & Metastasis
History
Presentation Local effects▪ Breathlessness▪ Cough▪ Chest Pain▪ Haemoptysis
Spread within the chest▪ Pancoast tumour▪ Horners Syndrome▪ SVC obstruction▪ Pleural infiltration
Metastatic▪ Bone▪ Brain▪ Lymph Nodes
Non Metastatic▪ Endocrine▪ Neurological▪ Vascular▪ Skeletal▪ Cutaneous
Important Information PMHx of
Malignancy Hodgkins Testicular Endometrial
Family History 1st degree increase
by 51%
Social History Smoking Occupation▪ Asbestos, Radon Gas,
Foreign Travel
Signs
Peripheral Clubbing Cyanosis Hypertrophic
Pulmonary Osteoarthropathy
Acanthosis Nigricans
Central Lymphadenopathy Tracheal Deviation Chest defects
Investigations
Bedside
Bloods
Imaging
Special Tests
Peak Flow Pulse Oximetry Sputum ABG Full Blood Count Bone – Calcium Urea +
Electrolytes Liver Function Thyroid Function
Chest X-ray CT Scan PET scan Bronchiolar Lavage Trans-thoracic Needle
Biopsy Pleural Aspiration Respiratory Function
Management
Biological Conservative Medical Surgical
Psychological
Social
In order to effectively manage this patient I would like to involve a multidisciplinary team to use the
biological – psychological - social
approach
Biological Conservative
Symptom relief Smoking Cessation
Medical Radiotherapy Chemotherapy
Surgical Assessment for surgery De-bulking
Psychological
Counselling
Mood altering medications
End of Life discussions
Social
Support Networks
Services for Families / Carers
Physiotherapy / Occupational Therapist Adaptation to home Maintaining Mobility
Prognosis
Staging Tumour Metastatic Nodes
Clinical stage
Five-year survival (%)Non-small cell lung
carcinoma
Small cell lung
carcinomaIA 50 38IB 47 21IIA 36 38IIB 26 18IIIA 19 13IIIB 7 9IV 2 1
Clinical Scenario
72 year old woman presents with worsening shortness of breath for the last 3 months. HxPC: 2 weeks she has been coughing up bright red blood with
her sputum 2 stone weight loss over 2/12
PMHx : COPD Hypertension
Meds: Seretide 250 2 puffs BD, Salbutamol PRN, Ramipril 5mg ODAllergies: NKDA
SHx: Retired, previously worked in a post office Stopped smoking 5 years ago after a 40 year pack history No alcohol
What are your main differential diagnoses for this lady?
?Risk Factors
How would you investigate her?
Clinical Scenario…
O/E Cachectic Stoney dullness at her right lung base No air entry right lower lobe
CXR Right sided pleural effusion
Other Investigations?
Transudate Vs Exudate
Exudates have a protein level of >30 g/LTransudates have a protein level of <30
g/L
Light's criteria state that the pleural fluid is an exudate if one or more of the following criteria are met Pleural fluid protein divided by serum protein
>0.5 Pleural fluid LDH divided by serum LDH >0.6 Pleural fluid LDH more than two-thirds the
upper limits of normal serum LDH
Emergencies
SVC Obstruction Steroids - Dexamethasone Stent Oncology R/v – Radiotherapy,
Chemotherapy
Erosion of Blood Vessels Supportive Palliation
Questions???