iBSc: Question 3

By Alan McLeod

Tested by Natalie Hayes

Getting the best marks

Read the whole question – a latter section may give you a

clue about an earlier one.

To see how many points you need look at the marks

allocated – for example a 3 point question is generally looking for 3 salient points

If giving a list answer put the best answers first – examiners will not usually mark answers too

far down a list

Always write something – it may get you part of a mark and is anonymised so

no one will think you are stupid!

If you genuinely have no clue then re-write the question to see if this sparks

some ideas.

If not then move on and come back at the end. And remember – always

write something.

Good luck!

Question 4

Mr Jackson, a 62 year old retired bricklayer has

been experiencing haemoptysis for

three weeks.

Q4.1• List 4 differentials for

haemoptysis (4)

Question 4

Mr Jackson has an 80 pack year

smoking history.

Q4.2• What is a ‘pack year’

(2)

Question 4

Cigarette smoke is a known carcinogen.

Q4.3• List two other

carcinogens (1)

Q4.4• What are the three

stages of carcinogenesis (3)

Question 4

You suspect lung cancer.

Q4.5• What additional

symptoms might you ask about to support your hypothesis (2)

Q4.6• What cancer specific

tests might you order (3)

Question 4

Tests reveal a squamous cell

carcinoma of the lung with liver metastases.

Q4.7• Aside from SCC, list two

other common types of lung cancer (2)

Q4.8• What changes occur in a

cancer cell to allow metastasis? (5)

Question 4

Tests reveal a squamous cell

carcinoma of the lung with liver metastases.

Q4.9• Compare the

characteristics of normal and neoplastic cells (4)

Question 4

When you tell him the diagnosis, Mr Jackson becomes

very angry - accusing you of

negligence for not spotting this

earlier.

Q4.10• Aside from anger,

what are the stages of grief in the model proposed by Kubler-Ross (4)

Question 4

You describe to Mr Jackson the

probable prognosis and progression of

the disease.

Q4.11• List one local and two

systemic effects that cancers in general may produce (3)

The Answers

View these on ‘note view’ rather than on full screen – additional

notes are provided for some slides

Haemoptysis? Where’s that wine…

I Infectious / inflammatory Pulmonary tuberculosis

G Genetic / idiopathic

E Endocrine

T Trauma Chest trauma

V Vascular Pulmonary embolism

I Iatrogenic / ingested

N Neoplastic Bronchial carcinoma

O Organs / otherNose: epistaxis; oesophagus: mallory weiss tearLung: bronchiectasis; Heart: mitral stenosis

Two Useful Concepts

Body Mass Index (BMI)

20-25: Ideal

26-30: Overweight

31-35: Obese

Pack Years

> 20 = increased chance complications

PY=Cigs / day

x Yrs20

BMI=Wt (kg)

Ht2 (M)

Carcinogens

Cigarette smoke

Chemicals• PAH• Aromatic amines• Nitrosamines

UV Radiation

Ionising radiation• Radiotherapy• Radon gas (lung)• Industry/military

Carcinogens

Viruses• EBV (Epstein-Barr)• HPV (Papilloma virus)• HBV (Hepatitis B

virus)

Stages in carcinogenesis

• Initiation• Promotion• Progression

Lung cancer

• Male: Female 7:1• Decreasing

• Male peak in 60s• Female peak in 70s• Rare under 25 years

Presenting complaints• 90% symptomatic

– 40% Haemoptysis– 75% Anorexia– 75% Dyspnoea– 75% Cough– 75% Pain

• Remember Weight Loss

• 10% Incidental imaging

Lung Cancer - Diagnosis

• Imaging– Plain film– CT– MRI

• Cytology– Sputum– Bronchoscopic

washings

Biopsy• Peripheral lesions

– Percutaneous biopsy

• Proximal lesions– Bronchoscopic biopsy

• Pleural Effusions– Fine needle aspiration

Lung Cancer

Types

• Small Cell (20-30%)

• Non-small Cell– Large Cell (10-15%)

– Adenocarcinoma (~20%)• Commonest non-smoking

– Squamous cell carcinoma (40-60%)

• Commonest smoking related

Treatment

• Small cell– Early metastasis

– Chemotherapy and radiotherapy first line

• Non-small cell– Surgery first line

• Lobectomy

• Pneumonectomy

– Radio / chemo as req

Invasion and Metastasis

• Invasion is the spread into adjacent tissues – may occur along natural tissue planes such as along nerves

• Metastasis is the spread of cells to distant parts of the body – there are several mechanisms for this

To Metastasise

• Changes occur in only some cells of the tumour

• By random mutation

• Binds to basement membr

• Becomes motile• Becomes able to attach

to extracellular matrix• Becomes able to degrade

extracellular matrix

• Must be able to survive and grow at site of implantation

Routes of

Metastasis

• Vascular

• Lymphatic

• Coelomic

Fig 1

Growth Characteristics

Benign Malignant

Expands onlyGrows locally

Expands and invades local tissuesMay metastasise

Generally slower Generally faster

Cytoplasmic Characteristics

Benign Malignant

Normal or slight increase in nucleus:cytoplasm ratio

High nucleus:cytoplasm ratio

Resembles cell of origin (well differentiated)

Failure of differentiation

Retains specialisations Loses specialisationsDiploid Range of ploidy

Histological CharacteristicsBenign Malignant

Few Mitoses Many mitoses – some of which are abnormal

Cell uniform throughout tumour

Cells vary in shape and size (cellular pleomorphism) and/orNuclei vary in shape and size (nuclear pleomorphism)

Organised tissue Disorganised tissue

Local and systemic effects

Local• Pressure• Invasion• Ulceration• Obstruction

Systemic• Weight loss

(cachexia)• Loss of appetite

(anorexia)• Fever• Anaemia• General Malaise• Paraneoplastic

The End

The slides here should allow you to mark your own work – remember 1 mark per

answer* up to the maximum for the question. Multiply by 3 to get percentage points. I assume a 60% pass mark. Sorry but I am unable to give further advice on

answers due to time constraints.