‘When is a stroke not a stroke?’

Danielle HannLucinda LaceyAnthony Li Emma BriggsSamu Pekwa

History

79 year old FemaleReferred by GP 3/52 ago to A&E with

?cord compressionP/C

Right arm pain Right sided weakness

History

HPC 4/52 right arm pain 3/52 right leg weakness

gradual onset

Finding mobility increasingly difficult Presented to another A&E 2/52 prior with

weakness but sent home Weakness progressively worsened Dizziness for 5 years but worse in last 3/52

History

HPC contd. 40 year Hx of cervical spondylosis Negative signs

HaemoptysisParaesthesiaBladder/bowel dysfunctionSensory levelNo fallsNo visual problems

• double vision, blurred vision

PMH TB with lymph node excision as child Rheumatic fever as child 40 year Hx cervical spondylosis

DH & Allergies Nil NKDA

History

HistorySH

Lives with Husband (Well) Maisonette - bed and bathroom on top floor Previously fully independent in ADLs

Husband does cooking and cleaning

2/52 prior to admission started using 1 stick for walking and chair transfers

Ex smoker stopped 8 years ago45 pack year Hx

AlcoholNil

Examination On admission - from notes

General Well Afebrile No weight loss

Resp Sats - 96% on air No clubbing/cyanosis Trachea central Bilat air entry No creps/wheeze FEV1 36% predicted FVC 56% predicted PEF 22% predicted

CVS P 80 reg BP - 170/66 HS I + II + 0 JVP No murmur/No carotid

bruit

Abdo Soft & non-tender No organomegaly Bowel sounds present

Examination

Neuro Left upper and lower limbs all 5/5 Wasting of small muscles of right hand

RUL RLLTested Power Tested PowerShoulderabduction

0/5 Hip flexion 3/5

Elbow flexion 3/5 Hip extension 3/5Elbowextension

0/5 Kneeextension

3/5

Finger flexion 3/5 Knee flexion 3/5Wrist flexion 3/5 Ankle

dorsiflexion4/5

Wristextension

0/5 Ankleplantarflexion

4/5

Neuro contd

Tone and sensation normalNo clonus

Examination

Reflex Right LeftBrachial +++ ++Supinator ++ ++Triceps +++ ++Knee +++ ++Ankle ++ ++Plantars

Examination

Neuro contd No hoarseness of voice CN II - XII

No ptosis/Normal pupillary reactions

Hoffmans -ve bilaterally No deep finger flexor reflex No pectoral reflex

Neck No tenderness or pain on movement

Impression and Plan

Impression Left hemisphere CVA

Wasting/no extensor plantars ?UMN

Spinal cord compressionNo bladder or bowel dysfunction or sensory level

Plan Bloods - FBC; U&E; Glucose; LFTs; CRP;

Cholesterol C-spine and Chest x-ray (AP and Lateral)

Results

Bloods

Hb 14.8 Na 135 Glucose 5.8 Chol 7.1WCC 8.6 K 4.2 Bilirub 10 TG 0.68Plt 275 Cl 96 ALT 8 HDL 2.0MCV 85 Bicarb 29 ALP 66 LDL 4.8ESR 21 Urea 4.7 Alb 37CRP 3.0 Creat 75 Ca 2.32

Results contd

CXR Features consistent

with old TB in RUZ Lesion in RMZ

peripheral, well demarcated, 2cm nodule

No rib involvement No hypertrophic

pulmonary osteoarthropathy

Revised Plan

CXR results and neurological signs indicate CT Head CT Chest CT guided biopsy

(peripheral lesion)

CT brain

Results

CT head Ring enhancing cystic mass in left petrous region

consistent with cystic tumour or abscess (?old TB)

CT chest probable lung primary right hilar lymph node

Biopsy histology Poorly differentiated squamous cell carcinoma (Non-small cell carcinoma)

Drug Treatment

RamiprilDexamethasoneSimvastatinRanitadineLanzoprazole

Management plan

Neurosurgical opinion ?burr hole or craniostomy to drain cyst

?Radiotherapy Adjuvant brain Palliative lung

No chemotherapyHome with large care package ASAP

Lung Cancer

Background

Leading cause of cancer-related mortality in both men and women.

Diagnosis at an advanced stage.

Smoking-related damage to the heart and lungs, making aggressive surgical or multimodality therapies less viable options.

Epidemiology

Men >Women (37.5 vs. 10.8 new cases/million)

Most common malignancy-related deaths in men and women.

17.8% of cancer-related deaths

Aetiology

Smoking: Cigarette smoke contains N-nitrosamines and aromatic

polycyclic hydrocarbons. hydroxylated by the P-450, leading to formation of

carcinogens that cause formation of DNA adducts. 78% in men and 90% in women. risk is 13.3 times that of a person who has never

smoked. varies with the number of cigarettes smoked. After quitting, risk increases for the first 2 years and

then gradually decreases, but never returns to the

same level.

Aetiology

Passive smoking: 15% of the lung cancers in nonsmokers are

believed to be caused by secondhand smoke.Asbestos: x5 risk. Synergistic.RadonOthers: Aromatic polycyclic

hydrocarbons, beryllium, nickel, copper, chromium, cadmium, and diesel exhaust.

Classification

Upper tract: Tracheal Laryngeal

Lower tract: Bronchial- most common primary (90-95%) Carcinoid Metastatic

Pleural tumours.

ClassificationBronchogenic

Small (Oat) Cell~20%

Non-Small Cell~80%

Squamous25-30%

Adenocarcinoma35-40%

Large-cell10-15%

•SCLC exhibits aggressive behaviour: •rapid growth, •early spread to distant sites, •exquisite sensitivity to chemotherapy and radiation •frequent association with distinct paraneoplastic syndromes.•Surgery usually plays no role in its management

Pathophysiology

Amplification of oncogenes and inactivation of tumor suppressor genes in NSCLC.

Mutations involving the ras family of oncogenes.

3 members: H-ras, K-ras, and N-ras. Encode a protein on the inner surface of the cell with GTPase activity and may be involved in signal transduction.

Almost exclusive to adeno Ca (30% 0f cases).

Natural History

Cytological Atypia

Piling of bronchial mucosa

Irregular, warty, erosive lesion

FungatesIntra-luminal mass

Rapid penetration, infiltration of peribronchial

tissue.

Intraparenchymalmass (caulifower)

•Tissue: •greyish white•haemorrhagic•Necrosis-cavitating

•Spread:•Lymphatic•Haematogenous

Histology

Adenocarcinomas: form glands and produce mucin. Identified with mucicarmine or periodic acid-

Schiff (PAS) staining. WHO classification of adeno Ca:

(1) acinar (2) papillary (3) bronchoalveolar (4) mucus secreting

HistologySquamous cell carcinoma:

distinct dose-response relationship to tobacco smoking

usually develops in proximal airways, classically presents as a cavitary lesion

Type most often associated with hypercalcemia. Progresses through stages of squamous

metaplasia to carcinoma in situ. Well-differentiated squamous cell carcinomas

contain keratin pearls.

Histology

Squamous Cell: Microscopic examination reveals cells

with large irregular nuclei and coarse nuclear chromatin with large nucleoli.

Cells are arranged in sheets and intercellular bridging is diagnostic.

Histology

Large Cell: Typically presents as a large peripheral mass on

CXR. Histologically, sheets of highly atypical cells with

focal necrosis, with No evidence of keratinization or gland formation Patients with large cell carcinoma are more likely to

develop gynecomastia and galactorrhea variant of large cell carcinoma - large cell

neuroendocrine carcinoma, carries a worse prognosis than large cell carcinomas.

Prognosis

Estimated 5-year survival rates: Stage IA - 75% Stage IB - 55% Stage IIA - 50% Stage IIB - 40% Stage IIIA - 10-35% Stage IIIB - <5% Stage IV - <5%

In Europe, the 5-year overall survival is 8%

Prognostic Factors

Tumour related: Physical

Stage/Grade Biochemical Molecular Haematological

Host related: Age Sex Performance Status Weight loss

Presentation

Local effects of tumour in bronchus

Spread to mediastinum

Spread to pleura and chest wall

Spread to lymph nodes

Distant blood bourne metastases

Paraneoplastic (non-metatastic)complications

Local effects of tumour in bronchus

1, Cough.2, Haemoptysis.3, Bronchial narrowing 4, Distal collapse 5, Finger clubbing

Spread to mediastinum

1, Left recurrent laryngeal nerve paralysis 2, SVC obstruction 3, Compression of oesophagus 4, Phrenic nerve paralysis 5, Pericardial invasion

Spread to pleura and chest wall

1, Pleural effusion 2, Chest wall pain 3, Pancoast tumours

Pain in T1 dermatomeWasting in small muscles of handHorner’s syndrome

Spread to lymph nodes

1, Hilar lymphadenopathy – bronchial narrowing, retrograde

obstruction of pulmonary lymphatics (lymphangitis carcinomatosis)

2, Mediastinal lymphadenopathy – can compress and invade other mediastinal structures.

Distant blood-borne metastases

Bone, liver, brain, adrenal glands, skin.

Paraneoplastic complications

1, Pulmonary hypertrophic osteoarthropathy 2, Endocrine syndromes – Cushings, hypercalcaemia, gynaecomastia.

3, Neuromuscular syndromes - Peripheral neuropathy, cerebellar dysfunction, dermatomyositis.

Investigations

Imaging

Laboratory studies

Procedures

Imaging

Chest X-rayHilar lymphadenopathy, area of pulmonary collapse, unresolved pneumonia, pleural effusion, lung abscess, peripheral mass, lymphangitis carcinomatosis, eroded ribs.Squamous cell carcinoma may be radiologically occult. It is slow growing and usually presents as a central mass that may cavitate.

CT + MRIChest and upper abdomen

Brain

Bone scintigraphy

Laboratory studies

Sputum cytological studiesFalse-positive rate for sputum cytology is 1%False-negative rate is as high as 40%.

Full blood count, LFTs

Electrolytes

Procedures

1, BronchoscopyEstablishes diagnosis and position of the tumour in the bronchial tree in over 70%

2, Mediastinoscopy

3, Thoracoscopy

4, CT-guided biopsy

5, Biopsy of other siteseg, enlarged palpable lymph nodes, liver, pleural and pericardial effusions.

Staging

Primary tumour (T) TX Malignant cells in bronchial secretions, no other evidence of tumour

Tis Carcinoma in situ

T0 None evident

T1 <3cm, in lobar or more distal airway

T2 >3cm / 2cm distal to carina / any size if pleural involvement or obstructive pneumonitis extending to

hilum, but not all the lung

T3 Involves the chest wall, disphragm, mediastinal pleura,

pericardium / 2cm from, but not at carina

T4 Involves the mediastinum, heart, great vessels, trachea,

oesophagus, vertebral body, carina / malignant effusion is present

Staging

Regional Nodes (N) N0 None involved (after mediastinoscopy)

N1 Peribronchial and/or ipsilateral hilum

N2 Ipsilateral medistinum or subcarinal

N3 Contralateral mediastinum or hilum, scalene or supraclavicular

Distant metastasis (M) M0 None

M1 Present

Staging

Stage Tumour Lymph Nodes Metastasis

Occult TX N0 M0

I Tis, T1 or T2 N0 M0

II T1 or T2 N1 M0

IIIa T3 N0 or N1 M0

T1-T3 N2 M0

IIIb T1-T3 N3 M0

T4 N0-N3 M0

IV T1-T4 N0-N3 M1

TREATMENT

Depends upon a variety of factors such as: Histopathologic type Tumour stage and characteristics Individual’s general health Medical problems that may affect

treatment

Non-Small cell Lung Carcinoma

Surgical resection is best potentially curative therapy

Only in those: Whose tumour is resectable With adequate respiratory reserve Without a major medical contraindication to

surgery An agreeable patientN.B. For those who are not fit for surgery, Radiation

and/or Chemotherapy are considered. Unresectable stage 3 treated with combined radio- and chemotherapy.

Limited Small Cell Lung Cancer

Highly chemosensitiveCombination chemotherapy and Thoracic

irradiation +/- prophylactic cranial irradiation is standard therapy for patients with limited SCLC.

Radiotherapy reduces local recurrence by 50%, but still with isolated local failure rates between 25% to 30%

Surgery may improve control at the local site.

Limited Small Cell Lung Cancer

5 - 10% of SCLC cases are found in combination with other lung cancer histologies including adenocarcinoma or squamous cell carcinoma.

Surgery may be necessary to treat the non-small cell component.

Late recurrences may be of non-small cell type (a new primary) and may be treated surgically if standard criteria for operability are met.

Extensive Small Cell Lung Cancer

Chemotherapy: - Rarely curative- Significantly improve survival- Palliative- The optimal induction are either Etoposide with Cisplatin or Cytoxan, Doxorubicin and vincristine.

Surgery has little role to play in stage 3 tumours as it does not significantly contribute to long-term survival.

Lung Cancer in the Elderly

80% are of NSCLCLess aggressive treatmentQuality of life is equally important Radiation therapy is valuable for both

types Monochemotherapy is more approppriate

in those over 75. Unresectable NSCLC stage 3 best treated

with combined chemo- and radiotherapy

Lung Cancer in the Elderly

Limited stage SCLC treated combination chemotherapy and radiotherapy

Recent minimally invasive techniques more suitable

Age alone is not a factor in determining the best operative procedure for lung cancer

Good health is essential to tolerate treatment

Palliative care

Multidisciplinary approachPsychological supportSymptom control essential

(Pain, Nausea, Vomiting, Anorexia, Malaise,Weakness, Bowel obstruction, Respiratory symptoms, etc.)