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

carcinoma

IA 50 38

IB 47 21

IIA 36 38

IIB 26 18

IIIA 19 13

IIIB 7 9

IV 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???