charlotte miller. definition classifications clinical presentation management prognosis ...
TRANSCRIPT
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Respiratory Malignancy
Charlotte Miller
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Contents
DefinitionClassificationsClinical PresentationManagementPrognosisClinical ScenarioEmergency
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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
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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
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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
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History
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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
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Important Information
PMHx of Malignancy Hodgkins Testicular Endometrial
Family History 1st degree increase
by 51%
Social History Smoking Occupation▪ Asbestos, Radon Gas,
Foreign Travel
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Signs
Peripheral Clubbing Cyanosis Hypertrophic
Pulmonary Osteoarthropathy
Acanthosis Nigricans
Central Lymphadenopathy Tracheal Deviation Chest defects
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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
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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
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Biological
Conservative Symptom relief Smoking Cessation
Medical Radiotherapy Chemotherapy
Surgical Assessment for surgery De-bulking
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Psychological
Counselling
Mood altering medications
End of Life discussions
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Social
Support Networks
Services for Families / Carers
Physiotherapy / Occupational Therapist Adaptation to home Maintaining Mobility
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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
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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
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What are your main differential diagnoses for this lady?
?Risk Factors
How would you investigate her?
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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?
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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
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Emergencies
SVC Obstruction Steroids - Dexamethasone Stent Oncology R/v – Radiotherapy,
Chemotherapy
Erosion of Blood Vessels Supportive Palliation
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Questions???