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  • pg 1
									A Fisherman’s Tale
          Group 13
  Hilary Graffy   Tomos Owens
  Huw Griffiths   Imogen Ptacek
 Conor McKenna    Ellena Wood
                      His Story
Details:   77 year old, male, retired plumber

PC:        Haemoptysis
•   Bronchial carcinoma
•   Metastatic carcinoma
•   Tuberculosis
•   Bronchiectasis
•   Bronchitis
•   Pneumonia
•   Post-intubation
•   PE
•   Vasculitides e.g. Wegener’s
                         His Story
Details:   77 year old, male, retired plumber

PC:        Haemoptysis

HxPC:      Presented to GP 1 month ago with increasing SOB, he
           was admitted to AMU for treatment of pseudomonas
           pneumonia. Discharged home 2 weeks ago.

           1st week – coughing up small amounts of blood.
           2nd week – coughing greater quantities of brown/bloody
           sputum, worse at morning and night.

           On direct questioning he described a 2 month history of
           2 stone weight loss with normal appetite.
                         His Story
PMHx:         Previous Lung Cancer (2002)
• Stage IIIB squamous cell carcinoma (Left Upper Lobe)
• Treated with 10 fractions of radiotherapy
• Aim was palliation – apparent cure achieved

DHx:          Nil

FHx:          Brother died of lung cancer
              Mother and father died of cancer
                     His Story
SHx:   Ex-smoker 50 pack years (Quit 2002)
       Drinks 18 units a week

       Plumber  Asbestos exposure from
       pipe lagging and bath panels

       Lives with supportive wife

       Keen fisher
                    On Examination
General:       Weak and lethargic
               Cachectic - Prominent clavicles (more so on left)
               Left thoracotomy scar

Temp:          36.8 oC
Pulse:         80 bpm
RR:            20 per minute
BP:            127/74
O2 Sat:        97% (Room air)

Hands: No clubbing or tar staining
                    On Examination
Head:          No conjunctival pallor
               No central cyanosis
               No palpable cervical/axillary lymphadenopathy
               Tracheal deviation to left
Chest:         Reduced expansion on left side
               Abnormal breath sounds over XRT site (bronchial)
   Left lower zone:   Stony dullness
                      Reduced tactile vocal fremitus
                      Reduced breath sounds
                      Reduced vocal resonance

Cardiovascular Examination – Normal
Neurological Examination – Normal
Differential Diagnosis?
        Differential Diagnosis?
•   Recurrence of previous lung cancer
•   New primary lung cancer
•   Mesothelioma
•   Metastases from another site
•   Infection – atypical pneumonia, TB

• Bloods – FBC, LFTs, U&E’s

• Sputum culture

• Imaging – CXR, CT Thorax
08/2/11       Treated by GP and hospital for pseudomonas
              pneumonia with antibiotics

12/2/11       Discharged from hospital

26/2/11         Re-presents with haemoptysis
• Shadowing on right lung
• Changes associated with previous radiotherapy in left upper lobe +
  fluid filled cavitating lesion – Positive for Aspergillus infection
28/2/11    CT scan:
          • Left sided XRT changes
          • Mediastinal nodes enlarged
          • Lung lesion with rib destruction
          • Enlarged left side axillary nodes found
1/3/11     FNA:
          • Biopsy of left axillary lymph node
          • Squamous cell carcinoma found
          • ? Metastases from new lung primary
3/3/11     Bronchoscopy:
          • Lesion identified on bronchoscopy in left lower lobe
          • Biopsies taken - Confirmed SCC lung
            Future management plan

MDT discussion – decision not to treat Aspergillus

No chemotherapy as >75 years and no
 radiotherapy due to previous exposure.

Palliative care with symptomatic control only to get
  him out fishing!
Lung Cancer
Leading cause of death by cancer in the UK

      3% of cancer research funding

   38,000 new cases/yr: 35,000 die/yr

  Only 8% of those diagnosed are cured

27% reduction in deaths in Men 1971-2006
Number of deaths in Women is increasing
            A Brief history of Lung cancer
“You ask me what it is we need
to win this war. I answer tobacco
as much as bullets”
                Occupational risk
• Asbestos
   – Those exposed are at 4.9-7.3 times greater risk than those not
   – Risk enhanced if those exposed also smoke – 93x higher than
     non-exposed non-smokers
• Radioactive isotopes:
   – miners
• Polycyclic aromatic hydrocarbons:
   – foundry workers
• Nickel refining
• Chromate manufacture
• Arsenic industry
                                             Large cell
                          Adenocarcinoma       10%

Small cell
  24%          Non
             Small cell


            Intrapulmonary                          Extrapulmonary
•   Persistent Cough                    •   Weight loss, anorexia
•   Haemoptysis                         •   Horner’s Syndrome
•   Chest pain                          •   Hoarseness
•   Dyspnoea                            •   SVC obstruction
•   Wheeze/Stridor                      •   Dysphagia
                                        •   Ipsilateral diaphragm paralysis
                                        •   Shoulder and inner arm pain
              Metastatic                      Paraneoplastic Syndromes
30% of patients present with symptoms   • SIADH
due to metastases                       • Ectopic ACTH syndrome
•Brain                                  • Hypercalcaemia
•Liver                                  • Gynaecomastia and testicular
•Bone                                     atrophy
•Spinal Cord                            • Neuromyopathies
•Adrenal glands                         • Finger clubbing
•Skin                                   • Hypertrophic pulmonary
•Lymph nodes                              osteoarthropathy
When to urgently refer?
              Persistent heamoptysis in an
                 smoker or ex-smoker > 40
              Unexplained or persistent hx.
          •   Cough (most common sx.)
          •   Weight loss
          •   Clubbing
          •   Chest pain
          •   Dyspnoea
          •   Hoarseness
          •   Cervical or supraclavicular
          •   Suggestion of metastases
              (bone, liver, brain, skin)
          •   SVC obstruction
          •   Stridor
          CXR suggestive of lung cancer
            1. Confirmation of presence   -Chest X-ray
            -Size                         -CT Scan
            -Location                     -Bronchoscopy
            -Metastases?                  -PET scan

                                          -Sputum cytology
            2. Histopathology
Diagnosis   -SC                           -Bronchoscopy
                     -Squamous            -Percutaneous
                     -adenocarcinoma      transthoracic needle
                     -Large cell          biopsy

                                          ultrasound- guided
            3. Staging                    transbronchial biopsy
            -TNM staging
                                          -Thoracoscopy or
TNM staging
             Non-Small Cell Carcinoma
Surgery                          Novel therapies

          Radiotherapy   Chemotherapy

    50% 2 year survival – without spread
    10% 2 year survival – with spread
              Small Cell Carcinoma

    Surgery                     Chemotherapy

Median Survival:
    3 months (without treatment)
    1 – 1 ½ years (with treatment)
Question Time
                      MCQ 1
 A 53 year old woman is diagnosed with lung cancer. Her
 main symptoms on presentation included breathlessness
and haemoptysis. She complained of stretch marks on her
abdomen and that her skin bruised easily. On examination
 you note purple abdominal striae. Which of the following
  types of lung cancer is she most likely to suffer from?

1.   Squamous cell                                          45%

2.   Large cell                       32%

3.   Adenocarcinoma
4.   Alveolar                                    13%

5.   Small cell                                        3%

                                       1    2     3    4     5
                       MCQ 2
A 61 year old man with a solitary lung nodule is referred for
  bronchoscopy. Biopsies from the mass reveal small cell
lung cancer. Staging investigations show localised disease
 with no spread to the mediastinal nodes or involvement of
either main bronchus or recurrent laryngeal nerve. What is
      the next most appropriate step in management?

1.   Surgery                             61%

2.   Radiotherapy
3.   Chemotherapy
4.   Endoscopic laser therapy                  16%

5.   Stenting                                              0%   0%

                                         1     2      3    4     5
                           EMQ 1
A 71 year old retired electrician presents to his GP
  with pleuritic chest pains and dyspnoea. After
   initial investigations a CT scan of the chest
 demonstrates a right pleural effusion with lobular
     pleural thickening in the right mid-zone.

1.   Idiopathic pulmonary fibrosis              68%

2.   Squamous cell carcinoma
3.   Mesothelioma
4.   Pulmonary abscess               26%

5.   Tuberculosis
6.   Small cell lung cancer                3%         3%
                                                           0%   0%

                                     1     2     3    4     5    6
                           EMQ 2
An 84 year old woman who worked in a munitions
factory in WW2 presents to her GP with abdominal
pain, constipation, polyuria, cough, haemoptysis
and weight loss. A CXR taken 3 years ago shows
multiple pleural plaques only.

1.   Idiopathic pulmonary fibrosis                          32%

2.   Squamous cell carcinoma               26%

3.   Mesothelioma
4.   Pulmonary abscess                                            13%

5.   Tuberculosis
6.   Small cell lung cancer
                                     1     2      3    4     5     6
Thank you!

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