Station1 **Respiratory** Lung cancer Please examine this patient who has had a 3-month history of chronic cough, malaise and weight loss. Clinical signs Cachectic Clubbing and tar-stained fingers Lymphadenopthy: cervical and axillary Tracheal deviation: towards (collapse) or away (effusion) from the lesion Reduced expansion Percussion note dull (collapse/consolidation) or stony dull (effusion) Auscultation: Crackles and bronchial breathing (consolidation/collapse) Reduced breath sounds and vocal resonance (effusion) Extra points Hepatomegaly or bony tenderness: metastasis Treatment: Lobectomy scar Radiotherapy: square burn and tattoo Complications: Superior vena cava obstruction: suffused and oedematous face and upper limbs, dilated superficial chest veins and stridor Recurrent laryngeal nerve palsy: hoarse with a ‘bovine’ cough Horner’s sign and wasted small muscles of the hand (T1): Pancoast’s tumour Endocrine: gynaecomastia (ectopic HCG) Neurological: Lambert–Eaton myasthenia syndrome, peripheral neuropathy, proximal myopathy and paraneoplastic cerebellar degeneration Dermatological: dermatomyositis (heliotrope rash on eye lids and purple papules on knuckles (Gottron’s papules associated with a raised CK) and acanthosis nigricans Discussion Commonest malignancy in the Western world Types Squamous 35%, small (oat) 24%, adeno 21%, large 19% and alveolar 1% Causes Smoking, Scarring, Soot (asbestos dust) and Smog (air pollution) Management Investigation order 1 Diagnosis of a mass: CXR: collapse, mass and hilar lymphadenopathy Volume acquisition CT thorax (so small tumours are not lost between slices during a breath) with contrast 2 Determine cell type: Induced sputum cytology Biopsy by bronchoscopy (central lesion and collapse) or percutaneous needle CT guided (peripheral lesion) 3 Stage (CT/bronchoscopy/mediastinoscopy/thoracoscopy/PET): Non-small cell carcinoma (NSCLC): TNM staging to assess operability Small cell carcinoma (SCLC): limited or extensive disease 4 Lung function tests for operability assessment: Pneumonectomy contraindicated if FEV1 < 1.2 L 5 Complications of the tumour: Metastasis: ↑ LFTs, ↑ Ca++, ↓ Hb NSCLC: ↑ PTHrP→↑Ca++ SCLC: ↑ ACTH, SIADH → Na+ ↓ Treatment NSCLC: Surgery: lobectomy or pneumonectomy Radiotherapy: single fractionation (weekly) versus hyper-fractionation (daily for 10 days) Chemotherapy: benefit unknown SCLC: Chemotherapy: benefit with six courses Multidisciplinary approach Palliative care Dexamethasone and radiotherapy for brain metastasis SVCO: dexamethasone plus radiotherapy or intravascular stent Radiotherapy for haemoptysis, bone pain and cough Chemical pleurodesis for effusion – talc; tetracycline no longer used Opiates for cough and pain Prognosis Untreated Treated SCLC (median survival) Limited 3/12 14/12 Extensive 6/52 10/12 NSCLC T1N0M0 60/12 TnN2M0 15/12 Causes of finger clubbing, ‘don’t LIGHT up!’ Lung: bronchial carcinoma, suppurative lung disease and cryptogenic fibrosing alveolitis Inherited (rare) Gastrointestinal: inflammatory bowel disease and cirrhosis/ hepatocellular carcinoma Heart: infective endocarditis and cyanotic congenital heart disease Thyroid: Grave’s disease (acropachy) Regards Sumanta Sir’s Academy Dhaka, Bangladesh Cell: +88-01757754457 Visit: Our Official Website: ssmrcpuk
Posted on: Wed, 25 Sep 2013 11:00:00 +0000
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