Acute Oncology and the Chest Physician

Neil Munro

Consultant Respiratory Physician

UHND

Acute Oncology What’s that all about?

Is acute oncology new or different?

Or simply what attentive physicians have always done?

Plus an attempt to standardise best practice for all patients with malignant disease

From the perspective of this chest physician:

• Lung cancer is common

• Cancer in the lung is common

• Lung cancer is commonly found when investigating or managing other diseases in all other specialities

• Being common, lung cancer often presents on the acute medical take

And…………

• (for those of us of a certain age) B.O. (before oncologists) chest physicians often gave their own chemotherapy and hence were accustomed to dealing with the complications thereof

• BPCP (before palliative care physicians) looked after our patients from diagnosis to grave, with some exceptions!

So some examples from my own recent practice #1

Mr B

In his late 50’s, reclusive, smokes, drinks, works as a gardener in the summer months

Presents to ED with syncope. Rapidly recovers. Nil to find on examination.

Na 126

CXR left apical shadow ?infection ?mass

#1

Histology NSCLC

Final staging T2N2M0

FEV1 < 50% predicted

Referred for chemo +/- radiotherapy

#2 more of the same

Mr I67. Looks after his mum (in her 90’s) who

calls the ambulance because her son is “confused”. Smokes, doesn’t drink. Denies other symptoms, though probably increased breathlessness

O/E mildly unreasonable. Not clubbed. No neurology. Nil else.

Na115

#2

#2 more of the same

Histology again NSCLC

CT staging T4N1M1b

Referred for Chemo/radiotherapy

Sodium improved with fluid restriction and Demeclocyclene to normal in 10 days

PE treated with LMWH long term

#3 pseudo acute oncology

Mr S

Late 60’s, retired builder. Admitted via GP with possible spinal cord compression (abnormal T spine X ray) and an abnormal CXR (bulky left hilum)

Smoker

Lives alone

#3 pseudo acute oncology

#3 continued

Alcohol foetor

Back pain since fell at Christmas

Minor cough of chronic bronchitis

No sinister symptoms

No neurology

#4 by the by in out patients

Mr P

Known melanoma

Recurrent cough and sputum “chest infection”, routine referral

Clinically suspected bronchiectasis.

HRCT chest and return to clinic

#4 by the by in out patients

#4 continued

On direct questioning

“leg has been giving way for some days”

“back pain getting worse”

“no, hadn't wanted to trouble GP as due back in clinic”!

Admit, Dex, MRI, Refer

#4 by the by in out patients

#5, keep coming back

Mr W

Chest clinic 2ww with abnormal CXR

Sweats

Wt loss

Fatigue

Non smoker

Ex Policeman

#5 continued

CT pulmonary masses

Biopsy showed lymphoma

S/B Haematology

Started RCHOP

#5 continued

Post cycle 2

Admitted acutely breathless, hypoxia

CXR & CT interstitial shadowing

Oxygen

Steroids

Antibiotics

#5 continued

A month in hospital but recovered

Completed CHOP only

Still in remission

But did have another bad patch

Possible underlying fibrosis

#6 one from the surgeons

Mrs K

70s, admitted with abdominal pain over a couple of days (possibly longer?)

Initial diagnosis constipation

Better have a CT to look for appendicitis

Smoker

Palpable liver

#6 one from the surgeons

Bronchoscopy extrinsic compression only

Liver biopsy – SMALL CELL LUNG CANCER

#7 facial swelling is it an allergy?

Mrs H 61 year old lady

Swollen face for some days, no improvement with antihistamines

#7 facial swelling is it an allergy?

What haven't I talked about?

Pleural effusion• Imaging• US guided aspiration• Percutanous biopsy• Thoracoscopy

(allows drainage, biopsy and pleurodesis)

• Tunnelled indwelling drain

What haven't I talked about?

Pulmonary Metastases• Usually known

primary• Can co-exist with lung

cancer eg bowel, breast.

• Treatment is as for the primary but most often palliative.

What haven't I talked about?

Endobronchial ultrasound (EBUS)

The next big thing (or the current big thing)

Allows staging and diagnosis without surgical biopsy

So is it that easy?

No of course it is not.

But early referral to the appropriate specialist, prompt imaging, and moving rapidly to the diagnostic test with the greatest likelihood of positive yield

Any questions?