Lung mechanics in the aging lung and in acute lung injury ...
Acute presentations of lung cancer
Transcript of Acute presentations of lung cancer
Acute presentations of lung
cancer
Dr Prina Ruparelia
Respiratory consultant
Cambridge University Hospital
The problem
• Incidence
• CADIAS report /NCIN
• Acute lung cancer presentations
• Future pathway developments
Incidence of lung cancer
CRUK
Emergency presentations of cancer
ncin.org.uk
Survival according to presentation
BJC 2012: 1220-1226
ncin.org.uk
Cancer Diagnosis in an Acute Setting
(CADIAS)
Barriers to seeking medical attention
• Patient perceived factors (66%)
• GP access factors- 25%
Local effects
• Lung
• Metastatic lesions- cardiac, neurological, bone
• Endocrine effects
• Paraneoplastic effects
Infection
• Local effects of occlusion for example
pneumonia more common in patients with an
occluded airway
Case 1
• 81 year old lady
• Ex-smoker
• History of memory impairment
• 3 week history of dyspnoea
• Persistent cough. New diagnosis of paroxysmal AF
• On examination – Oxygen sats 92% on air.
• Noted to have an inspiratory wheeze in the left
upper lobe
Presentation CXR Chest radiograph 2011
Measures to improve airway patency
• Chest clearance techniques
• Physiotherapy cautiously
• Saline nebulisers
• Steroid treatment
• Visualisation by bronchoscopy to assess suitable interventions
• Interventional techniques
• Bronchoscopy with cryotherapy
• Stenting
Improving airway patency
• Is an effective palliative measure
• May prolong survival and improve performance status such that the individual may be able to undergo chemotherapy
• Consider whether the airway may be at risk prior to discharging the patient, particular consideration of the main bronchi and proximity to the carina
• Be aware of your local arrangements-Interventional pulmonology, thoracic surgeons
Measures to improve airway patency
• Cryotherapy
• Argon Laser
• Stenting
• Combination of above
Case Report 2
• 65 year old lady never
smoker
• Presented with pleuritic
chest pain
• Shortness of breath
Predisposition –
thromboembolic disease
• Hypercoagulable state
• Clinical thromboembolism occurs in up to 11%
of patients with malignancy
• Certain malignancies may have higher
predisposition for example pancreatic cancer
• Other common cancers associated with PE are
GI malignancies, lung cancer
Thromboembolic disease
• Several investigators have attempted to define risk factors to identify the subset of patients likely to benefit from extensive screening for malignancy.
• In one study, cancer was diagnosed in 16 of 136 patients (12 percent) with idiopathic DVT during the index hospitalization 1. All 16 had one or more abnormalities suggestive of possible malignancy on at least one of the four components of the initial investigation: history, physical examination, basic laboratory testing, or chest X-ray.
• In a second series, 13 new malignancies were diagnosed among 326 patients with DVT during a 6-month follow-up period 2. Ten of the 13 had some type of clinical abnormality at presentation, and 7 were diagnosed within the first 16 days based upon patient characteristics and clinical findings on initial routine examination and laboratory testing.
2. Hettiarachchi RJ et al Cancer. 1998 Jul 1;83(1):180-5.
1. Cornuz J et al Ann Intern Med 1996 15;125(10):785-93.
Treatment- VTE
• There is both a risk and benefit in the treatment of patients with the malignant disease
• Retrospective analysis in 1303 patients with thromboembolic disease ( 264 patients in this group had underlying malignancy)
• Overall incidence of recurrent VTE in those with malignancy is 3.5 times higher
• 6.5 times higher risk of bleeding
• Van Doormal et al 2011
• 3.5 % of patients in extensive screening identified as having cancer ( CT abdo, chest and mammogram)
• 2.4% of patients in limited screening identified as having cancer (history, physical examination, basic lab test and CXR)
• Of those identified 8.3% died in extensive screening group versus 7.6% of limited screening group
Thromb Haemost. 2011 Jan;9(1):79-
84
Investigation for underlying
malignancy• Ensure people with unprovoked pulmonary embolism (PE) are investigated for
the possibility of an undiagnosed cancer if they are not already known to have cancer.
– Initially undertake:• A full history and physical examination to look for evidence of malignancy.
• A chest X-ray.
• Blood tests including a full blood count, serum calcium, and liver function tests.
• Urinalysis.
– Consider referral for further investigations for cancer with an abdomino-pelvic CT scan (and mammogram in women) in all people over 40 years with a first unprovoked PE who do not have features of cancer based on the initial investigations above.
• In people with an unprovoked PE, consider antiphospholipid testing (anti-cardiolipin or anti-beta glycoprotein I antibodies) before stopping anticoagulants.
• In people with an unprovoked PE who have a first-degree relative who has had a DVT or PE, consider arranging hereditary thrombophilia testing (antithrombin, protein C, and protein S testing).
Case 3
• 84 year old lady ex teacher
• Progressive dyspnoea
• Swelling anterior chest wall
• CT guided biopsy of left chest wall mass
• Histology: Mesothelioma
• Recurrent pleural aspirations
• Indwelling drain placed
Lungs and cancer
Pleural effusions
- Pleural aspiration
- Medical pleurodesis
- VATS pleurodesis
- Indwelling pleural drain
Indwelling drains
Case 4
• Mrs SS
• 74 year old lady recently retired
• 3 week history of increasing dyspnoea
• Ex-smoker
• PS 0
Management
• Pericardial aspiration ( therapeutic and diagnostic)
• Pericardiostomy ( pericardial window)
• Pericardial stripping
• Treat the malignancy
Pressure on local structures
• E.g. SVC obstruction
Further management
• SVC stent insertion
• Urgent need for biopsy
• High dose steroid treatment- consider timing
• Radiotherapy
Bony involvement
• Pain from metastatic lesions
• Pathological fractures
• Spinal cord compression
Case 5- bony lesions
• 91 year old gentleman
• Presented following a
fall
• Acute right hip pain on
a background of chronic
hip pain
MRI hip
Considerations
• Pain relief including bisphosphonates
• Hip involvement consider benefits from hip
stabilisation
• Consider radiotherapy for refractory pain
• This patient had resolution of hip pain
following surgery but then later had
recurrence of pain for which he required
radiotherapy
Case 5: spinal cord compression
• 63 year old current
smoker
• Presented with a 5
week history of back
pain radiating to the
groin
• Leg weakness
• No loss of sphincter
control
Spinal Instability Neoplasia score
Fourney et al:
JCO 29, 22;
3072-3077
Case 6
• Mrs RP
• 65 year old lady presented with generalised weakness
• Poor appetite
• During admission developed progressive neurological weakness
• Differential diagnosis myasthenia gravis, motor neurone disease, paraneoplastic disease
• Developed progressive respiratory failure
• EMG inconclusive
• CT chest mass
Imaging
Paraneoplastic conditions
• Paraneoplastic neurologic syndromes are a
heterogeneous group of disorders caused by
mechanisms other than metastases, metabolic
and nutritional deficits, infections,
coagulopathy or side effects of cancer
treatment. These syndromes may affect any
part of the nervous system from cerebral
cortex to neuromuscular junction and muscle
Paraneoplastic syndromes
• P/Q type voltage-gated calcium channel antibodies in the Lambert-Eaton myasthenic syndrome (LEMS)
• Acetylcholine receptor antibodies in myasthenia gravis
• NMDA receptor (NR1) antibodies in anti-NMDAR encephalitis
• AMPA receptor (GluR1/2) antibodies in a subgroup of limbic encephalitis
• Ganglionic acetylcholine receptor antibodies in autonomic neuropathy
• Recoverin antibodies in carcinoma associated retinopathy
Endocrine disturbance
• Hyponatremia
Medication
SIADH
Hypoadrenal due to adrenal metastates
• Hypercalcaemia
Bone mets
PTH related peptide
• Hyperkalaemia
Medication
ACTH producing tumour
Case 7
• 82 year old lady
• Previously fit and well
• Admitted with acute
confusional state
• Na 110
• Confirmed SIADH
• Na increased to 132
with fluid restriction
Skin and Cancer- Case 8
74 year old lady presented
with increased shortness of
breath
Had also noted 2 week history
of rash on the back of hands
On closer questioning
mentioned difficulty climbing
the stairs
Had proximal muscle weakness
Case 9
54 year old nurse
Referred to the rheumatology
department with bilateral
wrist and ankle swelling and
joint pains
CXR abnormal
Hypertrophic Pulmonary
Osteoarthropathy
Case 10
• 58 year old lady
• Admitted following a first
seizure which resulted in
RTA
• Patient also has a solitary
lung lesion
• Consider possibility of
surgery in the instance of
oligometastases.
Proposal
• Timed pathway for patients with suspected
lung cancer admitted as an emergency
• Seeing a member of acute oncology service/
lung team within 24 hours
• CT within 48 hours
• Review by the lung MDT within a week
• Seen by member of lung MDT within one
week
Screening using low dose CT
• NSLT ( US)
• Nelson
• UKLS
Questions