Troublesome Cough

Question 1

Red flag symptoms for lung cancer (8)

Answer 1

Cough (dry/productive) - productive = send sputum sample
Haemoptysis
Dyspnoea
Hoarse voice - recurrent laryngeal nerve - mediastinal involvement 
Chest pain - character important 
Fatigue
Loss of appetite 
Weight loss - quantify, intentional?

Question 2

What are para-neoplastic syndromes?

Answer 2

Rare disorders caused by immune response to cancer
Non-metastatic systemic effects
EG
- hypercalcaemia in squamous cell lung cancer due to PTrH
- HPOA

Question 3

What is HPOA?

Answer 3

Hypertrophic Osteoarthropathy
Characterised by abnormal proliferation of skin and periosteal tissues involving the extremities
Three clinical features 
-digital clubbing
-periotosis of tubular bones
-synovial effusions

Question 4

Management for patient (lifelong smoker) returning to GP with no improvement, following antibiotics given for cough 2 weeks prior

Answer 4

Urgent referral (2ww) for CXR
Smoking Cessation 

CT required if CXR is abnormal

Question 5

Information needed before CT contrast

Answer 5

Any previous reaction
Rental function - if GFR <40 there is a risk of contrast induced AKI
DM - metformin may need to be stopped pre contrast if renal impairment

Question 6

Importance of PMH in cancer patient

Answer 6

Consider fitness for treatment options:

Surgery - lung/cardiac function
Chemotherapy - renal/liver function
Radiotherapy - lying flat

Question 7

Bloods in suspected Lung Ca

Answer 7

FBC - anaemia
Rental function - check fitness for chemo
Bone profile - Increased calcium could be a sign of bony mets or a para-neoplastic syndrome
Liver function

Question 8

Further tests

Answer 8

Pulmonary function test - essential to measure lung reserve before potential surgery or radical radiotherapy

Bronchoscopy and biopsy - histological diagnosis and staging

PETCT

Question 9

Factors important in deciding treatment (6)

Answer 9

Patient preference 
Patients social support networks
Stage of disease 
Patient fitness/performance 
Histology and other characteristics
Co-morbidities

Question 10

When is surgery not possible in lung cancer?

Answer 10

If there is invasion of the mediastinum

Question 11

ECOG Performance Scale

Answer 11

0 - fully active, able to carry out all pre disease performance without restriction
1 - restricted in physically strenuous activity but ambulatory and able to carry out light work
2 - ambulatory and capable of self care but unable to carry out work activities. Up and about >50% waking hours
3 - capable of limited self care. Confined to bed/chair >50% waking hours
4 - completely disabled and confined to bed/chair. No self care
5 - deceased

Question 12

Important aspects of oncology history

Answer 12

Smoking history
Alcohol history
Occupation -asbestos, compensation, inability to work, loss of income
Who’s at home
Family history (preconceived pos/neg ideas)

Question 13

2 chemo drugs

Answer 13

Cisplatin

Etoposide

Question 14

Side effects of Radiotherapy

Answer 14

Fatigue
Pain flare
Diarrhoea
Oesophagitis -occurs within 2 weeks, settles within 2-4 weeks
Skin reaction
Nausea
Hair loss
Dyspnoea - due to lung damage (pneumonitis)
- can occur 2-3 weeks into therapy, can progress several months after treatment finishes
- can be life threatening

Question 15

Precautions for radiotherapy

Answer 15

Volume of lung receiving 20Gy should be kept to <35% to limit lung damage
Lung toxicity (pneumonitis) is treated with high dose steroids but may be irreversible

Question 16

Small Cell Lung Cancer (15%)

Answer 16

Usually disseminated - smoking related
Rapid growth - doubling approx 29 days
Very chemo/radiosensitive but rarely cured
No curative treatment - median survival 2-4 months
Median survival is 6-12 months for extensive (metastatic) disease
Median survival is 16-24 months for localised disease

Question 17

Squamous Cell Carcinoma(30%)

Answer 17

Typically central so symptoms develop early
Smoking related
Best survival due to potential operability
Doubling time 90 days

Question 18

Adenocarcinoma (30-40%)

Answer 18

Typically peripherally located
Slower growth - doubling time 160 days
Metastasise early 
Can occur in non smokers
Can respond to newer systemic agents - i.e tyrosine kinase inhibitors

Question 19

Tumour staging

T

Answer 19

T1 - <3cm
T2 - 3-5cm
T3 - 5-7cm or invades chest wall or separate nodule same lobe
T4 - >7cm or invading local structures - inoperable

Question 20

Tumour Staging

N

Answer 20

N0 - no nodes
N1 - local ipsilateral nose
N3 - ipsilateral mediastinal node(s)
N4 - contralateral mediastinal nodes

Question 21

Tumour Staging

M

Answer 21

M1a separate tumour nodule(s) in a contralateral lobe
M1b single extra thoracic metastasis in single organ
M1c multiple extra-thoracic metastases

Question 22

Complications of Lung cancer

Answer 22

1/3 of lung cancer patients develop brain mets
- Common in advanced disease and adenoma

CVA less likely but possible

Question 23

Treatment of headaches in cancer

Answer 23

Dexamethasone, 8mg BD PO
- Check baseline blood sugars as steroids can exacerbate diabetes

PPI may be helpful too

Question 24

1 year survival rate for patients diagnosed with lung cancer in UK

Answer 24

30%