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 I 67. 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?