1. Lung malignancy Dr Rachel Cary, FY1 Warwick Hospital

2. Learning outcomes

3. Case  72 year old woman, retired post office worker  Worsening SOB 3/12  Haemoptysis 2/52  Dull R sided chest pain, 15kg weight loss over 2/12  PMHx: COPD (seretide 250 TT BD, salbutamol PRN), HTN (ramipril)  Ex-smoker – 40 pack year history, quit 5 years ago  O/E: Cachectic, R base stony dull with no a/e  CXR: R sided pleural effusion

4. Differential diagnosis?  Malignancy  Small cell lung Ca (aka oat cell)  Non-small cell lung carcinoma  Large cell carcinoma  Squamous cell carcinoma  Adenocarcinoma  Unilateral effusion most likely malignancy, but be aware of other rare causes: e.g. empyema, chylothorax, haemothorax

5. ALARM symptoms  For any malignancy  Weight loss  Anaemia  Loss of appetite

6. Small cell lung cancer  15% lung cancers  Arise from Kulchitsky cells (part of amine precursor uptake and decarboxylation endocrine system)  Risk factor: smoking (very rare in non smokers)  Commonly presents at an advanced stage with symptoms of a few months duration from local tumour growth, intrathoracic or distant spread, or paraneoplastic syndroms.

7. Paraneoplastic syndroms  SIADH –dilutional hyponatraemia, tumour secretes ADH  Lambert-Eaton – proximal muscle weakness, due to autoimmune attack on VGCCs on presynaptic neuron (also found in high numbers on tumour cells)  Cushing’s syndrome – Ectopic ACTH/ ACTH-like substance secreted from tumour  Hyperparathyroidism –hypercalcaemia, typically squamous cell tumours secrete PTHrP

8. Non-small cell lung cancer  Squamous cell (42% of NSCLCs)  Often due to smoking  Often found near the main bronchi (obstructive)  Adenocarcinoma (39%)  Associated with asbestos  More common in non-smokers compared to other lung ca  Often metastasises to brain and bones  Large cell (8%)  Less differentiated forms of squamous/adeno  Metastasise early

9. Returning to the case

10. Apical tumours – anatomy!  New hoarseness – affected recurrent laryngeal nerve?  Bilaterally emerge from vagus nerve at level of arch of aorta  Left nerve loops under aortic arch  Right nerve travels directly upwards to larynx

11. Investigation  Bedside  Bloods  Radiology – CXR, CT thorax, CT-PET  Can you explain what they are and what they look for?  Special tests – cytology (aspirate, bronchoscopy), BAL

12. Management  Of any cancer – break it down  Conservative  Medical  Chemotherapy  Radiotherapy  Surgical

13. Chemotherapy  Chemotherapy in NSCLC late stage disease – normally third generation drug (e.g. docetaxel) and platinum drug  Post surgery – as adjuvant or after incomplete resection  SCLC respond to chemotherapy (normally multi-agent regimes), but the prognosis is poor

14. Radiotherapy  NSCLC when patients not suitable for surgery

15. Surgical  Can be curative in NSCLC  Treatment of choice in early stage disease  Lobar resection  Hilar and mediastinal lymph node sampling to provide accurate staging

16. Pleural fluid  Exudate – protein >30 g/L  Transudate – protein <30g/L  Light’s criteria (protein 25-35g/L)  The fluid is an exudate if one or more of the following criteria met:  Pleural fluid protein/serum protein >0.5  Pleural fluid LDH/serum LDH >0.6  Pleural fluid LDH > 2/3 upper limits normal serum LDH

17. Any questions?