1. iBSc: Question 3 By Alan McLeod Tested by Natalie Hayes

2. Getting the best marks Read the whole question – a latter section may give you a clue about an earlier one. To see how many points you need look at the marks allocated – for example a 3 point question is generally looking for 3 salient points If giving a list answer put the best answers first – examiners will not usually mark answers too far down a list Always write something – it may get you part of a mark and is anonymised so no one will think you are stupid! If you genuinely have no clue then re-write the question to see if this sparks some ideas. If not then move on and come back at the end. And remember – always write something. Good luck!

3. Question 4 Mr Jackson, a 62 year old retired bricklayer has been experiencing haemoptysis for three weeks. Q4.1 List 4 differentials for haemoptysis (4)

4. Question 4 Mr Jackson has an 80 pack year smoking history. Q4.2 What is a ‘pack year’ (2)

5. Question 4 Cigarette smoke is a known carcinogen. Q4.3 List two other carcinogens (1) Q4.4 What are the three stages of carcinogenesis (3)

6. Question 4 You suspect lung cancer. Q4.5 What additional symptoms might you ask about to support your hypothesis (2) Q4.6 What cancer specific tests might you order (3)

7. Question 4 Tests reveal a squamous cell carcinoma of the lung with liver metastases. Q4.7 Aside from SCC, list two other common types of lung cancer (2) Q4.8 What changes occur in a cancer cell to allow metastasis? (5)

8. Question 4 Tests reveal a squamous cell carcinoma of the lung with liver metastases. Q4.9 Compare the characteristics of normal and neoplastic cells (4)

9. Question 4 When you tell him the diagnosis, Mr Jackson becomes very angry - accusing you of negligence for not spotting this earlier. Q4.10 Aside from anger, what are the stages of grief in the model proposed by Kubler- Ross (4)

10. Question 4 You describe to Mr Jackson the probable prognosis and progression of the disease. Q4.11 List one local and two systemic effects that cancers in general may produce (3)

11. The Answers View these on ‘note view’ rather than on full screen – additional notes are provided for some slides

12. Haemoptysis? Where’s that wine… I Infectious / inflammatory Pulmonary tuberculosis G Genetic / idiopathic E Endocrine T Trauma Chest trauma V Vascular Pulmonary embolism I Iatrogenic / ingested N Neoplastic Bronchial carcinoma O Organs / other Nose: epistaxis; oesophagus: mallory weiss tear Lung: bronchiectasis; Heart: mitral stenosis

13. Two Useful Concepts Body Mass Index (BMI) 20-25: Ideal 26-30: Overweight 31-35: Obese Pack Years > 20 = increased chance complications PY= Cigs / day x Yrs 20 BMI= Wt (kg) Ht 2 (M)

14. Carcinogens Cigarette smoke Chemicals PAH Aromatic amines Nitrosamines UV Radiation Ionising radiation Radiotherapy Radon gas (lung) Industry/military

15. Carcinogens Viruses EBV (Epstein-Barr) HPV (Papilloma virus) HBV (Hepatitis B virus) Stages in carcinogenesis Initiation Promotion Progression

16. Lung cancer Male: Female 7:1 Decreasing Male peak in 60s Female peak in 70s Rare under 25 years Presenting complaints 90% symptomatic –40% Haemoptysis –75% Anorexia –75% Dyspnoea –75% Cough –75% Pain Remember Weight Loss 10% Incidental imaging

17. Lung Cancer - Diagnosis Imaging –Plain film –CT –MRI Cytology –Sputum –Bronchoscopic washings Biopsy Peripheral lesions –Percutaneous biopsy Proximal lesions –Bronchoscopic biopsy Pleural Effusions –Fine needle aspiration

18. Lung Cancer Types Small Cell (20-30%) Non-small Cell –Large Cell (10-15%) –Adenocarcinoma (~20%) Commonest non-smoking –Squamous cell carcinoma (40-60%) Commonest smoking related Treatment Small cell –Early metastasis –Chemotherapy and radiotherapy first line Non-small cell –Surgery first line Lobectomy Pneumonectomy –Radio / chemo as req

19. Invasion and Metastasis Invasion is the spread into adjacent tissues – may occur along natural tissue planes such as along nerves Metastasis is the spread of cells to distant parts of the body – there are several mechanisms for this

20. To Metastasise Changes occur in only some cells of the tumour By random mutation Binds to basement membr Becomes motile Becomes able to attach to extracellular matrix Becomes able to degrade extracellular matrix Must be able to survive and grow at site of implantation

21. Routes of Metastasis Vascular Lymphatic Coelomic Fig 1

22. Growth Characteristics BenignMalignant Expands only Grows locally Expands and invades local tissues May metastasise Generally slowerGenerally faster

23. Cytoplasmic Characteristics BenignMalignant Normal or slight increase in nucleus:cytoplasm ratio High nucleus:cytoplasm ratio Resembles cell of origin (well differentiated) Failure of differentiation Retains specialisationsLoses specialisations DiploidRange of ploidy

24. Histological Characteristics BenignMalignant Few MitosesMany mitoses – some of which are abnormal Cell uniform throughout tumour Cells vary in shape and size (cellular pleomorphism) and/or Nuclei vary in shape and size (nuclear pleomorphism) Organised tissueDisorganised tissue

26. Local and systemic effects Local Pressure Invasion Ulceration Obstruction Systemic Weight loss (cachexia) Loss of appetite (anorexia) Fever Anaemia General Malaise Paraneoplastic

27. The End The slides here should allow you to mark your own work – remember 1 mark per answer* up to the maximum for the question. Multiply by 3 to get percentage points. I assume a 60% pass mark. Sorry but I am unable to give further advice on answers due to time constraints.