Enhancement of the Ring
DR DRAPER & DR THOMAS
Shahan Nizar, Hamaira Ahmed, Elizabeth Batalla-Duran, Ian Lambert,
Emily Duncan, Vicnesan Sivanesan
MM, 65, Retired painter• 09/98: 2-3months Hx of:
– Chest pain– Haemoptysis– Dyspnoea– Weight loss
• Investigations:– CT thorax myeloma? – Bone scan - negative– Myeloma screen - negative– FNA (CT-guided)
• 12/98: Diagnosis - left upper lobe adenocarcinoma
• Management:– Combination chemotherapy– Radiotherapy– Itraconazole
Progress...• 11/99: Well and gaining weight
• 7/00:– Lethargy– SOBOE– Anaemia – Aspergilloma
• 10/00: Under investigation for myelosuppression
• 4/01: Mild hypothyroidism
• 2/02: Vit B12 deficiency injections
• 6/02: ECG Mitral valve prolapse and moderate mitral regurgitation
• 6/03:– weakness developing in left arm– mild distal paraesthesiae– mild facial asymmetry
PMH
• 1989 - Inferior MI
• 1991 - Haemoptysis
• 1996 - Gastric ulcers
Presenting Complaint• PC: (1)Weakness & decr. move. L arm
• (2) Slight weakness L leg
• (3) Slurred speech
• (4) Some facial droop
• HPC: Asthma» “Leaky heart valve” (MR)
» TB (30 years ago, incidental finding on CXR)
» DU (30 years ago)
» MI (15 years ago)
» Hypothyroid (recently diagnosed)
DHx
• DH:– Becotide inhaler 50mg/puff x2 od– Aspirin 75 po od– Simvastatin 20 po od– Co-proxamol – Folic acid 5m od– Ferrous Sulphate 200mg od
DHx cont.
– Itraconazole 100mg bd– Thyroxine 25mg od– Entera liquid feed (mixed flavours) tetrabik
200ml– Lisinopril 5mg od– Lanzoprazole 30mg od– Dexamethasone 2mg od (taken since his
presentation 10 days ago)
Hx - cont.
• SH: Lives in Balham in a house with his partner.
• Independent but tires easily.• Occupation: Retired printer (no asbestos
exposure)• Smoker - 40 per day for 40 yrs (80 pack
years) now cut down to 12 per day• Doesn’t drink.
Ex
• Comfortable, looks fit and well.
• Hands: Clubbing, tar staining.
• HR: 70bpm, BP: 134/65
• JACCOL, JVP <-->
• Chest clear. Normal heart sounds.
• RR:12, Sats 99% on air
Ex - cont.• Neuro.: CNs - NAD. No facial droop, no
slurred speech.
• PNS: Power L arm» EF 4/5
» EE 4/5
» Power L leg
» HE 4/5
» KF 4/5
» KE 4/5
» Tone, Reflexes and Sensation all normal
Mx
• Concerns: ? L Apical AdenoCA has infiltrated the brachial plexus
• ?Brain Metastases• Rx: Started on Dexamethasone.• Ix: MRI Brain 23/7/03 --> 3 ring-enhancing
lesions with surrounding oedema.(?mets?abcess)
• To have brain biopsy this week.
Aetiology of Lung cancer
• SMOKING- in ~90% of cases. Also exacerbates other factors.
• Asbestos exposure- also chromates, arsenic, nickel
• Radon
• Lung disease
• Diet
Pathology
• EPITHELIAL:- commonest– SMALL CELL-20-30%, secrete hormones– NON-SMALL CELL
• Squamous cell- necrotic mass
• large cell
• adenocarcinoma- common around scar tissue
• Mesothelioma- assoc with asbestos
Clinical Features
• Symptoms– cough, haemoptysis, breathlessness, chest pain,
weight loss, anorexia, malaise
• Signs– clubbing, wheeze, stridor, localising chest
signs, effusion
Clinical features contd
• Non-respiratory– Anaemia, hypercalcaemia, hypercoagulopathy,
SIADH, ectopic ACTH
• Advanced disease– Lymphadenopathy, hoarseness, hepatomegaly,
Horner’s syndrome, SVC obstruction, bone pain, confusion.
Performance status
• 0 Normal activity; asymptomatic
• 1 Symptomatic; fully ambulatory
• 2 Symptomatic; bed < 50% of time
• 3 Symptomatic: in bed 50% of time
• 4 100% bed-ridden
• 5 Dead
TNM Staging
• T1: <3cm not involving bronchus• T2: >3cm involving main bronchus, visceral pleura• T3: Invasion of chest wall, diaphragm or pericardium.• T4: Other local invasion or malignant effusion
• N1: ipsilateral or peribronchial or hilar nodes• N2: ipsilateral mediastinal or subcarianl nodes• N3: Contralateral or supraclavicular nodes
• MO: No detectable metastases• M1 : Metastases
LUNG CANCER: TREATMENT
• Depends on; Histological type (SCLC Vs NSCLC), Stage ( 1- 4) and Performance Status.
• NSCLC; Surgery mainstay of Rx, traditionally poor response to chemotherapy agents.
• Aim of surgery; resection of 1° tumour, leave clear lateral and bronchial margins, remove peribronhial lymphatics and hilar Lymph nodes.
• Lobectomy or Pneumonectomy (tumour crosses fissures, compresses bronchus or Pulmonary vessel.)
• Complications: Anaesthetic, General, Specific: Cardiovascular instability (30%), Mortality; 3% lobectomy, 8% pneumonectomy.
• Prognosis (5 yr survival): 80% stage 1, 40% stage 2, 20 -8% stage 3.
• Depends on; Histological type (SCLC Vs NSCLC), Stage ( 1- 4) and Performance Status.
• NSCLC; Surgery mainstay of Rx, traditionally poor response to chemotherapy agents.
• Aim of surgery; resection of 1° tumour, leave clear lateral and bronchial margins, remove peribronhial lymphatics and hilar Lymph nodes.
• Lobectomy or Pneumonectomy (tumour crosses fissures, compresses bronchus or Pulmonary vessel.)
• Complications: Anaesthetic, General, Specific: Cardiovascular instability (30%), Mortality; 3% lobectomy, 8% pneumonectomy.
• Prognosis (5 yr survival): 80% stage 1, 40% stage 2, 20 -8% stage 3.
NSCLC ctd...• Adjuvant Treatment: Radiotherapy to margins (dose
related sensitivity) and Brain (sanctuary site for mets).
• Radical Radiotherapy only suitable for small tumours (<3cm diameter) because of cardiac toxicity, 15n - 20 % 5 yr s.
• Palliative Radiotherapy for Haemoptysis and lobar collapse.
• Role of adjuvant chemotherapy: not used traditionally, (SCLC regimens had adverse effects) now Cis-platin & Platinum agents shown to have beneficial effect (BMJ 1995: 311: 889-90).
• Regimens: MIC & MVP(Mitomicin, Ifosfamide, Cisplatin, Vincristine).
• Palliative care and MDT involvement.
SCLC• Prognosis and Rx less dependent on stage, most present
with systemic metastases, surgery of no benefit.
• Most (70%) tumours are chemosensitive and respond to initial chemotherapy. Later on resistance is a problem.
• Very few have any long term survival (10% alive at 2 years.)
• Aim of Rx is to prolong survival and palliate symptoms (average 3 month survival un Rx, 6 -9 month with Rx)
• Standard regimens: CAV (Cyclophosphamide, Adriamicin, Vincristine) & ECMV (+ Etoposide +Methotrexate).
• Usually as out pt, 4 -6 cycles, Increased dose and intensity has no benefit. Major Side Effect : Bone Marrow toxicity.
• Adjuvant Radiotherapy and Prophylactic Cranial Irradiation (PCI) + Palliative radiotherapy for emergencies (SVC obstruction) and bone pain.
PALLIATIVE CARE• Pain relief: Analgesic ladder (NSAID, weak then strong
opioid), TAD’s & Carbemazepine for neuropathic pain, steroids.
• Full Multi Disciplinary Team involvement and Palliative care review.
• Emergency complications:– Bronchial obstruction - FOB laser ablation,
– SVC obstruction - stenting
– Dysphagia- stenting
– Hypercalcaemia - Fluids, Frusemide, Bisphosphonates
– Spinal cord compression - surgical decompression, radiotherapy
– Dyspnoea - morphine, drain effusions.