1. A Fisherman’s Tale Group 13 Hilary GraffyTomos Owens Huw GriffithsImogen Ptacek Conor McKennaEllena Wood

2. His Story Details:77 year old, male, retired plumber PC:Haemoptysis

3. Haemoptysis

4. Malignancy Bronchial carcinoma Metastatic carcinoma Infection Tuberculosis Bronchiectasis Bronchitis Pneumonia Trauma Post-intubation Vascular PE Vasculitides e.g. Wegener’s

5. His Story Details:77 year old, male, retired plumber PC:Haemoptysis HxPC:Presented to GP 1 month ago with increasing SOB, he was admitted to AMU for treatment of pseudomonas pneumonia. Discharged home 2 weeks ago. 1 st week – coughing up small amounts of blood. 2 nd week – coughing greater quantities of brown/bloody sputum, worse at morning and night. On direct questioning he described a 2 month history of 2 stone weight loss with normal appetite.

6. His Story PMHx: Previous Lung Cancer (2002) Stage IIIB squamous cell carcinoma (Left Upper Lobe) Treated with 10 fractions of radiotherapy Aim was palliation – apparent cure achieved DHx:Nil NKDA FHx: Brother died of lung cancer Mother and father died of cancer

7. His Story SHx: Ex-smoker 50 pack years (Quit 2002) Drinks 18 units a week Plumber  Asbestos exposure from pipe lagging and bath panels Lives with supportive wife Keen fisher

8. On Examination General: Weak and lethargic Cachectic - Prominent clavicles (more so on left) Left thoracotomy scar Temp:36.8 o C Pulse: 80 bpm RR:20 per minute BP:127/74 O2 Sat:97% (Room air) Hands: No clubbing or tar staining

9. On Examination Head: No conjunctival pallor No central cyanosis No palpable cervical/axillary lymphadenopathy Tracheal deviation to left Chest:Reduced expansion on left side Abnormal breath sounds over XRT site (bronchial) Left lower zone: Stony dullness Reduced tactile vocal fremitus Reduced breath sounds Reduced vocal resonance Cardiovascular Examination – Normal Neurological Examination – Normal

10. Differential Diagnosis?

11. Recurrence of previous lung cancer New primary lung cancer Mesothelioma Metastases from another site Infection – atypical pneumonia, TB Differential Diagnosis?

12. Investigations?

13. Bloods – FBC, LFTs, U&E’s Sputum culture Imaging – CXR, CT Thorax

16. Management 08/2/11Treated by GP and hospital for pseudomonas pneumonia with antibiotics 12/2/11Discharged from hospital 26/2/11Re-presents with haemoptysis CXR: Shadowing on right lung Changes associated with previous radiotherapy in left upper lobe + fluid filled cavitating lesion – Positive for Aspergillus infection

17. Management 28/2/11CT scan: Left sided XRT changes Mediastinal nodes enlarged Lung lesion with rib destruction Enlarged left side axillary nodes found 1/3/11FNA: Biopsy of left axillary lymph node Squamous cell carcinoma found ? Metastases from new lung primary 3/3/11Bronchoscopy: Lesion identified on bronchoscopy in left lower lobe Biopsies taken - Confirmed SCC lung

18. Future management plan MDT discussion – decision not to treat Aspergillus infection. No chemotherapy as >75 years and no radiotherapy due to previous exposure. Palliative care with symptomatic control only to get him out fishing!

19. Lung Cancer

21. Leading cause of death by cancer in the UK 3% of cancer research funding 38,000 new cases/yr: 35,000 die/yr Only 8% of those diagnosed are cured 27% reduction in deaths in Men 1971-2006 Number of deaths in Women is increasing

22. A Brief history of Lung cancer “You ask me what it is we need to win this war. I answer tobacco as much as bullets”

28. Occupational risk Asbestos –Those exposed are at 4.9-7.3 times greater risk than those not –Risk enhanced if those exposed also smoke – 93x higher than non-exposed non-smokers Radioactive isotopes: –miners Polycyclic aromatic hydrocarbons: –foundry workers Nickel refining Chromate manufacture Arsenic industry

29. Small cell 24% Non Small cell 76% Squamous 48% Adenocarcinoma 13% Large cell 10% Other 5%

30. Presentation Late!

31. IntrapulmonaryExtrapulmonary Persistent Cough Haemoptysis Chest pain Dyspnoea Wheeze/Stridor Weight loss, anorexia Horner’s Syndrome Hoarseness SVC obstruction Dysphagia Ipsilateral diaphragm paralysis Shoulder and inner arm pain MetastaticParaneoplastic Syndromes 30% of patients present with symptoms due to metastases Brain Liver Bone Spinal Cord Adrenal glands Skin Lymph nodes SIADH Ectopic ACTH syndrome Hypercalcaemia Gynaecomastia and testicular atrophy Neuromyopathies Finger clubbing Hypertrophic pulmonary osteoarthropathy Symptoms

33. When to urgently refer? Persistent heamoptysis in an smoker or ex-smoker > 40 CXR suggestive of lung cancer Unexplained or persistent hx. >3/52: Cough (most common sx.) Weight loss Clubbing Chest pain Dyspnoea Hoarseness Cervical or supraclavicular lymphadenopathy Suggestion of metastases (bone, liver, brain, skin) SVC obstruction Stridor

34. Diagnosis 1. Confirmation of presence -Size -Location -Metastases? 1. Confirmation of presence -Size -Location -Metastases? -Chest X-ray -CT Scan -Bronchoscopy -PET scan -Chest X-ray -CT Scan -Bronchoscopy -PET scan -Sputum cytology -Bronchoscopy -Percutaneous transthoracic needle biopsy -Endobronchial ultrasound- guided transbronchial biopsy -Thoracoscopy or mediastinoscopy -Sputum cytology -Bronchoscopy -Percutaneous transthoracic needle biopsy -Endobronchial ultrasound- guided transbronchial biopsy -Thoracoscopy or mediastinoscopy 2. Histopathology -SC -NSSC -Squamous -adenocarcinoma -Large cell 2. Histopathology -SC -NSSC -Squamous -adenocarcinoma -Large cell 3. Staging -TNM staging 3. Staging -TNM staging

35. TNM staging

36. Non-Small Cell Carcinoma Treatment Prognosis: 50% 2 year survival – without spread 10% 2 year survival – with spread Surgery RadiotherapyChemotherapy Novel therapies

37. Small Cell Carcinoma Treatment Median Survival: 3 months (without treatment) 1 – 1 ½ years (with treatment) Surgery Radiotherapy Chemotherapy

38. Question Time

39. A 53 year old woman is diagnosed with lung cancer. Her main symptoms on presentation included breathlessness and haemoptysis. She complained of stretch marks on her abdomen and that her skin bruised easily. On examination you note purple abdominal striae. Which of the following types of lung cancer is she most likely to suffer from? 1.Squamous cell 2.Large cell 3.Adenocarcinoma 4.Alveolar 5.Small cell MCQ 1

40. A 61 year old man with a solitary lung nodule is referred for bronchoscopy. Biopsies from the mass reveal small cell lung cancer. Staging investigations show localised disease with no spread to the mediastinal nodes or involvement of either main bronchus or recurrent laryngeal nerve. What is the next most appropriate step in management? MCQ 2 1.Surgery 2.Radiotherapy 3.Chemotherapy 4.Endoscopic laser therapy 5.Stenting

41. A 71 year old retired electrician presents to his GP with pleuritic chest pains and dyspnoea. After initial investigations a CT scan of the chest demonstrates a right pleural effusion with lobular pleural thickening in the right mid-zone. EMQ 1 1.Idiopathic pulmonary fibrosis 2.Squamous cell carcinoma 3.Mesothelioma 4.Pulmonary abscess 5.Tuberculosis 6.Small cell lung cancer

42. An 84 year old woman who worked in a munitions factory in WW2 presents to her GP with abdominal pain, constipation, polyuria, cough, haemoptysis and weight loss. A CXR taken 3 years ago shows multiple pleural plaques only. EMQ 2 1.Idiopathic pulmonary fibrosis 2.Squamous cell carcinoma 3.Mesothelioma 4.Pulmonary abscess 5.Tuberculosis 6.Small cell lung cancer

43. Thank you!