Acute presentations of lung cancer. Dr Prina Ruparelia Respiratory consultant Cambridge University Hospital

Transcription

1 Acute presentations of lung cancer Dr Prina Ruparelia Respiratory consultant Cambridge University Hospital

2 The problem Incidence CADIAS report /NCIN Acute lung cancer presentations Future pathway developments

3 CRUK Incidence of lung cancer

4 Emergency presentations of cancer ncin.org.uk

5 Survival according to presentation BJC 2012: ncin.org.uk

6 Cancer Diagnosis in an Acute Setting (CADIAS) Barriers to seeking medical attention Patient perceived factors (66%) GP access factors- 25%

7 Local effects Lung Metastatic lesions- cardiac, neurological, bone Endocrine effects Paraneoplastic effects

8 Infection Local effects of occlusion for example pneumonia more common in patients with an occluded airway

9 Case 1 81 year old lady Ex-smoker History of memory impairment 3 week history of dyspnoea Persistent cough. New diagnosis of paroxysmal AF On examination Oxygen sats 92% on air. Noted to have an inspiratory wheeze in the left upper lobe

10 Presentation CXR Chest radiograph 2011

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12 Measures to improve airway patency Chest clearance techniques Physiotherapy cautiously Saline nebulisers Steroid treatment Visualisation by bronchoscopy to assess suitable interventions Interventional techniques Bronchoscopy with cryotherapy Stenting

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14 Improving airway patency Is an effective palliative measure May prolong survival and improve performance status such that the individual may be able to undergo chemotherapy Consider whether the airway may be at risk prior to discharging the patient, particular consideration of the main bronchi and proximity to the carina Be aware of your local arrangements- Interventional pulmonology, thoracic surgeons

15 Measures to improve airway patency Cryotherapy Argon Laser Stenting Combination of above

16 Case Report 2 65 year old lady never smoker Presented with pleuritic chest pain Shortness of breath

17 Predisposition thromboembolic disease Hypercoagulable state Clinical thromboembolism occurs in up to 11% of patients with malignancy Certain malignancies may have higher predisposition for example pancreatic cancer Other common cancers associated with PE are GI malignancies, lung cancer

18 Thromboembolic disease Several investigators have attempted to define risk factors to identify the subset of patients likely to benefit from extensive screening for malignancy. In one study, cancer was diagnosed in 16 of 136 patients (12 percent) with idiopathic DVT during the index hospitalization 1. All 16 had one or more abnormalities suggestive of possible malignancy on at least one of the four components of the initial investigation: history, physical examination, basic laboratory testing, or chest X-ray. In a second series, 13 new malignancies were diagnosed among 326 patients with DVT during a 6-month follow-up period 2. Ten of the 13 had some type of clinical abnormality at presentation, and 7 were diagnosed within the first 16 days based upon patient characteristics and clinical findings on initial routine examination and laboratory testing. 1. Cornuz J et al Ann Intern Med ;125(10): Hettiarachchi RJ et al Cancer Jul 1;83(1):180-5.

19 Treatment- VTE There is both a risk and benefit in the treatment of patients with the malignant disease Retrospective analysis in 1303 patients with thromboembolic disease ( 264 patients in this group had underlying malignancy) Overall incidence of recurrent VTE in those with malignancy is 3.5 times higher 6.5 times higher risk of bleeding

20 Van Doormal et al % of patients in extensive screening identified as having cancer ( CT abdo, chest and mammogram) 2.4% of patients in limited screening identified as having cancer (history, physical examination, basic lab test and CXR) Of those identified 8.3% died in extensive screening group versus 7.6% of limited screening group Thromb Haemost Jan;9(1):79-84

21 Investigation for underlying malignancy Ensure people with unprovoked pulmonary embolism(pe) are investigated for the possibility of an undiagnosed cancer if they are not already known to have cancer. Initially undertake: A full history and physical examination to look for evidence of malignancy. A chest X-ray. Blood tests including a full blood count, serum calcium, and liver function tests. Urinalysis. Consider referral for further investigations for cancer with an abdomino-pelvic CT scan (and mammogram in women) in all people over 40 years with a first unprovoked PE who do not have features of cancer based on the initial investigations above. In people with an unprovoked PE, consider antiphospholipid testing (anticardiolipin or anti-beta glycoprotein I antibodies) before stopping anticoagulants. In people with an unprovoked PE who have a first-degree relative who has had a DVT or PE, consider arranging hereditary thrombophilia testing (antithrombin, protein C, and protein S testing).

22 84 year old lady ex teacher Progressive dyspnoea Swelling anterior chest wall CT guided biopsy of left chest wall mass Histology: Mesothelioma Recurrent pleural aspirations Indwelling drain placed Case 3

23 Lungs and cancer Pleural effusions - Pleural aspiration - Medical pleurodesis - VATS pleurodesis - Indwelling pleural drain

24 Indwelling drains

25 Case 4 Mrs SS 74 year old lady recently retired 3 week history of increasing dyspnoea Ex-smoker PS 0

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27 Management Pericardial aspiration ( therapeutic and diagnostic) Pericardiostomy ( pericardial window) Pericardial stripping Treat the malignancy

28 Pressure on local structures E.g. SVC obstruction

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31 Further management SVC stent insertion Urgent need for biopsy High dose steroid treatment- consider timing Radiotherapy

32 Bony involvement Pain from metastatic lesions Pathological fractures Spinal cord compression

33 Case 5- bony lesions 91 year old gentleman Presented following a fall Acute right hip pain on a background of chronic hip pain

34 MRI hip

35 Considerations Pain relief including bisphosphonates Hip involvement consider benefits from hip stabilisation Consider radiotherapy for refractory pain This patient had resolution of hip pain following surgery but then later had recurrence of pain for which he required radiotherapy

36 Case 5: spinal cord compression 63 year old current smoker Presented with a 5 week history of back pain radiating to the groin Leg weakness No loss of sphincter control

37 Spinal Instability Neoplasia score Fourney et al: JCO 29, 22;

38 Case 6 Mrs RP 65 year old lady presented with generalised weakness Poor appetite During admission developed progressive neurological weakness Differential diagnosis myasthenia gravis, motor neurone disease, paraneoplastic disease Developed progressive respiratory failure EMG inconclusive CT chest mass

39 Imaging

40 Paraneoplastic conditions Paraneoplastic neurologic syndromes are a heterogeneous group of disorders caused by mechanisms other than metastases, metabolic and nutritional deficits, infections, coagulopathy or side effects of cancer treatment. These syndromes may affect any part of the nervous system from cerebral cortex to neuromuscular junction and muscle

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42 Paraneoplastic syndromes P/Q type voltage-gated calcium channel antibodies in the Lambert-Eaton myasthenic syndrome (LEMS) Acetylcholine receptor antibodies in myasthenia gravis NMDA receptor (NR1) antibodies in anti-nmdar encephalitis AMPA receptor (GluR1/2) antibodies in a subgroup of limbic encephalitis Ganglionic acetylcholine receptor antibodies in autonomic neuropathy Recoverin antibodies in carcinoma associated retinopathy

43 Endocrine disturbance Hyponatremia Medication SIADH Hypoadrenal due to adrenal metastates Hypercalcaemia Bone mets PTH related peptide Hyperkalaemia Medication ACTH producing tumour

44 Case 7 82 year old lady Previously fit and well Admitted with acute confusional state Na 110 Confirmed SIADH Na increased to 132 with fluid restriction

45 Skin and Cancer- Case 8 74 year old lady presented with increased shortness of breath Had also noted 2 week history of rash on the back of hands On closer questioning mentioned difficulty climbing the stairs Had proximal muscle weakness

46 Case 9 54 year old nurse Referred to the rheumatology department with bilateral wrist and ankle swelling and joint pains CXR abnormal Hypertrophic Pulmonary Osteoarthropathy

47 Case year old lady Admitted following a first seizure which resulted in RTA Patient also has a solitary lung lesion Consider possibility of surgery in the instance of oligometastases.

48 Proposal Timed pathway for patients with suspected lung cancer admitted as an emergency Seeing a member of acute oncology service/ lung team within 24 hours CT within 48 hours Review by the lung MDT within a week Seen by member of lung MDT within one week

49 Screening using low dose CT NSLT ( US) Nelson UKLS

50 Questions