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.