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8/12/2019 Pneumonia and Lung Cancer
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Multidisciplinary Case-Based
Teaching
Prof. S. ONeill
Dr. D. RoystonDr. S. Shaikh
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MEDICINE
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Case
68 year old male
Presents to the Emergency Department with
increasing shortness of breath
Cough productive of green sputum
Chest pain on deep inspiration
Myalgia
Poor appetite
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On Examination
Temp 38.4C
Heart Rate 110bpm
Respiratory Rate 32rpm
O2Saturations 88% on room air
Blood Pressure 110/64mmHg
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On Examination
Decreased chest expansion bilaterally
Dullness to percussion over left lower lobe
Increased vocal resonance Bronchial breath sounds
Coarse crepitations
DIAGNOSIS
COMMUNITY ACQUIRED PNEUMONIA
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Initial Laboratory Investigations
FBC
WCC 16 (4-11)
Hb 11 (13-15)
Plts 300 (150-400)
Renal Profile
Urea 15 (4-7mmol/L)
Creatinine 94 (70-
110mol/L)
CRP raised
LFTsnormal
Blood cultures sent
ABG
pH 7.40 (7.35-7.45)
pCO25.8 (4.7-6kPa)
pO27.8 (11-13kPa)
Sputum cultures sent
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Contamination (saliva)
This is not sputum! No conclusion is possible.Please repeat the sampling
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S. pneumoniae!
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RADIOLOGY
http://www.google.ie/url?sa=i&rct=j&q=radiologist+cartoon&source=images&cd=&cad=rja&docid=rH8uEhFMw-RRxM&tbnid=PoEu0wMEMjEgZM:&ved=0CAUQjRw&url=http://www.zjobs.com.au/2007-11/&ei=MqRmUf-rEtSShgeX2IE4&bvm=bv.45107431,d.ZG4&psig=AFQjCNEpKmn4EXl7DcavzCiNxnVCAOnnfw&ust=13657675906098028/12/2019 Pneumonia and Lung Cancer
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Radiology
Is there a need to image this patient?
Yes
No
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Radiology
What modality will you use for imaging?
MRI
Nuclear Medicine
CT
Ultrasound
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Radiology
What does a normal chest x-ray (radiograph) look like?
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Radiology
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Radiology
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Radiology
Radiology take-home points:
Pneumonia is more opaque than normal lung
Margins may be fluffy and indistinct Affected areas homogenous in density
May contain air-bronchgrams
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PATHOLOGY
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Primary functions of the lungs:
Oxygenation of blood and
Removal of carbon dioxide
Inspired air leads to
Exposure to infection Pollutants
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Defences
Cough reflex
Upward flow of mucus
Ciliated epithelium
IgA secretion
Phagocytic activity of alveolar macrophages
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Pneumonia
Inflammatory condition of lung with
consolidation due to an inflammatory exudate
(air spaces involved)
Usually caused by bacterial infection
Pneumonia used to be known as The
CAPTAIN OF THE MEN OF DEATH(OSLER)
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Bronchopneumonia is a disease of the
extremes of lifeElderly and very young are particularly
susceptible
In the elderly other diseases may be present
e.g. Cancer, COPD, stroke
In the young the immune system may be
immature
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Classification - Two Types
1. Source of organism
Community acquired or
Hospital acquired (nosocomial)
2. Anatomical
Bronchopneumonia
Lobar
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Sites Affected
GROSS FINDINGS
Lower lobes
Unilateral or bilateral
Discrete patchy
MICROSCOPIC
Polymorphs in alveoli and
small bronchi
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Lobar Pneumonia RARE
Neglected people
Alcoholics
Male > Female 3:1
30 - 50 years (Common in third world)
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Complications of Pneumonia
RESPIRATORY AND CIRCULATORY
FAILURE
ACUTE RESPIRATORY DISTRESS
SYNDROME
SEPTIC SHOCK
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Complications of
Pneumonia Spread to pleura
- Effusion
- Empyema
Lung abscess
Bacterial endocarditis,meningitis, otitis, arthritis.
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Pathogenetic Factors
Aetiologic Agent - Some bacteria more
virulent than others
Host Reaction - may be compromised due to
associated illness
Extent of involvement -This is closely related
to the above factors
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Prevention
APPROPRIATE TREATMENT OF
UNDERLYING ILLNESS eg. AIDS
SMOKING CESSATION
VACCINATIONS
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MEDICINE
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Show of hands.
Should this patient be admitted to hospital?
YES
NO
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Hospital Admission Assessment
Scores
CURB-65 criteriaConfusion
Urea 7 mmol/L
Increased respiratory rate >30
Low blood pressure (SBP
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CURB 65Management of CAP
CURB 65
Confusion
BUN > 11RR > 30
BP
SBP
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Assignment to risk class based on the PSI
Aujesky D , Fine M J Clin Infect Dis. 2008;47:S133-S139
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CAPOutpatient Treatment Options
Previously healthy and no use of antimicrobials withinthe previous 3 months A macrolide (strong rec; level 1 evidence)
Doxycycline (weak rec; level 3 evidence)
Presence of comorbidities or use of antimicrobials withinthe previous 3 months Fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin)
A -lactam plus a macrolide (strong rec; level 1)
In regions with a high-rate of macrolide-resistant Strep.pneumoniae, consider treatment as patients with co-morbidities
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensusguidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27.
Mandell LA, et al. Clin Infect Dis 2007; 44 Suppl 2:S27.
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CAP Inpatient Treatment Options
Non-ICU
Fluoroquinolone
-lactam plusmacrolide
ICU
-lactam plusazithromycin/fluoroquinolone
Fluoroquinolone+ aztreonam
Mandell LA, et al. Clin Infect Dis 2007; 44 Suppl 2:S27.
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CAP Common Pathogens
Mandell LA, et al. Clin Infect Dis 2007; 44 Suppl 2:S27.
Patient type Aetiology
Outpatient Streptococcus pneumoniae
Mycoplasma pneumoniae
Haemophilus influenzae
Chlamydophila pneumoniae
Respiratory viruses
Inpatient (non-ICU) S. pneumoniae
M. pneumoniae
C. Pneumoniae
Legionellaspecies
Aspiration
Respiraoty viruses
Inpatient (ICU) S. Pneumoniae
Staphylococcus aureus
Legionellaspecies
Gram-negative bacilli
H. influenzae
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Department of Medicine,
RCSI
Systemic Complications
Hyponatraemia (any, esp legionella)
Haemolytic anaemia (mycoplasma)
GI features: diarrhoea, abdominal pain (legionella)
Headache (mycoplasma) Pericarditis, myocarditis (mycoplasma)
LFTs abnormalities, hepatitis
Renal failure (esp. Legionella)
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Patient Progress
Our patient responded well to therapy
Discharged home
Returns six weeks later for follow-up
including repeat chest x-ray
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Clinical Significance
the most widespread and fatal of all acute diseases,pneumonia is now Captain of the Men of DeathOsler, 1901
Leading infectious cause of death
5 million deaths/year worldwide
Mortality rate Outpatient: 5%
Inpatient: 12%
ITU: 40%
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RADIOLOGY
http://www.google.ie/url?sa=i&rct=j&q=radiologist+cartoon&source=images&cd=&cad=rja&docid=rH8uEhFMw-RRxM&tbnid=PoEu0wMEMjEgZM:&ved=0CAUQjRw&url=http://www.zjobs.com.au/2007-11/&ei=MqRmUf-rEtSShgeX2IE4&bvm=bv.45107431,d.ZG4&psig=AFQjCNEpKmn4EXl7DcavzCiNxnVCAOnnfw&ust=13657675906098028/12/2019 Pneumonia and Lung Cancer
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Radiology
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Radiology
Differential Diagnosis:
Mediastinal origin
1.Anterior: thymoma, teratoma, thyroid goitre, (terrible) lymphoma
2.Middle: lymphadenopathy, aortic aneurysms
3.Posterior: neurogenic tumors (neurofibroma, ganglioneuroma, neuroblastoma)
Pulmonary origin
1.Malignant (adenocarcinoma, squamous cell carcinoma, large cell carcinoma)
2.Benign (granuloma, hamartoma)
Lung collapse
Effusion
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Radiology
Way forwardfurther assessment of nature of
lesion; rule out malignancy
What imaging will you further do:
a. Another x-ray 6 months later
b. Urgent CT
c. Ultrasound
d. Surgery
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Radiology
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What next?
Radiology
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CT-guided percutaneous biopsy
Radiology
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Radiology
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PATHOLOGY
T
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Lung Tumours
B i T
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Benign Tumours
Rare
EXAMPLE Hamartoma
Tumour usually composed of a mixture of cartilage andepithelium
M li L T
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Malignant Lung Tumours
COMMON
Commonest fatal cancer
in males
Second to breast in
females
Causes more deaths than
breast & colon combined
7% of cancer deaths
I id i I l d
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Incidence in Ireland
1995 940 cases
1996 958 cases
1997 919 cases
1998 1002 cases 2005 1831 cases
Rising incidence in women
Accounts for 13% of cancer deaths in men,7% in women.
A i l
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Aetiology
CIGARETTE SMOKING
CITY LIVING
INDUSTRIAL EXPOSURE
Asbestos
Haematite
Chromate
Ci S ki
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Cigarette Smoking
25 Cigarettes a day x many years12% risk of cancer
M d f A i f Ci
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Mode of Action of Cigarettes
Tar contains 18 hydrocarbons
Many hydrocarbons lead to skin cancer in
laboratory animals
It is an example of a chemical carcinogen
L n n r l kn n
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Lung cancer also known asBRONCHOGENIC CANCER
(Bronchial cancer)Majority arise from major bronchi
Di M
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Distant Metastases
Lymph nodes - axilla, cervical, other
Bone
Liver
Brain
Adrenal
Skin
Other
Di i
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Diagnosis
Sputum Cytology Malignant cells shed from
bronchus and may be seen in sputum
Bronchial washings/brushings/biopsy
2/3 of patients have visible lesion atbronchoscopy
Trans thoracic biopsyFNA - For diagnosis
of peripheral tumours
Sh f h d
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Show of hands...
What is the most common type of lung
cancer?
A. Large cell carcinoma
B. Small cell carcinoma
C. Squamous cell carcinoma
D. Adenocarcinoma
Hi t l i T
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Histologic Types
Squamous cell carcinoma35-50%
Small cell carcinoma 20-
30%
Adenocarcinoma 15-30%
Large cell carcinoma 10-
15%
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Normal columnar epithelium undergoes
metaplasia to a squamous type due
to irritant effect of tobacco
B h i r f Diff r t T p
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Behaviour of Different Types
? Increasing incidence of adenocarcinoma-
may be due to different chemical composition
of cigarettes
Adenocarcinomas are more slowly growing Grow from 1-3 cm in 36 months
Squamous carcinomas take 16 months
Small cell - rapidly growing tumour
R nt Ad n s in M l l r
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Recent Advances in Molecular
Diagnosis
EPIDERMAL GROWTH FACTOR
RECEPTOR (EGFR) MUTATIONS Identified
in some adenocarcinomas DRUGS HAVE BEEN DEVELOPED
TARGETTING THIS RECEPTOR WITH
SOME DRAMATIC RESPONSES CHALLENGE IS TO IDENTIFY
ACCURATELY THESE TUMOURS
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Major distinction is between small cell
and non-small cell carcinoma
Prognostic and treatment differences
AUDIT Beaumont hospital
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AUDIT Beaumont hospital
1 year 198 cases
118 males, 80 females
198 cases
Mean age 68 years
150 cases non-small cell carcinoma
33% squamous,25% adenocarcinoma
17% small cell carcinoma
84% of non-small cell tumours stage 3 or 4
Conclusions
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Conclusions
LUNG CANCER MOST COMMON CAUSEOF CANCER GLOBALLY
1 MILLION DEATHS PER YEAR
15 % PATIENTS SURVIVE 5 YEARS ORMORE
HIGH MORTALITY DUE TO EARLY AND
WIDESPREAD CANCER DISSEMINATION
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MEDICINE
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Diagnosis Definitive
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Diagnosis - Definitive
Contrast-enhanced computed tomography(CT) through lungs, liver, and adrenal glands
Bronchoscopy, Broncho-alveolar lavage
(washings sent for cytology) and biopsy-histo-pathological diagnosis is imperative
Department of Medicine,
RCSI
Diagnosis - Staging
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Diagnosis - Staging
Staging of NSCLC grades the primary tumour characteristics (T),
presence or absence of regional lymph nodeinvolvement (N),
and presence or absence of distant metastasis(M)
The combination of T, N, and M grades
determines the overall disease stage (stage Ithrough IV)
Department of Medicine,
RCSI
Diagnosis - Staging
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Diagnosis - Staging
1. Contrast enhanced CT (as before)2. Regional lymph nodes:
1. Endobronchial ultrasound
2. Transesophageal endoscopic ultrasound
3. Transbronchial needle aspiration
4. Cervical mediastinoscopy3. Pleural tap- if pleural effusion present, confirmation of malignant
cells on cytology is mandatory in all patients with NSCLC if thisdetermination influences the disease stage.
4. Radioisotope Bone scan- Bony metastases
5. PET scanning
Department of Medicine,
RCSI
Diagnosis - Complications
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Diagnosis Complications
Chest X ray- coin-shaped lesion: rare
CBC- anaemia due to malignancy, leucocytosis due to
post-obstructive pneumonia
Calcium, phosphate, magnesium profile-
Hypercalcaemia due to PNS or due to bony metastases
PFTs- especially important if considering resection
ESR,CRP- often raised
ABG- assessment of functional status
Department of Medicine,
RCSI
CT Peripheral Tumour
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CT Peripheral Tumour
Department of Medicine,
RCSI
CT PET: Tumour in RUL affecting local ribs and
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g
left adrenal
Department of Medicine,
RCSI
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Any questions?