• No results found

Lung cancer case study

N/A
N/A
Protected

Academic year: 2021

Share "Lung cancer case study"

Copied!
33
0
0

Loading.... (view fulltext now)

Full text

(1)

Change Presentation title and date in Footer dd.mm.yyyy 1

Lung cancer case study

Dr Jaishree Bhosle

(2)

Part One – Initial presentation

60 year old lady, presents with a 6 week history of

right sided chest pain. The pain is like a dull ache, but comes and goes. It is eased with occasional

paracetamol use. It has not changed over the last few weeks; neither worsening or improving Respiratory examination is unremarkable and there is no chest wall tenderness.

(3)

What are you thinking?

1. This sounds routine

2. This sounds serious

3. She’s wasting my time

10 4-1 0% 25 -36 % 43 -58 % 58 -73 % 0% 0% 0% 0%

(4)

Please join your groups to discuss. Return at

10.25am.

– Groups 1&2 – Stay here (Julian Bloom Lecture Theatre)

– Groups 3&4 – Blackstone room (entrance opposite Julian Bloom Lecture Theatre)

(5)

Change Presentation title and date in Footer dd.mm.yyyy 5

Lung cancer case study:

panel discussion

Dr Jaishree Bhosle

Dr Afsana Safa

(6)

Part One – Initial presentation

60 year old lady, presents with a 6 week history of

right sided chest pain. The pain is like a dull ache, but comes and goes. It is eased with occasional

paracetamol use. It has not changed over the last few weeks; neither worsening or improving Respiratory examination is unremarkable and there is no chest wall tenderness.

(7)

Q1. What other information would you like to

elicit?

Smoking history

Any symptoms of infection Haemoptysis Change in voice Family History Cough Weight loss Asbestos exposure Past medical history Current medications

(8)

Q2. What are the differential diagnoses?

– Respiratory: COPD, bronchospasm, infection, lung cancer, mesothelioma, PE

– Cardiovascular: ischaemic heart disease – Gastrointestinal: Reflux

– Musculoskeletal and soft tissue: Breast pathology, trauma, shoulder pain, costochondritis

(9)

Q3. What investigations could you perform at

this stage if any?

None

CXR if not done recently Spirometry

(10)

She is an ex-smoker, having smoked from the age of 16 to 52; she smoked 20 cigarettes a day. She has a family history of lung cancer, with her father dying from the disease at the age of 64. She has lost

around five pounds in the last three months, but she has been trying to lose weight. She has a chest x-ray which is reported as normal.

(11)

Q4. From her history does she have any risk

factors the development of lung cancer?

Duration of smoking history

Started smoking at a young age Family history of lung cancer

(12)

symptoms which suggest a diagnosis of lung

cancer

Chest pain Weight loss

(13)

Part Two – She attends your surgery after

being seen in a TWR clinic by a respiratory

physician

She has undergone a CT scan of the lower neck, chest and abdomen. The respiratory physician has explained that she probably has lung cancer but

requires further investigations with a PET, PFTs, CT brain and perhaps an EBUS. She has evidence of

obstructive airway disease on spirometry and has been commenced on inhalers. She is told that

(14)

the delay in just ‘getting rid of it’. What are the further investigations and why are they important?

– PET- Positron Emission Tomography- nuclear imaging performed to fully stage lung cancer. Can detect

metastatic disease not demonstrated by conventional CT, especially bone metastases

– EBUS- Endobronchial Ultrasound- used to investigate mediastinal nodes and obtain tissue by transbronchial nodal aspiration to ascertain the type of lung cancer and confirm lymph node involvement

– CT brain- to enable full staging prior to undergoing treatment with curative intent

– PFTs- Pulmonary function tests- to evaluate lung function to enable treatment planning.

(15)

Q2. She wishes to stop the inhalers she has been

prescribed. Why should she continue with these?

It is important to maximise lung function prior to any definitive treatment. Pulmonary function tests will be undertaken to help ascertain whether a patient has enough lung function to undergo a surgical resection or treatment with radical radiotherapy

(16)

Q3. Where does lung cancer commonly

metastasise to?

Liver Bone Brain Adrenals

Other parts of the lung Lymph-nodes

(17)

Q4. She is fearful of undergoing surgery. Are

there any other options, which may still offer a

cure?

Depends upon tumour size, site and the involvement of lymph nodes

Radical chemoradiotherapy

(18)

possible options and will she need any other

treatment afterwards?

Type of surgical resection will depend on the position of the tumour, whether there is lymph node involvement, lung function and co-morbidities

Can include

Lobectomy and lymph node dissection

Pneumonectomy and lymph node dissection Wedge resection

May need chemotherapy after surgery depending on tumour size and lymph node involvement

Occasionally radiotherapy is needed if there are positive resection margins

(19)

Part three – Management in primary care

She was diagnosed with a 3.3 cm adenocarcinoma of the lung, with involvement of a hilar lymph node. She

underwent a lobectomy and adjuvant chemotherapy at The Royal Marsden 18 months ago.

She is being seen by her oncologist every six months and she was last seen three months ago by a respiratory

physician when a chest x-ray was unchanged. She is now fatigued and complaining of weight loss. Her next

(20)

Q1. What investigations would you undertake at

this point?

History to ascertain if her symptoms could be due to the development of metastatic disease.

Physical examination to look for evidence of metastatic disease (pleural effusion, hepatomegaly, cervical lymph nodes).

Urgent referral back to oncologist for imaging chest and abdomen

?FBC (anaemia), LFT (abnormal ALT or ALP)

Differential diagnosis is: metastatic disease, depression/ mood, side effects of treatment, new pathology.

Metastatic disease: the diagnosis of cancer must be coded on the problem list for all clinicians to see.

In this context the GP would organise urgent CXr, bloods and contact the CNS if appropriate.

(21)

What is her 5 year survival rate following

surgery?

1. 4-10% 2. 25-36% 3. 43-58% 4. 58-73% 4-1 0% 25 -36 % 43 -58 % 58 -73 % 0% 0% 0% 0% 10

(22)

What is her 5 year survival following surgery?

Final pathological stage was T2

N1 M0, stage 2B

5-year survival is around 25-36%

Most relapses occur within the

first 24 months

Stage 5-year survival

1A 1B ~ 58-73% ~ 43-58% 2A 2B ~ 36-46% ~ 25-36% 3A 3B ~ 19-24% ~ 7-9% 4 ~ 4-10%

(23)

She has developed liver and adrenal metastases and has been told that she now has incurable disease. Treatment is aimed at improving her symptoms and may lengthen her survival.

She has been asked to undergo another biopsy to

allow molecular testing as if she has a ‘mutation’ she may be able to have a tablet rather than

(24)

Q2. What are the treatment options of

advanced lung cancer

– Palliative chemotherapy, in adenocarcinoma this would be with pemetrexed and a platinum agent given every three weeks, possibly followed by maintenance chemotherapy

– If the tumour contains an sensitising mutation in the epidermal growth factor receptor (EGFR), treatment with an EGFR targeted tyrosine kinase inhibitor

– Palliative radiotherapy for symptom control

– Bisphosphonate given intravenously to prevent skeletal events in patients with bone metastases

(25)

Q3. She elects for treatment with a oral

tyrosine kinase inhibitor. What are the common

side-effects?

Diarrhoea

Acne like rash affecting face, chest, back and scalp Dry skin

Dry eyes Fatigue

Hair growth, including eyelashes and facial hair Mouth ulcers

Brittle nails Pneumonitis

Interaction with clarithromycin, erythromycin and fluconazole

(26)

Key learnings

Risk factors for developing lung cancer

Smoking history

COPD

Asbestos exposure Family History

>40 years old

Previous history of cancer History of pneumonia

(27)

Key learnings

Symptoms of lung cancer

Cough Haemoptysis Dyspnoea Weight loss Chest pain Shoulder pain Fatigue Hoarse voice Finger clubbing

(28)

Key learnings

When to refer

Persistent symptoms last more than 3 weeks

-persistent symptoms require investigation/referral even if initial investigations are normal

Chest x-ray suggestive of lung cancer – chest x-ray can be normal

Signs of superior vena cava obstruction Stridor

Symptoms suggestive of metastatic

(29)

Key learnings

Investigations

Primary Care CXR FBC Secondary care

CT chest and abdomen

PET

CT brain if considering treatment with curative intent

Pulmonary function test Bone scan if PET not done

(30)

Key learnings

Treatment options

Curative Surgery

Radical radiotherapy +/- chemotherapy Stereotatic ablative radiotherapy

Palliative Chemotherapy Targeted therapies Radiotherapy Bisphosphonates Bronchial stents Pleurodesis

(31)

How can you help?

Think about a possible

diagnosis of cancer Encourage stopping

smoking

Diagnosing COPD and optimising pulmonary function whilst your patient is undergoing investigation

Optimising pulmonary function after surgical resection

(32)

How can you help?

Optimising

management of COPD patients

Ensure follow up of patients with non resolution of

symptoms

Importance of

communication back from secondary care (e.g. regarding side effects of treatment)

(33)

Thank you

References

Related documents

Power function, Binomial coefficient, Binomial Theorem, Finite difference, Perfect cube, Exponential function, Pascal’s triangle, Series repre- sentation, Binomial Sum,

Slopes from the SRTM data, computed at 3-arc-second resolution, were summarized at 30-arc- second resolution, along with statistics developed to describe the distribution of

Aqueous and ethanolic extracts of this plant were prepared and blood glucose lowering effect and improvement of body weight gain in alloxan induced diabetic rats were

In this section, we analyze and compare the performance of MSBM with that of Newton’s method NM , Fixed Newton’s method FNM and Broyden’s method BM for solving systems

I test first how the residual income valuation model performs relative to the pricing - multiples model for a set of different value drivers and industries,

WordPress Drupal DotNetNuke Typo3 OpenCMS Plone Movable Type Alfresco Tiki Xoops CMSMadeSimple eZ Publish MODx Liferay Umbraco e107 Silverstripe TextPattern Concrete5.. Exhibit 10

The Cape Town Holocaust Centre provided the South African Jewish community with a legitimate identity in post-apartheid South Africa and a way to bypass an examination of

Assuming order of the filter as 32 and convergence value as µ=0.2 for LMS and γ =0.98 for RLS .The simulation result shows RLS algorithm can recover the original echo