Acute presentations of lung

cancer

Dr Prina Ruparelia

Respiratory consultant

Cambridge University Hospital

The problem

• Incidence

• CADIAS report /NCIN

• Acute lung cancer presentations

• Future pathway developments

Incidence of lung cancer

CRUK

Emergency presentations of cancer

ncin.org.uk

Survival according to presentation

BJC 2012: 1220-1226

ncin.org.uk

Cancer Diagnosis in an Acute Setting

(CADIAS)

Barriers to seeking medical attention

• Patient perceived factors (66%)

• GP access factors- 25%

Local effects

• Lung

• Metastatic lesions- cardiac, neurological, bone

• Endocrine effects

• Paraneoplastic effects

Infection

• Local effects of occlusion for example

pneumonia more common in patients with an

occluded airway

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

Presentation CXR Chest radiograph 2011

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

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

Measures to improve airway patency

• Cryotherapy

• Argon Laser

• Stenting

• Combination of above

Case Report 2

• 65 year old lady never

smoker

• Presented with pleuritic

chest pain

• Shortness of breath

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

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.

2. Hettiarachchi RJ et al Cancer. 1998 Jul 1;83(1):180-5.

1. Cornuz J et al Ann Intern Med 1996 15;125(10):785-93.

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

• Van Doormal et al 2011

• 3.5 % 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. 2011 Jan;9(1):79-

84

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 (anti-cardiolipin 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).

Case 3

• 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

Lungs and cancer

Pleural effusions

- Pleural aspiration

- Medical pleurodesis

- VATS pleurodesis

- Indwelling pleural drain

Indwelling drains

Case 4

• Mrs SS

• 74 year old lady recently retired

• 3 week history of increasing dyspnoea

• Ex-smoker

• PS 0

Management

• Pericardial aspiration ( therapeutic and diagnostic)

• Pericardiostomy ( pericardial window)

• Pericardial stripping

• Treat the malignancy

Pressure on local structures

• E.g. SVC obstruction

Further management

• SVC stent insertion

• Urgent need for biopsy

• High dose steroid treatment- consider timing

• Radiotherapy

Bony involvement

• Pain from metastatic lesions

• Pathological fractures

• Spinal cord compression

Case 5- bony lesions

• 91 year old gentleman

• Presented following a

fall

• Acute right hip pain on

a background of chronic

hip pain

MRI hip

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

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

Spinal Instability Neoplasia score

Fourney et al:

JCO 29, 22;

3072-3077

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

Imaging

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

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

Endocrine disturbance

• Hyponatremia

Medication

SIADH

Hypoadrenal due to adrenal metastates

• Hypercalcaemia

Bone mets

PTH related peptide

• Hyperkalaemia

Medication

ACTH producing tumour

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

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

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

Case 10

• 58 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.

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

Screening using low dose CT

• NSLT ( US)

• Nelson

• UKLS

Questions