Lung Cancer / Metastatic Disease
Definition & DDx
2WW referral if: - Weight/appetite loss
- Findings on CXR Consider urgent CXR in ≥40yo:
- ≥40 with unexplained haemoptysis - Persistent/recurrent chest
Offer urgent CXR in ≥40yo and ≥2sx or infection
≥1sx+smoker: - Finger clubbing
- Cough - Supraclavicular/persistent cervical
- Fatigue lymphadenopathy
- SOB - Chest signs consistent with Ca
- Chest pain - Thrombocytosis
Anatomy & Risks
SCLC – 15% cases; worse prognosis - Bronchial adenoma
- Usually central o Mostly carcinoid
NSCLC (hepatomegaly/flushing/
- Adenocarcinoma (most common) diarrhoea)
o Often seen in non-smokers
o Pleural effusion Risk factors
- Squamous - Smoking (tobacco and cannabis)
o Cavitating lesions - Passive smoking
o Hypercalcaemia - Occupational exposure
- Large cell o Asbestos
- Alveolar cell carcinoma o Silica
o ++sputum o Welding fumes
o Not related to smoking o Coal
- HIV
- Organ transplantation
- Radiation exposure (XR/gamma rays)
- B-carotene supplements in smokers
Symptoms & Complications
Symptoms o Consolidation (pneumonia)
- Cough o Collapse (absent breath
- Haemoptysis** sounds, ipsilateral tracheal
- Dyspnoea deviation)
- Chest pain o Pleural effusion (stony dull
- Weight loss percussion, decreased vocal
- N&V resonance/breath sounds)
- Anorexia - Paraneoplastic syndromes
- Hoarseness (Pancoast tumour) o Cushing’s/SIADH/Lambert-
Signs Eaton*/Addison’s–SCLC
- Cachexia o Hyperparathyroidism –
- Clubbing squamous cell
- Anaemia o Polyneuropathy
- Horner’s syndrome (apical tumour) o Cerebellar degeneration
- Lymphadenopathy *Abs against Ca channels causing
- Chest signs myasthenic syndrome
,Complications Investigations
- Thrombophlebitis migrans Sputum cytology/biopsy via bronchoscopy
- Mets – brain, breast, adrenals, bone CXR
- HPOA = hypertrophic pulmonary - Nodules
osteoarthropathy - Lung collapse
o Proliferative periostitis - Pleural effusion
involving long bones – painful - Consolidation
- SVC syndrome - Bony mets
- Horner’s syndrome Contrast CT
o Ptosis/miosis/anhidrosis - Including adrenals and liver for mets
o Enophthalmos/ Other
ophthalmoplegia - ADH/ACTH/Lambert-Eaton syndrome
o Can also be caused by carotid = SCLC
artery dissection - PTH-rp/ clubbing/ hyperthyroid/
hyperCa/HPOA = squamous
- Gynaecomastia/HPOA =
adenocarcinoma
- Raised platelets
Treatment/Management & Side effects
NSCLC
- PET scanning to establish eligibility for curative treatment
- Lobectomy 1st line
o CI: mets, malignant pleural effusion, tumour near hilum, vocal cord paralysis, SVC
obstruction, FEV1<1.5L
- Curative radiotherapy if stage I-III
- Palliative chemo if stage III-IV
SCLC
- Usually mets by time of diagnosis
**Other causes of haemoptysis
- Goodpasture’s
- Granulomatosis with Polyangiitis
- Pneumonia
- TB
- Aspergilloma
- Bronchiectasis
- PE
Metastasis – occurs through local invasion or haematogenous/LN spread
Bones = pain/fractures
Brain = headaches/seizures/neurological deficits
Lungs = cough/SOB/chest pain
, Pneumothorax
Definition & DDx Iatrogenic
Spontaneous - Medical procedures
- 1º = without underlying lung disease o Thoracocentesis
o Often tall, thin, young pts o CVC placement
o Rupture of subpleural bullae o Ventilation (including non-
- 2º = pre-existing lung disease invasive ventilation)
o COPD/asthma/CF/cancer/pneu o Lung biopsy
monia/CTD e.g., Marfan’s
Traumatic Anatomy & Risks
- Penetrating/blunt chest trauma Tension pneumothorax – displacement of
o Lung injury and air mediastinal structures resulting in severe
accumulation respiratory distress and haemodynamic
compromise
Symptoms & Complications
Sudden onset - Tachypnoea/tachycardia
- Dyspnoea Tension pneumothorax
- Pleuritic chest pain - Respiratory distress
- Hyper-resonant lung percussion - Tracheal deviation away from side of
- Reduced breath sounds/lung pneumothorax
expansion - Hypotension
Treatment/Management & Side effects
Asymptomatic/minimal symptoms = conservative management regardless of pneumothorax
size
Tension pneumothorax = life-threatening emergency
Symptomatic:
- High risk characteristics and safe to intervene = chest drain
o Haemodynamic compromise
o Significant hypoxia
o Bilateral pneumothorax
o Underlying lung disease
o ≥50yo significant smoking hx
o Haemothorax
- No high-risk characteristics and safe to intervene = choice of conservative/ambulatory
device/needle aspiration
o Ambulatory device e.g., pleural vent
o Insert chest drain if needle aspiration unsuccessful
Safe to intervene if of sufficient size:
- 2cm laterally/apically on CXR
- Any size on CT which radiology can safely access
Fit to fly 2wks after successful drainage with no residual air, scuba diving permanently
avoided
Referral for pleurodesis if recurrence
Definition & DDx
2WW referral if: - Weight/appetite loss
- Findings on CXR Consider urgent CXR in ≥40yo:
- ≥40 with unexplained haemoptysis - Persistent/recurrent chest
Offer urgent CXR in ≥40yo and ≥2sx or infection
≥1sx+smoker: - Finger clubbing
- Cough - Supraclavicular/persistent cervical
- Fatigue lymphadenopathy
- SOB - Chest signs consistent with Ca
- Chest pain - Thrombocytosis
Anatomy & Risks
SCLC – 15% cases; worse prognosis - Bronchial adenoma
- Usually central o Mostly carcinoid
NSCLC (hepatomegaly/flushing/
- Adenocarcinoma (most common) diarrhoea)
o Often seen in non-smokers
o Pleural effusion Risk factors
- Squamous - Smoking (tobacco and cannabis)
o Cavitating lesions - Passive smoking
o Hypercalcaemia - Occupational exposure
- Large cell o Asbestos
- Alveolar cell carcinoma o Silica
o ++sputum o Welding fumes
o Not related to smoking o Coal
- HIV
- Organ transplantation
- Radiation exposure (XR/gamma rays)
- B-carotene supplements in smokers
Symptoms & Complications
Symptoms o Consolidation (pneumonia)
- Cough o Collapse (absent breath
- Haemoptysis** sounds, ipsilateral tracheal
- Dyspnoea deviation)
- Chest pain o Pleural effusion (stony dull
- Weight loss percussion, decreased vocal
- N&V resonance/breath sounds)
- Anorexia - Paraneoplastic syndromes
- Hoarseness (Pancoast tumour) o Cushing’s/SIADH/Lambert-
Signs Eaton*/Addison’s–SCLC
- Cachexia o Hyperparathyroidism –
- Clubbing squamous cell
- Anaemia o Polyneuropathy
- Horner’s syndrome (apical tumour) o Cerebellar degeneration
- Lymphadenopathy *Abs against Ca channels causing
- Chest signs myasthenic syndrome
,Complications Investigations
- Thrombophlebitis migrans Sputum cytology/biopsy via bronchoscopy
- Mets – brain, breast, adrenals, bone CXR
- HPOA = hypertrophic pulmonary - Nodules
osteoarthropathy - Lung collapse
o Proliferative periostitis - Pleural effusion
involving long bones – painful - Consolidation
- SVC syndrome - Bony mets
- Horner’s syndrome Contrast CT
o Ptosis/miosis/anhidrosis - Including adrenals and liver for mets
o Enophthalmos/ Other
ophthalmoplegia - ADH/ACTH/Lambert-Eaton syndrome
o Can also be caused by carotid = SCLC
artery dissection - PTH-rp/ clubbing/ hyperthyroid/
hyperCa/HPOA = squamous
- Gynaecomastia/HPOA =
adenocarcinoma
- Raised platelets
Treatment/Management & Side effects
NSCLC
- PET scanning to establish eligibility for curative treatment
- Lobectomy 1st line
o CI: mets, malignant pleural effusion, tumour near hilum, vocal cord paralysis, SVC
obstruction, FEV1<1.5L
- Curative radiotherapy if stage I-III
- Palliative chemo if stage III-IV
SCLC
- Usually mets by time of diagnosis
**Other causes of haemoptysis
- Goodpasture’s
- Granulomatosis with Polyangiitis
- Pneumonia
- TB
- Aspergilloma
- Bronchiectasis
- PE
Metastasis – occurs through local invasion or haematogenous/LN spread
Bones = pain/fractures
Brain = headaches/seizures/neurological deficits
Lungs = cough/SOB/chest pain
, Pneumothorax
Definition & DDx Iatrogenic
Spontaneous - Medical procedures
- 1º = without underlying lung disease o Thoracocentesis
o Often tall, thin, young pts o CVC placement
o Rupture of subpleural bullae o Ventilation (including non-
- 2º = pre-existing lung disease invasive ventilation)
o COPD/asthma/CF/cancer/pneu o Lung biopsy
monia/CTD e.g., Marfan’s
Traumatic Anatomy & Risks
- Penetrating/blunt chest trauma Tension pneumothorax – displacement of
o Lung injury and air mediastinal structures resulting in severe
accumulation respiratory distress and haemodynamic
compromise
Symptoms & Complications
Sudden onset - Tachypnoea/tachycardia
- Dyspnoea Tension pneumothorax
- Pleuritic chest pain - Respiratory distress
- Hyper-resonant lung percussion - Tracheal deviation away from side of
- Reduced breath sounds/lung pneumothorax
expansion - Hypotension
Treatment/Management & Side effects
Asymptomatic/minimal symptoms = conservative management regardless of pneumothorax
size
Tension pneumothorax = life-threatening emergency
Symptomatic:
- High risk characteristics and safe to intervene = chest drain
o Haemodynamic compromise
o Significant hypoxia
o Bilateral pneumothorax
o Underlying lung disease
o ≥50yo significant smoking hx
o Haemothorax
- No high-risk characteristics and safe to intervene = choice of conservative/ambulatory
device/needle aspiration
o Ambulatory device e.g., pleural vent
o Insert chest drain if needle aspiration unsuccessful
Safe to intervene if of sufficient size:
- 2cm laterally/apically on CXR
- Any size on CT which radiology can safely access
Fit to fly 2wks after successful drainage with no residual air, scuba diving permanently
avoided
Referral for pleurodesis if recurrence
