Transcript presentation source

‘When is a stroke not a
stroke?’
Danielle Hann
Lucinda Lacey
Anthony Li
Emma Briggs
Samu Pekwa
History
79 year old Female
Referred by GP 3/52 ago to A&E with
?cord compression
P/C
Right arm pain
Right sided weakness
History
HPC
4/52 right arm pain
3/52 right leg weakness
gradual onset
Finding mobility increasingly difficult
Presented to another A&E 2/52 prior with
weakness but sent home
Weakness progressively worsened
Dizziness for 5 years but worse in last
3/52
History
HPC contd.
40 year Hx of cervical spondylosis
Negative signs
Haemoptysis
Paraesthesia
Bladder/bowel dysfunction
Sensory level
No falls
No visual problems
• double vision, blurred vision
History
PMH
TB with lymph node excision as child
Rheumatic fever as child
40 year Hx cervical spondylosis
DH & Allergies
Nil
NKDA
History
SH
Lives with Husband (Well)
Maisonette - bed and bathroom on top floor
Previously fully independent in ADLs
Husband does cooking and cleaning
2/52 prior to admission started using 1 stick for
walking and chair transfers
Ex smoker
stopped 8 years ago
45 pack year Hx
Alcohol
Nil
Examination
On admission - from notes
 General
Well
Afebrile
No weight loss
 Resp
Sats - 96% on air
No clubbing/cyanosis
Trachea central
Bilat air entry
No creps/wheeze
FEV1 36% predicted
FVC 56% predicted
PEF 22% predicted
 CVS
P 80 reg
BP - 170/66
HS I + II + 0
JVP 
No murmur/No carotid
bruit
 Abdo
Soft & non-tender
No organomegaly
Bowel sounds present
Examination
 Neuro
Left upper and lower limbs all 5/5
Wasting of small muscles of right hand
Tested
RUL
Power
Tested
RLL
Power
Shoulder
abduction
Elbow flexion
Elbow
extension
Finger flexion
Wrist flexion
0/5
Hip flexion
3/5
3/5
0/5
3/5
3/5
Wrist
extension
0/5
Hip extension
Knee
extension
Knee flexion
Ankle
dorsiflexion
Ankle
plantarflexion
3/5
3/5
3/5
4/5
4/5
Examination
Neuro contd
Reflex
Brachial
Supinator
Triceps
Knee
Ankle
Plantars
Right
+++
++
+++
+++
++

Left
++
++
++
++
++

Tone and sensation normal
No clonus
Examination
Neuro contd
No hoarseness of voice
CN II - XII
No ptosis/Normal pupillary reactions
Hoffmans -ve bilaterally
No deep finger flexor reflex
No pectoral reflex
Neck
No tenderness or pain on movement
Impression and Plan
Impression
Left hemisphere CVA
Wasting/no extensor plantars  ?UMN
Spinal cord compression
No bladder or bowel dysfunction or sensory level
Plan
Bloods - FBC; U&E; Glucose; LFTs; CRP;
Cholesterol
C-spine and Chest x-ray (AP and Lateral)
Results
Bloods
Hb
WCC
Plt
MCV
ESR
CRP
14.8
8.6
275
85
21
3.0
Na
K
Cl
Bicarb
Urea
Creat
135
4.2
96
29
4.7
75
Glucose
Bilirub
ALT
ALP
Alb
Ca
5.8
10
8
66
37
2.32
Chol
TG
HDL
LDL
7.1
0.68
2.0
4.8
Results contd
 CXR
Features consistent
with old TB in RUZ
Lesion in RMZ
peripheral, well
demarcated, 2cm
nodule
No rib involvement
No hypertrophic
pulmonary
osteoarthropathy
Revised Plan
CXR results and
neurological signs
indicate
CT Head
CT Chest
CT guided biopsy
(peripheral lesion)
CT brain
Results
CT head
Ring enhancing cystic mass in left petrous region consistent
with cystic tumour or abscess (?old TB)
CT chest
probable lung primary
right hilar lymph node
Biopsy histology
Poorly differentiated squamous cell carcinoma
(Non-small cell carcinoma)
Drug Treatment
Ramipril
Dexamethasone
Simvastatin
Ranitadine
Lanzoprazole
Management plan
Neurosurgical opinion
?burr hole or craniostomy to drain cyst
?Radiotherapy
Adjuvant brain
Palliative lung
No chemotherapy
Home with large care package ASAP
Lung Cancer
Background
Leading cause of cancer-related mortality
in both men and women.
Diagnosis at an advanced stage.
Smoking-related damage to the heart and
lungs, making aggressive surgical or
multimodality therapies less viable
options.
Epidemiology
Men >Women (37.5 vs. 10.8 new
cases/million)
Most common malignancy-related deaths
in men and women.
17.8% of cancer-related deaths
Aetiology
Smoking:
Cigarette smoke contains N-nitrosamines and aromatic
polycyclic hydrocarbons.
hydroxylated by the P-450, leading to formation of
carcinogens that cause formation of DNA adducts.
78% in men and 90% in women.
risk is 13.3 times that of a person who has never smoked.
varies with the number of cigarettes smoked.
After quitting, risk increases for the first 2 years and then
gradually decreases, but never returns to the same level.
Aetiology
Passive smoking:
15% of the lung cancers in nonsmokers are
believed to be caused by secondhand smoke.
Asbestos: x5 risk. Synergistic.
Radon
Others: Aromatic polycyclic hydrocarbons,
beryllium, nickel, copper, chromium,
cadmium, and diesel exhaust.
Classification
Upper tract:
Tracheal
Laryngeal
Lower tract:
Bronchial- most common primary (90-95%)
Carcinoid
Metastatic
Pleural tumours.
Classification
Bronchogenic
Small (Oat) Cell
~20%
Adenocarcinoma
35-40%
Non-Small Cell
~80%
Squamous
25-30%
•SCLC exhibits aggressive behaviour:
•rapid growth,
•early spread to distant sites,
•exquisite sensitivity to chemotherapy and radiation
•frequent association with distinct paraneoplastic syndromes.
•Surgery usually plays no role in its management
Large-cell
10-15%
Pathophysiology
Amplification of oncogenes and inactivation of
tumor suppressor genes in NSCLC.
Mutations involving the ras family of oncogenes.
3 members: H-ras, K-ras, and N-ras. Encode a
protein on the inner surface of the cell with
GTPase activity and may be involved in signal
transduction.
Almost exclusive to adeno Ca (30% 0f cases).
Natural History
Cytological Atypia
Piling of bronchial mucosa
Irregular, warty, erosive lesion
Fungates
Intra-luminal mass
Rapid penetration,
infiltration of peribronchial
tissue.
•Tissue:
•greyish white
•haemorrhagic
•Necrosis-cavitating
Intraparenchymal
mass (caulifower)
•Spread:
•Lymphatic
•Haematogenous
Histology
Adenocarcinomas:
form glands and produce mucin.
Identified with mucicarmine or periodic acidSchiff (PAS) staining.
WHO classification of adeno Ca:
(1)
(2)
(3)
(4)
acinar
papillary
bronchoalveolar
mucus secreting
Histology
Squamous cell carcinoma:
distinct dose-response relationship to tobacco
smoking
usually develops in proximal airways, classically
presents as a cavitary lesion
Type most often associated with hypercalcemia.
Progresses through stages of squamous
metaplasia to carcinoma in situ.
Well-differentiated squamous cell carcinomas
contain keratin pearls.
Histology
Squamous Cell:
Microscopic examination reveals cells with
large irregular nuclei and coarse nuclear
chromatin with large nucleoli.
Cells are arranged in sheets and intercellular
bridging is diagnostic.
Histology
Large Cell:
Typically presents as a large peripheral mass
on CXR.
Histologically, sheets of highly atypical cells
with focal necrosis, with
No evidence of keratinization or gland
formation
Patients with large cell carcinoma are more
likely to develop gynecomastia and
galactorrhea
Prognosis
 Estimated 5-year survival rates:
 Stage IA - 75%
 Stage IB - 55%
 Stage IIA - 50%
 Stage IIB - 40%
 Stage IIIA - 10-35%
 Stage IIIB - <5%
 Stage IV - <5%
In Europe, the 5-year overall survival is
8%
Prognostic Factors
Tumour related:
Physical
Stage/Grade
Biochemical
Molecular
Haematological
Host related:
Age
Sex
Performance Status
Weight loss
Presentation
Local effects of tumour in bronchus
Spread to mediastinum
Spread to pleura and chest wall
Spread to lymph nodes
Distant blood bourne metastases
Paraneoplastic (non-metatastic)complications
Local effects of tumour in
bronchus
1, Cough.
2, Haemoptysis.
3, Bronchial narrowing
4, Distal collapse
5, Finger clubbing
Spread to mediastinum
1, Left recurrent laryngeal nerve paralysis
2, SVC obstruction
3, Compression of oesophagus
4, Phrenic nerve paralysis
5, Pericardial invasion
Spread to pleura and chest wall
1, Pleural effusion
2, Chest wall pain
3, Pancoast tumours
Pain in T1 dermatome
Wasting in small muscles of hand
Horner’s syndrome
Spread to lymph nodes
1, Hilar lymphadenopathy – bronchial narrowing, retrograde
obstruction of pulmonary lymphatics (lymphangitis carcinomatosis)
2, Mediastinal lymphadenopathy – can compress and invade
other mediastinal structures.
Distant blood-borne metastases
Bone, liver, brain, adrenal glands, skin.
Paraneoplastic complications
1, Pulmonary hypertrophic osteoarthropathy
2, Endocrine syndromes – Cushings, hypercalcaemia,
gynaecomastia.
3, Neuromuscular syndromes - Peripheral neuropathy, cerebellar
dysfunction, dermatomyositis.
Investigations
Imaging
Laboratory studies
Procedures
Imaging
Chest X-ray
Hilar lymphadenopathy, area of pulmonary collapse, unresolved pneumonia,
pleural effusion, lung abscess, peripheral mass, lymphangitis carcinomatosis,
eroded ribs.
Squamous cell carcinoma may be radiologically occult. It is slow growing
and usually presents as a central mass that may cavitate.
CT + MRI
Chest and upper abdomen
Brain
Bone scintigraphy
Laboratory studies
Sputum cytological studies
False-positive rate for sputum cytology is 1%
False-negative rate is as high as 40%.
Full blood count, LFTs
Electrolytes
Procedures
1, Bronchoscopy
Establishes diagnosis and position of the tumour in the bronchial tree in over 70%
2, Mediastinoscopy
3, Thoracoscopy
4, CT-guided biopsy
5, Biopsy of other sites
eg, enlarged palpable lymph nodes, liver, pleural and pericardial effusions.
Staging
Primary tumour (T) TX
Malignant cells in bronchial secretions, no other
evidence of tumour
Tis
Carcinoma in situ
T0
None evident
T1
<3cm, in lobar or more distal airway
T2
>3cm / 2cm distal to carina / any size if pleural
involvement or obstructive pneumonitis extending to hilum,
but not all the lung
T3
Involves the chest wall, disphragm, mediastinal pleura,
pericardium / 2cm from, but not at carina
T4
Involves the mediastinum, heart, great vessels, trachea,
oesophagus, vertebral body, carina / malignant effusion is
present
Staging
Regional Nodes (N)
Distant metastasis (M)
N0
None involved (after mediastinoscopy)
N1
Peribronchial and/or ipsilateral hilum
N2
Ipsilateral medistinum or subcarinal
N3
Contralateral mediastinum or hilum,
scalene or supraclavicular
M0
None
M1
Present
Staging
Stage
Tumour
Lymph Nodes
Metastasis
Occult
TX
N0
M0
I
Tis, T1 or T2
N0
M0
II
T1 or T2
N1
M0
IIIa
T3
N0 or N1
M0
T1-T3
N2
M0
T1-T3
N3
M0
T4
N0-N3
M0
T1-T4
N0-N3
M1
IIIb
IV
TREATMENT
Depends upon a variety of factors such
as:
 Histopathologic type
 Tumour stage and characteristics
 Individual’s general health
Medical problems that may affect treatment
Non-Small cell Lung
Carcinoma
Surgical resection is best potentially curative
therapy
Only in those:
 Whose tumour is resectable
 With adequate respiratory reserve
 Without a major medical contraindication to surgery
 An agreeable patient
N.B. For those who are not fit for surgery, Radiation
and/or Chemotherapy are considered. Unresectable
stage 3 treated with combined radio- and
chemotherapy.
Limited Small Cell Lung
Cancer
Highly chemosensitive
Combination chemotherapy and Thoracic
irradiation +/- prophylactic cranial irradiation is
standard therapy for patients with limited SCLC.
Radiotherapy reduces local recurrence by 50%,
but still with isolated local failure rates between
25% to 30%
Surgery may improve control at the local site.
Limited Small Cell Lung
Cancer
5 - 10% of SCLC cases are found in combination
with other lung cancer histologies including
adenocarcinoma or squamous cell carcinoma.
Surgery may be necessary to treat the nonsmall cell component.
Late recurrences may be of non-small cell type
(a new primary) and may be treated surgically if
standard criteria for operability are met.
Extensive Small Cell Lung
Cancer
Chemotherapy:
- Rarely curative
- Significantly improve survival
- Palliative
- The optimal induction are either Etoposide
with Cisplatin or Cytoxan, Doxorubicin and
vincristine.
Surgery has little role to play in stage 3 tumours
as it does not significantly contribute to longterm survival.
Lung Cancer in the Elderly
80% are of NSCLC
Less aggressive treatment
Quality of life is equally important
Radiation therapy is valuable for both
types
Monochemotherapy is more approppriate
in those over 75.
Unresectable NSCLC stage 3 best treated
with combined chemo- and radiotherapy
Lung Cancer in the Elderly
Limited stage SCLC treated combination
chemotherapy and radiotherapy
Recent minimally invasive techniques
more suitable
Age alone is not a factor in determining
the best operative procedure for lung
cancer
Good health is essential to tolerate
treatment
Palliative care
Multidisciplinary approach
Psychological support
Symptom control essential
(Pain, Nausea, Vomiting,
Anorexia,
Malaise,Weakness, Bowel obstruction,
Respiratory symptoms, etc.)