Lung cancer case study

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1 Change Presentation title and date in Footer dd.mm.yyyy Lung cancer case study Dr Jaishree Bhosle Consultant Medical Oncologist Change Presentation title and date in Footer dd.mm.yyyy 1

2 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 0% 0% 0% 0% 4-10% 25-36% 43-58% 58-73% 10

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) Groups 5,6&7 Refreshment area, ground floor

5 Change Presentation title and date in Footer dd.mm.yyyy Lung cancer case study: panel discussion Dr Jaishree Bhosle Dr Afsana Safa Karon Payne Change Presentation title and date in Footer dd.mm.yyyy 5

6 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 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 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 9 Q3. What investigations could you perform at this stage if any? None CXR if not done recently Spirometry FBC

10 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 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 12 Q5. From her presentation, does she have any symptoms which suggest a diagnosis of lung cancer Chest pain Weight loss

13 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 surgery may be an option.

14 14 Q1. She is concerned that more tests are being done and 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 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 16 Q3. Where does lung cancer commonly metastasise to? Liver Bone Brain Adrenals Other parts of the lung Lymph-nodes

17 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 Sterotatic ablative radiotherapy (SABR)

18 18 If she elects to undergo surgery what are the 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 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 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 appointment with oncology is in two months time.

20 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? % % % % 0% 0% 0% 0% 4-10% 25-36% 43-58% 58-73% 10

22 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 1A 1B 2A 2B 3A 3B 5-year survival ~ 58-73% ~ 43-58% ~ 36-46% ~ 25-36% ~ 19-24% ~ 7-9% 4 ~ 4-10%

23 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 chemotherapy

24 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 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 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 Autoimmune conditions e.g. Rheumatoid arthritis

27 27 Key learnings Symptoms of lung cancer Cough Haemoptysis Dyspnoea Weight loss Chest pain Shoulder pain Fatigue Hoarse voice Finger clubbing Cervical/supraclavicular lymph nodes

28 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 diseaseunremitting pain, weight loss, shortness of breath.

29 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 Mediastinocopy or EBUS for nodal staging

30 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 Change Presentation title and date in Footer dd.mm.yyyy Thank you Any questions?

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