pneumonia and lung cancer

8/12/2019 Pneumonia and Lung Cancer

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Multidisciplinary Case-Based

Teaching

Prof. S. ONeill

Dr. D. RoystonDr. S. Shaikh


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MEDICINE


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Case

68 year old male

Presents to the Emergency Department with

increasing shortness of breath

Cough productive of green sputum

Chest pain on deep inspiration

Myalgia

Poor appetite


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On Examination

Temp 38.4C

Heart Rate 110bpm

Respiratory Rate 32rpm

O2Saturations 88% on room air

Blood Pressure 110/64mmHg


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On Examination

Decreased chest expansion bilaterally

Dullness to percussion over left lower lobe

Increased vocal resonance Bronchial breath sounds

Coarse crepitations

DIAGNOSIS

COMMUNITY ACQUIRED PNEUMONIA


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Initial Laboratory Investigations

FBC

WCC 16 (4-11)

Hb 11 (13-15)

Plts 300 (150-400)

Renal Profile

Urea 15 (4-7mmol/L)

Creatinine 94 (70-

110mol/L)

CRP raised

LFTsnormal

Blood cultures sent

ABG

pH 7.40 (7.35-7.45)

pCO25.8 (4.7-6kPa)

pO27.8 (11-13kPa)

Sputum cultures sent


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Contamination (saliva)

This is not sputum! No conclusion is possible.Please repeat the sampling


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S. pneumoniae!


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RADIOLOGY
http://www.google.ie/url?sa=i&rct=j&q=radiologist+cartoon&source=images&cd=&cad=rja&docid=rH8uEhFMw-RRxM&tbnid=PoEu0wMEMjEgZM:&ved=0CAUQjRw&url=http://www.zjobs.com.au/2007-11/&ei=MqRmUf-rEtSShgeX2IE4&bvm=bv.45107431,d.ZG4&psig=AFQjCNEpKmn4EXl7DcavzCiNxnVCAOnnfw&ust=1365767590609802


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Radiology

Is there a need to image this patient?

Yes

No


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Radiology

What modality will you use for imaging?

MRI

Nuclear Medicine

CT

Ultrasound


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Radiology

What does a normal chest x-ray (radiograph) look like?


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Radiology


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Radiology


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Radiology

Radiology take-home points:

Pneumonia is more opaque than normal lung

Margins may be fluffy and indistinct Affected areas homogenous in density

May contain air-bronchgrams


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PATHOLOGY


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Primary functions of the lungs:

Oxygenation of blood and

Removal of carbon dioxide

Inspired air leads to

Exposure to infection Pollutants


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Defences

Cough reflex

Upward flow of mucus

Ciliated epithelium

IgA secretion

Phagocytic activity of alveolar macrophages


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Pneumonia

Inflammatory condition of lung with

consolidation due to an inflammatory exudate

(air spaces involved)

Usually caused by bacterial infection

Pneumonia used to be known as The

CAPTAIN OF THE MEN OF DEATH(OSLER)


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Bronchopneumonia is a disease of the

extremes of lifeElderly and very young are particularly

susceptible

In the elderly other diseases may be present

e.g. Cancer, COPD, stroke

In the young the immune system may be

immature


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Classification - Two Types

1. Source of organism

Community acquired or

Hospital acquired (nosocomial)

2. Anatomical

Bronchopneumonia

Lobar


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Sites Affected

GROSS FINDINGS

Lower lobes

Unilateral or bilateral

Discrete patchy

MICROSCOPIC

Polymorphs in alveoli and

small bronchi


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Lobar Pneumonia RARE

Neglected people

Alcoholics

Male > Female 3:1

30 - 50 years (Common in third world)


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Complications of Pneumonia

RESPIRATORY AND CIRCULATORY

FAILURE

ACUTE RESPIRATORY DISTRESS

SYNDROME

SEPTIC SHOCK


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Complications of

Pneumonia Spread to pleura

- Effusion

- Empyema

Lung abscess

Bacterial endocarditis,meningitis, otitis, arthritis.


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Pathogenetic Factors

Aetiologic Agent - Some bacteria more

virulent than others

Host Reaction - may be compromised due to

associated illness

Extent of involvement -This is closely related

to the above factors


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Prevention

APPROPRIATE TREATMENT OF

UNDERLYING ILLNESS eg. AIDS

SMOKING CESSATION

VACCINATIONS


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MEDICINE


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Show of hands.

Should this patient be admitted to hospital?

YES

NO


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Hospital Admission Assessment

Scores

CURB-65 criteriaConfusion

Urea 7 mmol/L

Increased respiratory rate >30

Low blood pressure (SBP


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CURB 65Management of CAP

CURB 65

Confusion

BUN > 11RR > 30

BP

SBP


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Assignment to risk class based on the PSI

Aujesky D , Fine M J Clin Infect Dis. 2008;47:S133-S139


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CAPOutpatient Treatment Options

Previously healthy and no use of antimicrobials withinthe previous 3 months A macrolide (strong rec; level 1 evidence)

Doxycycline (weak rec; level 3 evidence)

Presence of comorbidities or use of antimicrobials withinthe previous 3 months Fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin)

A -lactam plus a macrolide (strong rec; level 1)

In regions with a high-rate of macrolide-resistant Strep.pneumoniae, consider treatment as patients with co-morbidities

Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensusguidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27.

Mandell LA, et al. Clin Infect Dis 2007; 44 Suppl 2:S27.


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CAP Inpatient Treatment Options

Non-ICU

Fluoroquinolone

-lactam plusmacrolide

ICU

-lactam plusazithromycin/fluoroquinolone

Fluoroquinolone+ aztreonam



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CAP Common Pathogens


Patient type Aetiology

Outpatient Streptococcus pneumoniae

Mycoplasma pneumoniae

Haemophilus influenzae

Chlamydophila pneumoniae

Respiratory viruses

Inpatient (non-ICU) S. pneumoniae

M. pneumoniae

C. Pneumoniae

Legionellaspecies

Aspiration

Respiraoty viruses

Inpatient (ICU) S. Pneumoniae

Staphylococcus aureus

Legionellaspecies

Gram-negative bacilli

H. influenzae


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Department of Medicine,

RCSI

Systemic Complications

Hyponatraemia (any, esp legionella)

Haemolytic anaemia (mycoplasma)

GI features: diarrhoea, abdominal pain (legionella)

Headache (mycoplasma) Pericarditis, myocarditis (mycoplasma)

LFTs abnormalities, hepatitis

Renal failure (esp. Legionella)


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Patient Progress

Our patient responded well to therapy

Discharged home

Returns six weeks later for follow-up

including repeat chest x-ray


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Clinical Significance

the most widespread and fatal of all acute diseases,pneumonia is now Captain of the Men of DeathOsler, 1901

Leading infectious cause of death

5 million deaths/year worldwide

Mortality rate Outpatient: 5%

Inpatient: 12%

ITU: 40%


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RADIOLOGY
http://www.google.ie/url?sa=i&rct=j&q=radiologist+cartoon&source=images&cd=&cad=rja&docid=rH8uEhFMw-RRxM&tbnid=PoEu0wMEMjEgZM:&ved=0CAUQjRw&url=http://www.zjobs.com.au/2007-11/&ei=MqRmUf-rEtSShgeX2IE4&bvm=bv.45107431,d.ZG4&psig=AFQjCNEpKmn4EXl7DcavzCiNxnVCAOnnfw&ust=1365767590609802


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Radiology


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Radiology

Differential Diagnosis:

Mediastinal origin

1.Anterior: thymoma, teratoma, thyroid goitre, (terrible) lymphoma

2.Middle: lymphadenopathy, aortic aneurysms

3.Posterior: neurogenic tumors (neurofibroma, ganglioneuroma, neuroblastoma)

Pulmonary origin

1.Malignant (adenocarcinoma, squamous cell carcinoma, large cell carcinoma)

2.Benign (granuloma, hamartoma)

Lung collapse

Effusion


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Radiology

Way forwardfurther assessment of nature of

lesion; rule out malignancy

What imaging will you further do:

a. Another x-ray 6 months later

b. Urgent CT

c. Ultrasound

d. Surgery


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Radiology


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What next?

Radiology


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CT-guided percutaneous biopsy

Radiology


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Radiology


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PATHOLOGY

T


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Lung Tumours

B i T


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Benign Tumours

Rare

EXAMPLE Hamartoma

Tumour usually composed of a mixture of cartilage andepithelium

M li L T


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Malignant Lung Tumours

COMMON

Commonest fatal cancer

in males

Second to breast in

females

Causes more deaths than

breast & colon combined

7% of cancer deaths

I id i I l d


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Incidence in Ireland

1995 940 cases

1996 958 cases

1997 919 cases

1998 1002 cases 2005 1831 cases

Rising incidence in women

Accounts for 13% of cancer deaths in men,7% in women.

A i l


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Aetiology

CIGARETTE SMOKING

CITY LIVING

INDUSTRIAL EXPOSURE

Asbestos

Haematite

Chromate

Ci S ki


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Cigarette Smoking

25 Cigarettes a day x many years12% risk of cancer

M d f A i f Ci


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Mode of Action of Cigarettes

Tar contains 18 hydrocarbons

Many hydrocarbons lead to skin cancer in

laboratory animals

It is an example of a chemical carcinogen

L n n r l kn n


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Lung cancer also known asBRONCHOGENIC CANCER

(Bronchial cancer)Majority arise from major bronchi

Di M


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Distant Metastases

Lymph nodes - axilla, cervical, other

Bone

Liver

Brain

Adrenal

Skin

Other

Di i


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Diagnosis

Sputum Cytology Malignant cells shed from

bronchus and may be seen in sputum

Bronchial washings/brushings/biopsy

2/3 of patients have visible lesion atbronchoscopy

Trans thoracic biopsyFNA - For diagnosis

of peripheral tumours

Sh f h d


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Show of hands...

What is the most common type of lung

cancer?

A. Large cell carcinoma

B. Small cell carcinoma

C. Squamous cell carcinoma

D. Adenocarcinoma

Hi t l i T


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Histologic Types

Squamous cell carcinoma35-50%

Small cell carcinoma 20-

30%

Adenocarcinoma 15-30%

Large cell carcinoma 10-

15%


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Normal columnar epithelium undergoes

metaplasia to a squamous type due

to irritant effect of tobacco

B h i r f Diff r t T p


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Behaviour of Different Types

? Increasing incidence of adenocarcinoma-

may be due to different chemical composition

of cigarettes

Adenocarcinomas are more slowly growing Grow from 1-3 cm in 36 months

Squamous carcinomas take 16 months

Small cell - rapidly growing tumour

R nt Ad n s in M l l r


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Recent Advances in Molecular

Diagnosis

EPIDERMAL GROWTH FACTOR

RECEPTOR (EGFR) MUTATIONS Identified

in some adenocarcinomas DRUGS HAVE BEEN DEVELOPED

TARGETTING THIS RECEPTOR WITH

SOME DRAMATIC RESPONSES CHALLENGE IS TO IDENTIFY

ACCURATELY THESE TUMOURS


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Major distinction is between small cell

and non-small cell carcinoma

Prognostic and treatment differences

AUDIT Beaumont hospital


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AUDIT Beaumont hospital

1 year 198 cases

118 males, 80 females

198 cases

Mean age 68 years

150 cases non-small cell carcinoma

33% squamous,25% adenocarcinoma

17% small cell carcinoma

84% of non-small cell tumours stage 3 or 4

Conclusions


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Conclusions

LUNG CANCER MOST COMMON CAUSEOF CANCER GLOBALLY

1 MILLION DEATHS PER YEAR

15 % PATIENTS SURVIVE 5 YEARS ORMORE

HIGH MORTALITY DUE TO EARLY AND

WIDESPREAD CANCER DISSEMINATION


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MEDICINE


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Diagnosis Definitive


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Diagnosis - Definitive

Contrast-enhanced computed tomography(CT) through lungs, liver, and adrenal glands

Bronchoscopy, Broncho-alveolar lavage

(washings sent for cytology) and biopsy-histo-pathological diagnosis is imperative


RCSI

Diagnosis - Staging


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Diagnosis - Staging

Staging of NSCLC grades the primary tumour characteristics (T),

presence or absence of regional lymph nodeinvolvement (N),

and presence or absence of distant metastasis(M)

The combination of T, N, and M grades

determines the overall disease stage (stage Ithrough IV)


RCSI

Diagnosis - Staging


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Diagnosis - Staging

1. Contrast enhanced CT (as before)2. Regional lymph nodes:

1. Endobronchial ultrasound

2. Transesophageal endoscopic ultrasound

3. Transbronchial needle aspiration

4. Cervical mediastinoscopy3. Pleural tap- if pleural effusion present, confirmation of malignant

cells on cytology is mandatory in all patients with NSCLC if thisdetermination influences the disease stage.

4. Radioisotope Bone scan- Bony metastases

5. PET scanning


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Diagnosis - Complications


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Diagnosis Complications

Chest X ray- coin-shaped lesion: rare

CBC- anaemia due to malignancy, leucocytosis due to

post-obstructive pneumonia

Calcium, phosphate, magnesium profile-

Hypercalcaemia due to PNS or due to bony metastases

PFTs- especially important if considering resection

ESR,CRP- often raised

ABG- assessment of functional status


RCSI

CT Peripheral Tumour


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CT Peripheral Tumour


RCSI

CT PET: Tumour in RUL affecting local ribs and


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g

left adrenal


RCSI


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Any questions?

pneumonia and lung cancer

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