Download Acute Oncology and the Chest Physician

Acute Oncology and the Chest
Physician
Neil Munro
Consultant Respiratory Physician
UHND
Acute Oncology
What’s that all about?
Is acute oncology new or different?
Or simply what attentive physicians have
always done?
Plus an attempt to standardise best practice
for all patients with malignant disease
From the perspective of this chest physician:
• Lung cancer is common
• Cancer in the lung is common
• Lung cancer is commonly found when
investigating or managing other diseases
in all other specialities
• Being common, lung cancer often
presents on the acute medical take
And…………
• (for those of us of a certain age) B.O.
(before oncologists) chest physicians often
gave their own chemotherapy and hence
were accustomed to dealing with the
complications thereof
• BPCP (before palliative care physicians)
looked after our patients from diagnosis to
grave, with some exceptions!
So some examples from my own
recent practice #1
Mr B
In his late 50’s, reclusive, smokes, drinks,
works as a gardener in the summer
months
Presents to ED with syncope. Rapidly
recovers. Nil to find on examination.
Na 126
CXR left apical shadow ?infection ?mass
#1
Histology NSCLC
Final staging T2N2M0
FEV1 < 50% predicted
Referred for chemo +/radiotherapy
#2 more of the same
Mr I
67. Looks after his mum (in her 90’s) who
calls the ambulance because her son is
“confused”. Smokes, doesn’t drink. Denies
other symptoms, though probably
increased breathlessness
O/E mildly unreasonable. Not clubbed. No
neurology. Nil else.
Na115
#2
#2 more of the same
Histology again NSCLC
CT staging T4N1M1b
Referred for Chemo/radiotherapy
Sodium improved with fluid restriction and
Demeclocyclene to normal in 10 days
PE treated with LMWH long term
#3 pseudo acute oncology
Mr S
Late 60’s, retired builder. Admitted via GP
with possible spinal cord compression
(abnormal T spine X ray) and an abnormal
CXR (bulky left hilum)
Smoker
Lives alone
#3 pseudo acute oncology
#3 continued
Alcohol foetor
Back pain since fell at Christmas
Minor cough of chronic bronchitis
No sinister symptoms
No neurology
#4 by the by in out patients
Mr P
Known melanoma
Recurrent cough and sputum “chest
infection”, routine referral
Clinically suspected bronchiectasis.
HRCT chest and return to clinic
#4 by the by in out patients
#4 continued
On direct questioning
“leg has been giving way for some days”
“back pain getting worse”
“no, hadn't wanted to trouble GP as due
back in clinic”!
Admit, Dex, MRI, Refer
#4 by the by in out patients
#5, keep coming back
Mr W
Chest clinic 2ww with
abnormal CXR
Sweats
Wt loss
Fatigue
Non smoker
Ex Policeman
#5 continued
CT pulmonary masses
Biopsy showed
lymphoma
S/B Haematology
Started RCHOP
#5 continued
Post cycle 2
Admitted acutely
breathless, hypoxia
CXR & CT interstitial
shadowing
Oxygen
Steroids
Antibiotics
#5 continued
A month in hospital but
recovered
Completed CHOP only
Still in remission
But did have another
bad patch
Possible underlying
fibrosis
#6 one from the surgeons
Mrs K
70s, admitted with abdominal pain over a
couple of days (possibly longer?)
Initial diagnosis constipation
Better have a CT to look for appendicitis
Smoker
Palpable liver
#6 one from the surgeons
Bronchoscopy extrinsic compression only
Liver biopsy – SMALL CELL LUNG
CANCER
#7 facial swelling is it an allergy?
Mrs H 61 year old lady
Swollen face for some
days, no improvement
with antihistamines
#7 facial swelling is it an allergy?
What haven't I talked about?
Pleural effusion
• Imaging
• US guided aspiration
• Percutanous biopsy
• Thoracoscopy
(allows drainage,
biopsy and
pleurodesis)
• Tunnelled indwelling
drain
What haven't I talked about?
Pulmonary Metastases
• Usually known
primary
• Can co-exist with lung
cancer eg bowel,
breast.
• Treatment is as for
the primary but most
often palliative.
What haven't I talked about?
Endobronchial
ultrasound (EBUS)
The next big thing (or
the current big thing)
Allows staging and
diagnosis without
surgical biopsy
So is it that easy?
No of course it is not.
But early referral to the appropriate
specialist, prompt imaging, and moving
rapidly to the diagnostic test with the
greatest likelihood of positive yield
Any questions?