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 I67. 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?