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Questions Answered: 300

Final Score 76%

229
71

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Oncology & Palliative Care

Question 36 of 300

A 72 year old woman, who has smoked all her life, presents to the Emergency Department with malaise, weight loss, a persistent cough and a hoarse voice, which have been ongoing for the last 4 weeks. What is the diagnosis?

Answer:

Pancoast tumour refers to a relatively uncommon situation where a primary lung cancer arises in the lung apex and invades the surrounding soft tissues. Most Pancoast tumours are non small cell cancers and most commonly squamous cell cancer. The hoarse voice is most likely from involvement of the recurrent laryngeal nerve.

Lung Malignancy

Oncology & Palliative Care / Respiratory

Last Updated: 6th September 2022

Risk factors

Risk factors for lung cancer:

  • Smoking
  • Asbestos exposure and other industrial lung disease
  • Increasing age
  • History of malignancy
  • History of radiation

Clinical features

  • Cough
  • Shortness of breath
  • Haemoptysis
  • Persistent chest and/or shoulder pain
  • Weight loss
  • Anorexia
  • Malaise
  • Persistent/recurrent chest infection
  • Finger clubbing
  • Cervical or supraclavicular lymphadenopathy
  • Thrombocytosis

Pancoast tumour

Pancoast tumour refers to a relatively uncommon situation where a primary lung cancer arises in the lung apex and invades the surrounding soft tissues. Most Pancoast tumours are non small cell cancers and most commonly squamous cell cancer. Pancoast tumors may lead to several other syndromes caused by the compression of surrounding anatomical structures.

  • Horner’s syndrome (compression of the paravertebral sympathetic chain and the inferior cervical ganglion)
    • Miosis
    • Anhidrosis
    • Ptosis
    • Enophthalmos
  • Superior vena cava syndrome (compression of the SVC)
    • Dyspnoea
    • Cough
    • Headache
    • Dizziness/syncope
    • Disturbed vision
    • Neck, face and arm swelling
    • Venous distention over arms, neck and anterior chest wall
    • Cyanosis
    • Engorged conjunctiva
    • Positive Pemberton sign
  • Thoracic outlet syndrome (compression of the neurovascular bundle of the upper limb)
    • Upper extremity swelling
    • Diffuse arm or hand pain and paraesthesia
    • Ulceration or venous or arterial gangrene
  • Recurrent laryngeal nerve involvement
    • Hoarse voice
    • Bovine cough
  • Brachial plexus involvement
    • Severe pain in the shoulder or scapula
    • Pain and weakness in muscles of the shoulder, arm and hand
  • Phrenic nerve involvement
    • Hemidiaphragm paralysis

Investigations

Most lung cancers can be identified on a plain chest X-ray, though false-negatives may occur. Other imaging techniques, especially CT, may be used, though these are generally performed following an indeterminate chest X-ray, or when the person has continuing symptoms and a normal chest X-ray. Definitive diagnosis requires biopsy, usually guided by CT or via bronchoscopy. Sputum cytology is only used in those unable to have biopsy.

Management

Patients with suspected malignancy should be referred urgently to a respiratory specialist.

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l
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