‘When is a stroke not a stroke?’ Danielle Hann Lucinda Lacey Anthony Li Emma Briggs Samu Pekwa.
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Transcript of ‘When is a stroke not a stroke?’ Danielle Hann Lucinda Lacey Anthony Li Emma Briggs Samu Pekwa.
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‘When is a stroke not a stroke?’
Danielle HannLucinda LaceyAnthony Li Emma BriggsSamu Pekwa
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History
79 year old FemaleReferred by GP 3/52 ago to A&E with
?cord compressionP/C
Right arm pain Right sided weakness
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History
HPC 4/52 right arm pain 3/52 right leg weakness
gradual onset
Finding mobility increasingly difficult Presented to another A&E 2/52 prior with
weakness but sent home Weakness progressively worsened Dizziness for 5 years but worse in last 3/52
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History
HPC contd. 40 year Hx of cervical spondylosis Negative signs
HaemoptysisParaesthesiaBladder/bowel dysfunctionSensory levelNo fallsNo visual problems
• double vision, blurred vision
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PMH TB with lymph node excision as child Rheumatic fever as child 40 year Hx cervical spondylosis
DH & Allergies Nil NKDA
History
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HistorySH
Lives with Husband (Well) Maisonette - bed and bathroom on top floor Previously fully independent in ADLs
Husband does cooking and cleaning
2/52 prior to admission started using 1 stick for walking and chair transfers
Ex smoker stopped 8 years ago45 pack year Hx
AlcoholNil
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Examination On admission - from notes
General Well Afebrile No weight loss
Resp Sats - 96% on air No clubbing/cyanosis Trachea central Bilat air entry No creps/wheeze FEV1 36% predicted FVC 56% predicted PEF 22% predicted
CVS P 80 reg BP - 170/66 HS I + II + 0 JVP No murmur/No carotid
bruit
Abdo Soft & non-tender No organomegaly Bowel sounds present
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Examination
Neuro Left upper and lower limbs all 5/5 Wasting of small muscles of right hand
RUL RLLTested Power Tested PowerShoulderabduction
0/5 Hip flexion 3/5
Elbow flexion 3/5 Hip extension 3/5Elbowextension
0/5 Kneeextension
3/5
Finger flexion 3/5 Knee flexion 3/5Wrist flexion 3/5 Ankle
dorsiflexion4/5
Wristextension
0/5 Ankleplantarflexion
4/5
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Neuro contd
Tone and sensation normalNo clonus
Examination
Reflex Right LeftBrachial +++ ++Supinator ++ ++Triceps +++ ++Knee +++ ++Ankle ++ ++Plantars
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Examination
Neuro contd No hoarseness of voice CN II - XII
No ptosis/Normal pupillary reactions
Hoffmans -ve bilaterally No deep finger flexor reflex No pectoral reflex
Neck No tenderness or pain on movement
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Impression and Plan
Impression Left hemisphere CVA
Wasting/no extensor plantars ?UMN
Spinal cord compressionNo bladder or bowel dysfunction or sensory level
Plan Bloods - FBC; U&E; Glucose; LFTs; CRP;
Cholesterol C-spine and Chest x-ray (AP and Lateral)
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Results
Bloods
Hb 14.8 Na 135 Glucose 5.8 Chol 7.1WCC 8.6 K 4.2 Bilirub 10 TG 0.68Plt 275 Cl 96 ALT 8 HDL 2.0MCV 85 Bicarb 29 ALP 66 LDL 4.8ESR 21 Urea 4.7 Alb 37CRP 3.0 Creat 75 Ca 2.32
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Results contd
CXR Features consistent
with old TB in RUZ Lesion in RMZ
peripheral, well demarcated, 2cm nodule
No rib involvement No hypertrophic
pulmonary osteoarthropathy
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Revised Plan
CXR results and neurological signs indicate CT Head CT Chest CT guided biopsy
(peripheral lesion)
CT brain
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Results
CT head Ring enhancing cystic mass in left petrous region
consistent with cystic tumour or abscess (?old TB)
CT chest probable lung primary right hilar lymph node
Biopsy histology Poorly differentiated squamous cell carcinoma (Non-small cell carcinoma)
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Drug Treatment
RamiprilDexamethasoneSimvastatinRanitadineLanzoprazole
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Management plan
Neurosurgical opinion ?burr hole or craniostomy to drain cyst
?Radiotherapy Adjuvant brain Palliative lung
No chemotherapyHome with large care package ASAP
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Lung Cancer
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Background
Leading cause of cancer-related mortality in both men and women.
Diagnosis at an advanced stage.
Smoking-related damage to the heart and lungs, making aggressive surgical or multimodality therapies less viable options.
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Epidemiology
Men >Women (37.5 vs. 10.8 new cases/million)
Most common malignancy-related deaths in men and women.
17.8% of cancer-related deaths
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Aetiology
Smoking: Cigarette smoke contains N-nitrosamines and aromatic
polycyclic hydrocarbons. hydroxylated by the P-450, leading to formation of
carcinogens that cause formation of DNA adducts. 78% in men and 90% in women. risk is 13.3 times that of a person who has never
smoked. varies with the number of cigarettes smoked. After quitting, risk increases for the first 2 years and
then gradually decreases, but never returns to the
same level.
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Aetiology
Passive smoking: 15% of the lung cancers in nonsmokers are
believed to be caused by secondhand smoke.Asbestos: x5 risk. Synergistic.RadonOthers: Aromatic polycyclic
hydrocarbons, beryllium, nickel, copper, chromium, cadmium, and diesel exhaust.
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Classification
Upper tract: Tracheal Laryngeal
Lower tract: Bronchial- most common primary (90-95%) Carcinoid Metastatic
Pleural tumours.
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ClassificationBronchogenic
Small (Oat) Cell~20%
Non-Small Cell~80%
Squamous25-30%
Adenocarcinoma35-40%
Large-cell10-15%
•SCLC exhibits aggressive behaviour: •rapid growth, •early spread to distant sites, •exquisite sensitivity to chemotherapy and radiation •frequent association with distinct paraneoplastic syndromes.•Surgery usually plays no role in its management
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Pathophysiology
Amplification of oncogenes and inactivation of tumor suppressor genes in NSCLC.
Mutations involving the ras family of oncogenes.
3 members: H-ras, K-ras, and N-ras. Encode a protein on the inner surface of the cell with GTPase activity and may be involved in signal transduction.
Almost exclusive to adeno Ca (30% 0f cases).
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Natural History
Cytological Atypia
Piling of bronchial mucosa
Irregular, warty, erosive lesion
FungatesIntra-luminal mass
Rapid penetration, infiltration of peribronchial
tissue.
Intraparenchymalmass (caulifower)
•Tissue: •greyish white•haemorrhagic•Necrosis-cavitating
•Spread:•Lymphatic•Haematogenous
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Histology
Adenocarcinomas: form glands and produce mucin. Identified with mucicarmine or periodic acid-
Schiff (PAS) staining. WHO classification of adeno Ca:
(1) acinar (2) papillary (3) bronchoalveolar (4) mucus secreting
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HistologySquamous cell carcinoma:
distinct dose-response relationship to tobacco smoking
usually develops in proximal airways, classically presents as a cavitary lesion
Type most often associated with hypercalcemia. Progresses through stages of squamous
metaplasia to carcinoma in situ. Well-differentiated squamous cell carcinomas
contain keratin pearls.
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Histology
Squamous Cell: Microscopic examination reveals cells
with large irregular nuclei and coarse nuclear chromatin with large nucleoli.
Cells are arranged in sheets and intercellular bridging is diagnostic.
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Histology
Large Cell: Typically presents as a large peripheral mass on
CXR. Histologically, sheets of highly atypical cells with
focal necrosis, with No evidence of keratinization or gland formation Patients with large cell carcinoma are more likely to
develop gynecomastia and galactorrhea variant of large cell carcinoma - large cell
neuroendocrine carcinoma, carries a worse prognosis than large cell carcinomas.
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Prognosis
Estimated 5-year survival rates: Stage IA - 75% Stage IB - 55% Stage IIA - 50% Stage IIB - 40% Stage IIIA - 10-35% Stage IIIB - <5% Stage IV - <5%
In Europe, the 5-year overall survival is 8%
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Prognostic Factors
Tumour related: Physical
Stage/Grade Biochemical Molecular Haematological
Host related: Age Sex Performance Status Weight loss
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Presentation
Local effects of tumour in bronchus
Spread to mediastinum
Spread to pleura and chest wall
Spread to lymph nodes
Distant blood bourne metastases
Paraneoplastic (non-metatastic)complications
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Local effects of tumour in bronchus
1, Cough.2, Haemoptysis.3, Bronchial narrowing 4, Distal collapse 5, Finger clubbing
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Spread to mediastinum
1, Left recurrent laryngeal nerve paralysis 2, SVC obstruction 3, Compression of oesophagus 4, Phrenic nerve paralysis 5, Pericardial invasion
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Spread to pleura and chest wall
1, Pleural effusion 2, Chest wall pain 3, Pancoast tumours
Pain in T1 dermatomeWasting in small muscles of handHorner’s syndrome
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Spread to lymph nodes
1, Hilar lymphadenopathy – bronchial narrowing, retrograde
obstruction of pulmonary lymphatics (lymphangitis carcinomatosis)
2, Mediastinal lymphadenopathy – can compress and invade other mediastinal structures.
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Distant blood-borne metastases
Bone, liver, brain, adrenal glands, skin.
Paraneoplastic complications
1, Pulmonary hypertrophic osteoarthropathy 2, Endocrine syndromes – Cushings, hypercalcaemia, gynaecomastia.
3, Neuromuscular syndromes - Peripheral neuropathy, cerebellar dysfunction, dermatomyositis.
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Investigations
Imaging
Laboratory studies
Procedures
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Imaging
Chest X-rayHilar lymphadenopathy, area of pulmonary collapse, unresolved pneumonia, pleural effusion, lung abscess, peripheral mass, lymphangitis carcinomatosis, eroded ribs.Squamous cell carcinoma may be radiologically occult. It is slow growing and usually presents as a central mass that may cavitate.
CT + MRIChest and upper abdomen
Brain
Bone scintigraphy
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Laboratory studies
Sputum cytological studiesFalse-positive rate for sputum cytology is 1%False-negative rate is as high as 40%.
Full blood count, LFTs
Electrolytes
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Procedures
1, BronchoscopyEstablishes diagnosis and position of the tumour in the bronchial tree in over 70%
2, Mediastinoscopy
3, Thoracoscopy
4, CT-guided biopsy
5, Biopsy of other siteseg, enlarged palpable lymph nodes, liver, pleural and pericardial effusions.
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Staging
Primary tumour (T) TX Malignant cells in bronchial secretions, no other evidence of tumour
Tis Carcinoma in situ
T0 None evident
T1 <3cm, in lobar or more distal airway
T2 >3cm / 2cm distal to carina / any size if pleural involvement or obstructive pneumonitis extending to
hilum, but not all the lung
T3 Involves the chest wall, disphragm, mediastinal pleura,
pericardium / 2cm from, but not at carina
T4 Involves the mediastinum, heart, great vessels, trachea,
oesophagus, vertebral body, carina / malignant effusion is present
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Staging
Regional Nodes (N) N0 None involved (after mediastinoscopy)
N1 Peribronchial and/or ipsilateral hilum
N2 Ipsilateral medistinum or subcarinal
N3 Contralateral mediastinum or hilum, scalene or supraclavicular
Distant metastasis (M) M0 None
M1 Present
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Staging
Stage Tumour Lymph Nodes Metastasis
Occult TX N0 M0
I Tis, T1 or T2 N0 M0
II T1 or T2 N1 M0
IIIa T3 N0 or N1 M0
T1-T3 N2 M0
IIIb T1-T3 N3 M0
T4 N0-N3 M0
IV T1-T4 N0-N3 M1
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TREATMENT
Depends upon a variety of factors such as: Histopathologic type Tumour stage and characteristics Individual’s general health Medical problems that may affect
treatment
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Non-Small cell Lung Carcinoma
Surgical resection is best potentially curative therapy
Only in those: Whose tumour is resectable With adequate respiratory reserve Without a major medical contraindication to
surgery An agreeable patientN.B. For those who are not fit for surgery, Radiation
and/or Chemotherapy are considered. Unresectable stage 3 treated with combined radio- and chemotherapy.
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Limited Small Cell Lung Cancer
Highly chemosensitiveCombination chemotherapy and Thoracic
irradiation +/- prophylactic cranial irradiation is standard therapy for patients with limited SCLC.
Radiotherapy reduces local recurrence by 50%, but still with isolated local failure rates between 25% to 30%
Surgery may improve control at the local site.
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Limited Small Cell Lung Cancer
5 - 10% of SCLC cases are found in combination with other lung cancer histologies including adenocarcinoma or squamous cell carcinoma.
Surgery may be necessary to treat the non-small cell component.
Late recurrences may be of non-small cell type (a new primary) and may be treated surgically if standard criteria for operability are met.
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Extensive Small Cell Lung Cancer
Chemotherapy: - Rarely curative- Significantly improve survival- Palliative- The optimal induction are either Etoposide with Cisplatin or Cytoxan, Doxorubicin and vincristine.
Surgery has little role to play in stage 3 tumours as it does not significantly contribute to long-term survival.
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Lung Cancer in the Elderly
80% are of NSCLCLess aggressive treatmentQuality of life is equally important Radiation therapy is valuable for both
types Monochemotherapy is more approppriate
in those over 75. Unresectable NSCLC stage 3 best treated
with combined chemo- and radiotherapy
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Lung Cancer in the Elderly
Limited stage SCLC treated combination chemotherapy and radiotherapy
Recent minimally invasive techniques more suitable
Age alone is not a factor in determining the best operative procedure for lung cancer
Good health is essential to tolerate treatment
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Palliative care
Multidisciplinary approachPsychological supportSymptom control essential
(Pain, Nausea, Vomiting, Anorexia, Malaise,Weakness, Bowel obstruction, Respiratory symptoms, etc.)