iBSc: Question 3

1
iBSc Question 3

• By Alan McLeod
• Tested by Natalie Hayes

2
Getting the best marks

• Read the whole question a latter section may
  give you a clue about an earlier one.
• To see how many points you need look at the marks
  allocated for example a 3 point question is
  generally looking for 3 salient points
• If giving a list answer put the best answers
  first examiners will not usually mark answers
  too far down a list

• Always write something it may get you part of a
  mark and is anonymised so no one will think you
  are stupid!
• If you genuinely have no clue then re-write the
  question to see if this sparks some ideas.
• If not then move on and come back at the end. And
  remember always write something.
• Good luck!

3
Question 4

• Mr Jackson, a 62 year old retired bricklayer has
  been experiencing haemoptysis for three weeks.

• Q4.1
• List 4 differentials for haemoptysis (4)

4
Question 4

• Mr Jackson has an 80 pack year smoking history.

• Q4.2
• What is a pack year (2)

5
Question 4

• Cigarette smoke is a known carcinogen.

• Q4.3
• List two other carcinogens (1)
• Q4.4
• What are the three stages of carcinogenesis (3)

6
Question 4

• You suspect lung cancer.

• Q4.5
• What additional symptoms might you ask about to
  support your hypothesis (2)
• Q4.6
• What cancer specific tests might you order (3)

7
Question 4

• Tests reveal a squamous cell carcinoma of the
  lung with liver metastases.

• Q4.7
• Aside from SCC, list two other common types of
  lung cancer (2)
• Q4.8
• What changes occur in a cancer cell to allow
  metastasis? (5)

8
Question 4

• Tests reveal a squamous cell carcinoma of the
  lung with liver metastases.

• Q4.9
• Compare the characteristics of normal and
  neoplastic cells (4)

9
Question 4

• When you tell him the diagnosis, Mr Jackson
  becomes very angry - accusing you of negligence
  for not spotting this earlier.

• Q4.10
• Aside from anger, what are the stages of grief in
  the model proposed by Kubler-Ross (4)

10
Question 4

• You describe to Mr Jackson the probable prognosis
  and progression of the disease.

• Q4.11
• List one local and two systemic effects that
  cancers in general may produce (3)

11
The Answers

• View these on note view rather than on full
  screen additional notes are provided for some
  slides

12
Haemoptysis? Wheres that wine
I Infectious / inflammatory Pulmonary tuberculosis
G Genetic / idiopathic
E Endocrine
T Trauma Chest trauma
V Vascular Pulmonary embolism
I Iatrogenic / ingested
N Neoplastic Bronchial carcinoma
O Organs / other Nose epistaxis oesophagus mallory weiss tear Lung bronchiectasis Heart mitral stenosis
13
Two Useful Concepts

• Body Mass Index (BMI)
• 20-25 Ideal
• 26-30 Overweight
• 31-35 Obese

• Pack Years
• gt 20 increased chance complications

PY Cigs / day x Yrs
PY 20 x Yrs
BMI Wt (kg)
BMI Ht2 (M)
14
Carcinogens

• Cigarette smoke
• Chemicals
• PAH
• Aromatic amines
• Nitrosamines

• UV Radiation
• Ionising radiation
• Radiotherapy
• Radon gas (lung)
• Industry/military

15
Carcinogens

• Viruses
• EBV (Epstein-Barr)
• HPV (Papilloma virus)
• HBV (Hepatitis B virus)

• Stages in carcinogenesis
• Initiation
• Promotion
• Progression

16
Lung cancer

• Male Female 71
• Decreasing
• Male peak in 60s
• Female peak in 70s
• Rare under 25 years

• Presenting complaints
• 90 symptomatic
• 40 Haemoptysis
• 75 Anorexia
• 75 Dyspnoea
• 75 Cough
• 75 Pain
• Remember Weight Loss
• 10 Incidental imaging

17
Lung Cancer - Diagnosis

• Imaging
• Plain film
• CT
• MRI
• Cytology
• Sputum
• Bronchoscopic washings

• Biopsy
• Peripheral lesions
• Percutaneous biopsy
• Proximal lesions
• Bronchoscopic biopsy
• Pleural Effusions
• Fine needle aspiration

18
Lung Cancer

• Types
• Small Cell (20-30)
• Non-small Cell
• Large Cell (10-15)
• Adenocarcinoma (20)
• Commonest non-smoking
• Squamous cell carcinoma (40-60)
• Commonest smoking related

• Treatment
• Small cell
• Early metastasis
• Chemotherapy and radiotherapy first line
• Non-small cell
• Surgery first line
• Lobectomy
• Pneumonectomy
• Radio / chemo as req

19
Invasion and Metastasis

• Invasion is the spread into adjacent tissues
  may occur along natural tissue planes such as
  along nerves

• Metastasis is the spread of cells to distant
  parts of the body there are several mechanisms
  for this

20
To Metastasise

• Changes occur in only some cells of the tumour
• By random mutation

• Binds to basement membr
• Becomes motile
• Becomes able to attach to extracellular matrix
• Becomes able to degrade extracellular matrix
• Must be able to survive and grow at site of
  implantation

21

• Routes of
• Metastasis
• Vascular
• Lymphatic
• Coelomic

22
Growth Characteristics
Benign Malignant
Expands only Grows locally Expands and invades local tissues May metastasise
Generally slower Generally faster
23
Cytoplasmic Characteristics
Benign Malignant
Normal or slight increase in nucleuscytoplasm ratio High nucleuscytoplasm ratio
Resembles cell of origin (well differentiated) Failure of differentiation
Retains specialisations Loses specialisations
Diploid Range of ploidy
24
Histological Characteristics
Benign Malignant
Few Mitoses Many mitoses some of which are abnormal
Cell uniform throughout tumour Cells vary in shape and size (cellular pleomorphism) and/or Nuclei vary in shape and size (nuclear pleomorphism)
Organised tissue Disorganised tissue
25
(No Transcript)
26
Local and systemic effects

• Local
• Pressure
• Invasion
• Ulceration
• Obstruction

• Systemic
• Weight loss (cachexia)
• Loss of appetite (anorexia)
• Fever
• Anaemia
• General Malaise
• Paraneoplastic

27
The End

• The slides here should allow you to mark your own
  work remember 1 mark per answer up to the
  maximum for the question. Multiply by 3 to get
  percentage points. I assume a 60 pass mark.
  Sorry but I am unable to give further advice on
  answers due to time constraints.