iBSc: Question 3
By Alan McLeod
Tested by Natalie Hayes
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!
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)
Question 4
Mr Jackson has an
80 pack year
smoking history.
Q4.2
• What is a ‘pack year’
(2)
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)
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)
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)
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)
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 KublerRoss (4)
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)
The Answers
View these on ‘note view’ rather
than on full screen – additional
notes are provided for some slides
Haemoptysis? Where’s that wine…
I
G
E
T
V
I
N
O
Infectious / inflammatory Pulmonary tuberculosis
Genetic / idiopathic
Endocrine
Trauma
Chest trauma
Vascular
Pulmonary embolism
Iatrogenic / ingested
Neoplastic
Bronchial carcinoma
Organs / other
Nose: epistaxis; oesophagus: mallory weiss
tear
Lung: bronchiectasis; Heart: mitral stenosis
Two Useful Concepts
Body Mass Index
(BMI)
BMI=
Wt (kg)
Ht2 (M)
20-25: Ideal
26-30: Overweight
31-35: Obese
Pack Years
PY=
Cigs / day
20
x Yrs
> 20 = increased
chance complications
Carcinogens
Cigarette smoke
UV Radiation
Chemicals
• PAH
• Aromatic amines
• Nitrosamines
Ionising radiation
• Radiotherapy
• Radon gas (lung)
• Industry/military
Carcinogens
Viruses
• EBV (Epstein-Barr)
• HPV (Papilloma virus)
• HBV (Hepatitis B
virus)
Stages in
carcinogenesis
• Initiation
• Promotion
• Progression
Lung cancer
• Male: Female 7:1
• 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
Lung Cancer - Diagnosis
• Imaging
– Plain film
– CT
– MRI
Biopsy
• Peripheral lesions
– Percutaneous biopsy
• Proximal lesions
– Bronchoscopic biopsy
• Cytology
– Sputum
– Bronchoscopic
washings
• Pleural Effusions
– Fine needle aspiration
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
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
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
Routes of
Metastasis
• Vascular
• Lymphatic
• Coelomic
Growth Characteristics
Benign
Expands only
Grows locally
Generally slower
Malignant
Expands and invades local
tissues
May metastasise
Generally faster
Cytoplasmic Characteristics
Benign
Normal or slight increase in
nucleus:cytoplasm ratio
Resembles cell of origin (well
differentiated)
Retains specialisations
Diploid
Malignant
High nucleus:cytoplasm ratio
Failure of differentiation
Loses specialisations
Range of ploidy
Histological Characteristics
Benign
Few Mitoses
Cell uniform throughout
tumour
Organised tissue
Malignant
Many mitoses – some of which
are abnormal
Cells vary in shape and size
(cellular pleomorphism) and/or
Nuclei vary in shape and size
(nuclear pleomorphism)
Disorganised tissue
Local and systemic effects
Local
• Pressure
• Invasion
• Ulceration
• Obstruction
Systemic
• Weight loss
(cachexia)
• Loss of appetite
(anorexia)
• Fever
• Anaemia
• General Malaise
• Paraneoplastic
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.