Cancer for PLAB 1

A 67 year old man with a 45 pack-year smoking history has had a cough for four months and has coughed up blood twice in the past fortnight. He has lost 7 kg. His chest examination is normal and he has finger clubbing. What is the SINGLE most likely diagnosis?

1. Pulmonary tuberculosis Weeks of cough with night sweats, weight loss and a hollowed-out patch at the top of the lung on imaging (upper lobe cavitation), with a relevant exposure history. But coughing up blood with 7 kg of weight loss in a heavy smoker does not point to it.
2. Bronchiectasis Long-standing large amounts of phlegm with crackly breath sounds and repeated infections over years. That does not match coughing up blood with 7 kg of weight loss in a heavy smoker.
3. Lung cancer correct Correct. Four months of cough, coughing up blood, real weight loss and clubbed fingers in a 45 pack-year smoker over 40. Any one of these on its own would need investigating; together, cancer is the working diagnosis until a scan says otherwise, and a normal chest examination is entirely usual here.
4. Mesothelioma Thickening and fluid around the lung lining, linked to asbestos exposure, often decades earlier. It does not fit coughing up blood with 7 kg of weight loss in a heavy smoker.
5. Chronic obstructive pulmonary disease (COPD) Breathlessness with a long-standing phlegmy cough and airways that stay narrowed, but no separate lump and no coughing up blood. Here, coughing up blood with 7 kg of weight loss in a heavy smoker points elsewhere.

The point: Refer on a suspected cancer pathway (a fast-track route where the patient is seen within two weeks) if a chest X-ray looks like lung cancer, or if the patient is 40 or over with coughing up blood (haemoptysis) that has no other explanation. Offer an urgent chest X-ray within two weeks for a cough that will not go away, breathlessness, chest pain, weight loss, loss of appetite, tiredness, or rounded, swollen fingertips (finger clubbing) in smokers over 40. Small cell lung cancer has usually already spread around the body by the time it is found, so it is treated with chemotherapy, not surgery.

Source: NICE NG12 — Suspected cancer: recognition and referral NICE · tier 1, national regulator or guidance

A 67 year old man with a 45 pack-year smoking history has had a cough for four months and has coughed up blood twice in the past fortnight. He has lost 7 kg. His chest examination is normal and he has finger clubbing. What is the SINGLE most appropriate initial investigation?

1. Urgent chest radiograph correct Correct. The first test to do, and the one that sets everything else in motion, requested within two weeks. It is worth knowing that a normal chest X-ray does NOT rule out lung cancer. If suspicion stays high, the patient still needs a CT scan.
2. Bronchoscopy and biopsy Gets a tissue sample from a lump near the centre of the lung, which is what decides the exact cell type and therefore the treatment. But coughing up blood with 7 kg of weight loss in a heavy smoker does not point to it.
3. Sputum cytology Looking for cancer cells in a phlegm sample. This misses a lot of cases and is rarely used now; a negative result does not rule out cancer. It does not fit coughing up blood with 7 kg of weight loss in a heavy smoker.
4. CT chest, abdomen and pelvis with contrast Shows how far the disease has spread (stages it) once the X-ray is abnormal, and identifies the best spot for a biopsy. That does not match coughing up blood with 7 kg of weight loss in a heavy smoker.
5. Serum sodium Low sodium from SIADH (a hormone problem where the body holds onto too much water) is a known effect of small cell lung cancer, but it does not diagnose the tumour itself. Here, coughing up blood with 7 kg of weight loss in a heavy smoker points elsewhere.

The point: Refer on a suspected cancer pathway (a fast-track route where the patient is seen within two weeks) if a chest X-ray looks like lung cancer, or if the patient is 40 or over with coughing up blood (haemoptysis) that has no other explanation. Offer an urgent chest X-ray within two weeks for a cough that will not go away, breathlessness, chest pain, weight loss, loss of appetite, tiredness, or rounded, swollen fingertips (finger clubbing) in smokers over 40. Small cell lung cancer has usually already spread around the body by the time it is found, so it is treated with chemotherapy, not surgery.

Source: NICE NG12 — Suspected cancer: recognition and referral NICE · tier 1, national regulator or guidance

A 67 year old man with a 45 pack-year smoking history has had a cough for four months and has coughed up blood twice in the past fortnight. He has lost 7 kg. His chest examination is normal and he has finger clubbing. What is the SINGLE most appropriate immediate management?

1. Suspected cancer pathway referral within two weeks correct Correct. Coughing up blood with no other explanation in someone aged 40 or over is itself a reason for a two-week-wait referral under NG12, regardless of what the X-ray shows. He meets that on its own.
2. Chemotherapy The main treatment for small cell lung cancer, which has usually already spread by the time it is found and is not treated with surgery. But coughing up blood with 7 kg of weight loss in a heavy smoker does not point to it.
3. Urgent dexamethasone and radiotherapy Given for the vein carrying blood back from the head being blocked (superior vena cava obstruction) or the spinal cord being squeezed (spinal cord compression), both of which are cancer emergencies. It does not fit coughing up blood with 7 kg of weight loss in a heavy smoker.
4. Surgical resection For lung cancer caught early that is not small cell type, in a patient well enough for the operation. This is the only treatment reliably able to cure it. That does not match coughing up blood with 7 kg of weight loss in a heavy smoker.
5. Reassure and review in six weeks Not safe where cancer is suspected, since any delay lets the cancer progress further. Here, coughing up blood with 7 kg of weight loss in a heavy smoker points elsewhere.

The point: Refer on a suspected cancer pathway (a fast-track route where the patient is seen within two weeks) if a chest X-ray looks like lung cancer, or if the patient is 40 or over with coughing up blood (haemoptysis) that has no other explanation. Offer an urgent chest X-ray within two weeks for a cough that will not go away, breathlessness, chest pain, weight loss, loss of appetite, tiredness, or rounded, swollen fingertips (finger clubbing) in smokers over 40. Small cell lung cancer has usually already spread around the body by the time it is found, so it is treated with chemotherapy, not surgery.

Source: NICE NG12 — Suspected cancer: recognition and referral NICE · tier 1, national regulator or guidance