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 upper lobe cavitation, and a relevant exposure history. Haemoptysis with 7 kg of weight loss in a heavy smoker makes it worth excluding but less likely.
2. Bronchiectasis Chronic copious sputum with coarse crackles and recurrent infection over years. Haemoptysis with 7 kg of weight loss in a heavy smoker does not describe it.
3. Lung cancer correct Correct. Four months of cough, haemoptysis, substantial weight loss and clubbing in a 45 pack-year smoker over 40. Any one of these would warrant investigation; together they make cancer the working diagnosis until imaging says otherwise, and a normal chest examination is entirely usual.
4. Mesothelioma Pleural thickening and effusion with asbestos exposure, often decades earlier. Haemoptysis with 7 kg of weight loss in a heavy smoker makes exposure history the key question.
5. Chronic obstructive pulmonary disease (COPD) Breathlessness with a chronic productive cough and fixed obstruction, but not a discrete mass or haemoptysis. Haemoptysis with 7 kg of weight loss in a heavy smoker points beyond it.

The point: Refer on a suspected cancer pathway (seen within two weeks) if the chest radiograph suggests lung cancer, or if aged 40 and over with unexplained haemoptysis. Offer an urgent chest radiograph within two weeks for persistent cough, breathlessness, chest pain, weight loss, appetite loss, fatigue or finger clubbing in smokers over 40. Small cell disease is usually disseminated at diagnosis and 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-line test and the one that triggers everything else, requested within two weeks. It is worth knowing that a normal chest radiograph does NOT exclude lung cancer, if suspicion stays high, the patient still needs a CT.
2. Bronchoscopy and biopsy Obtains tissue for a central lesion, which is what determines histological type and therefore treatment. Haemoptysis with 7 kg of weight loss in a heavy smoker makes tissue the priority.
3. Sputum cytology Poor sensitivity and rarely used now; it does not exclude cancer if negative. Haemoptysis with 7 kg of weight loss in a heavy smoker makes it inadequate.
4. CT chest, abdomen and pelvis with contrast Stages the disease once the radiograph is abnormal, and identifies a target for biopsy. Haemoptysis with 7 kg of weight loss in a heavy smoker makes it the next step.
5. Serum sodium Hyponatraemia from SIADH is a recognised paraneoplastic feature of small cell disease, but it does not diagnose the tumour. Haemoptysis with 7 kg of weight loss in a heavy smoker makes it supportive.

The point: Refer on a suspected cancer pathway (seen within two weeks) if the chest radiograph suggests lung cancer, or if aged 40 and over with unexplained haemoptysis. Offer an urgent chest radiograph within two weeks for persistent cough, breathlessness, chest pain, weight loss, appetite loss, fatigue or finger clubbing in smokers over 40. Small cell disease is usually disseminated at diagnosis and 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. Unexplained haemoptysis in someone aged 40 or over is itself a two-week-wait criterion under NG12, independent of the radiograph result. He meets it on that alone.
2. Reassure and review in six weeks Unsafe where cancer is suspected, and delay costs stage. Haemoptysis with 7 kg of weight loss in a heavy smoker makes it wrong.
3. Urgent dexamethasone and radiotherapy For superior vena cava obstruction or spinal cord compression, which are oncological emergencies. Haemoptysis with 7 kg of weight loss in a heavy smoker is one of them.
4. Surgical resection For early-stage non-small cell disease in a patient fit enough, and the only reliably curative option. Haemoptysis with 7 kg of weight loss in a heavy smoker makes it possible.
5. Smoking cessation support Offered at the same appointment rather than after the diagnosis is confirmed. It improves surgical outcome and treatment tolerance, and a cancer diagnosis is the single most effective moment to offer it, and haemoptysis with 7 kg of weight loss in a heavy smoker here points elsewhere.

The point: Refer on a suspected cancer pathway (seen within two weeks) if the chest radiograph suggests lung cancer, or if aged 40 and over with unexplained haemoptysis. Offer an urgent chest radiograph within two weeks for persistent cough, breathlessness, chest pain, weight loss, appetite loss, fatigue or finger clubbing in smokers over 40. Small cell disease is usually disseminated at diagnosis and is treated with chemotherapy, not surgery.

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