JC M CLINICAL ONCOLOGY
OPD
Prof Sham
Oncology
Wed 23-10-02
PATIENT 1
- 52/M ® NPC
- C/O L-sided neck mass (appeared 1m ago)
- Mucus + nasal discharge blood-streaked for 3w
- No wt loss, appetite D
- Smoked 20y (1.5 pack/ day), quit 11y ago
Discussion
- Wt loss - features of advanced disease ( tumour bulk, spread), non-specific \ ask at end of Hx (except ca lung - Pt presents late, wt loss)
- Conditions causing neck swelling
- Infection - pain
- Malignancy 1o (lymphoma) 2o (pharynx, posterior tongue, tonsil)
- Cyst
- Lipoma [according to anat or pathology]
- Infection
- NPC
- Tonsil
- Tongue
- Symptom of nasal fossa tumour
- Anterior
- blood discharge
- Lateral
+ Posterior (Eustachian tube) - ear (tinnitus, deafness)
- Superior
extension - cavernous sinus either side of sphenoid (CN VI - lateral rectus, diplopia, V - face numbness/ pain esp. V2, IV - rare, III - v advanced tumour) [note: loss of smell rare - traumatic, extensive lesion)
- Centre of forehead (frontal sinus)
- Trigeminal neuralgia (not centred)
-
ICP (occipital pain)
- Referred pain from skull base erosion (temporoparietal area - ipsilateral)
- Site
- Size - must measure (nearest 0.5cm)
- Shape
- Surface/ Edge
- Consistency
- Mobility/ Attachment
- Tenderness
- Fluctuation/ Illumination
- Most neck LN DEEP to SCM (describe - eg. middle part jugular chain) - note: top of posterior triangle overlaps with jugular chain
- If LN attached to underlying tissue, large LN which has infiltrated surrounding structure (may be so large that ST is stretched \ appears fixed but is not)
- CN V
® sensation (x3 areas), m mastication (avoid corneal reflex - harm to Pt, only do when subtle loss of sensation, leave to neurologist, if must do - do last)
- Hearing
(1) Cover ear, whisper, repeat other side
- NPC - radiation
- Dry mouth (rad salivary glands)
- Dentist (teeth probs)
- ¯
Hearing (returns within 1y - audiologist)
- Hair loss at nape (exit radiation) - most grows back
- Stiff neck
- Give staging + Px
- Otoscope - L hand L ear
, finger against Pt's face
- EBV DNA detected in >90% NPC
- MRI - ask about claustrophobia
- Iodine compound used as contrast between ca and N tissue (used universally in CT)
PATIENT 2
- M/55 c/o coughing up white sputum (no blood), no pattern, lost 10lb in past 2y, appetite normal
Discussion
- Cough without irritation = lung (no subjective sensation) ® but due to coughing, subsequently develop throat irritation
-
Purulent sputum production in ca lung - obstruction, ¯ immunity
- Superficial pain can pin-point
(cf. visceral, cannot)
- CXR
- 1o stippled edge, 2o sharp edge
- Chest P/E -
¯ sensitivity for ca lung, sensitivity for chest infection
- Mass due to lung tumour -
vocal resonance ¯ percussion note (spread - bone/ pain, brain, liver, other lung ® (1) Lymphatic obstruction - transudate - ¯ protein (2) Spread to pleural cavity - exudate - protein
- Distinguish between SVCO + heart failure - no hepatojugular reflex in SVCO
- Tumour location - large cell + squamous (central), small cell + adenocarc (peripheral)
- Adenocarcinoma
- tumour can arise for long-standing scar (eg. TB)
- Early Dx ca lung -
¯ bulk, ¯ metastasis (Px depends on tumour behaviour)
- At time of Dx, only 10% of ca lung curable