8 May Flashcards
Solitary pulmonary nodule DDx and workup including features of benign vs cancerous lesions
DDx: pneumonia, cancer, carcinoid tumor, granuloma, hamartoma
Workup: compare to previous x-rays to assess progression and growth of lesion, if not available then do CT scan
Benign lesions: less than 35y, no change from prior films, central uniform lesion with smooth margins, less than 2cm, no LAD; followup CXR 3-6mo
Cancerous lesions: smoker, over 45y, new or progressing lesion, no calcifications or irregular calcifications, greater than 2 cm, irregular margins; get Pet scan or biopsy, or immediate resection
What is the most common type of lung cancer seen in non-smokers?
Adenocarcinoma
How are lung nodules diagnosed definitively?
Bronchoscopy with biopsy and brushings or fine needle aspiration
Name the four types of primary lung cancer
Squamous cell carcinoma
Adenocarcinoma
Small cell carcinoma
Large cell carcinoma
What is the location and characteristics of squamous cell carcinoma?
Centrally located
Cavitary lesions, direct extension to hilar lymph nodes
What is the location and characteristics of adenocarcinoma?
Peripherally located
wide metastases, can be caused by asbestos, pleural effusions show increased hyaluronidase levels, bronchialveolar cancer is a subtype that is low grade and occurs in single nodules
What is the location and characteristics of small cell carcinoma?
Centrally located
rapidly growing, early distant metastases, several neoplastic syndromes
What is the location and characteristics of large cell carcinoma?
late distant metastases, early cavitation
Which lung cancers are centrally located?
Squamous cell and small cell
Squamous and Small are Sentrally located (Remember the S)
Which lung cancers are peripherally located?
Adenocarcinoma, Large cell carcinoma
Which lung cancer is associated with hypercalcemia?
Squamous cell
Which lung cancer is associated with gynecomastia?
Large cell
Which lung cancer is associated with cushing syndrome?
Small cell
Which lung cancer is associated with DIC, thrombophlebitis, microangiopathic hemolytic anemia?
Adenocarcinoma
Which lung cancer is associated with SIADH, neuropathy, ectopic growth hormone production, subacute cerebellar degeneration, and many others?
Small cell
What paraneoplastic syndrome is associated with all four lung cancers?
Dermatomyositis
What is Pancoast syndrome?
Horner syndrome with addition of brachial plexus involvement
Which lung cancer is peripherally located and would show elevated hyaluronidase levels in pleural effusion?
Adenocarcinoma
Which lung cancer is centrally located and shows cavitary lesions?
Squamous cell
What is the primary treatment for small cell carcinoma of the lung?
Primary therapy is chemotherapy
What is primary treatment for non-small cell carcinoma of the lung?
Primary therapy is radiation
Surgery is performed in cases without mediastinal node involvement or metastases into the mediastinum
What is the prognosis overall for lung cancer?
Prognosis is poor with a 10% survival at 5 years
Recurrence is common for primary tumors
Laryngeal cancer cause, H/P, radiology, tx
Cause: smoking and alcohol use
H/P: progressive hoarseness, dysphagia, hemoptysis, ear pain
Rad: MRI/CT with contrast, or PET early on
Tx: combination of surgery, radiation, chemo
What is FEV1/FVC ratio like in restrictive lung disease?
Normal
Describe idiopathic pulmonary fibrosis
Inflammatory disease of unknown cause
Most common over 50y
Leads to fibrosis of the lungs (a restrictive disease)
What will CXR and CT of lung show in idiopathic pulmonary fibrosis?
CXR: honeycomb appearance in advanced cases
CT: show ground glass appearance
Tx of pulmonary fibrosis?
Steroids, cyclophosphamide, azathioprine
Goal to decrease inflammatory response leading to lung damage and fibrosis
Monitor PFT’s to asses effectiveness
Lung transplant often indicated, but many die before getting one
Describe sarcoidosis and who gets it
Noncaseating granulomatous disease of unknown cause
Affects hilar lymph nodes, causes skin lesions, and pulmonaryinfiltrates
More common in blacks, females, 10-40y
What is found on H/P with sarcoidosis?
cough, malaise, weight loss, dyspnea, arthritis in knees and ankles, chest pain, fever, erythema nodosum, LAD, vision loss, CN palsies
What are common lab findings for sarcoidosis?
Increased ACE, Ca, Alk Phos, ESR
Decreased WBC
Hypercalciuria
Tx for sarcoidosis
Self-resolving in some cases
Corticosteroids in advanced cases
Lung transplant usually not needed
Workers in what industries get exposed to asbestos?
Working with insulation, construction, demolition, building maintenance, automobiles
Workers in what industries get silicosis?
Mining, pottery making, sandblasting, cutting granite
Workers in what industry develop berylliosis?
Electronics, ceramics, tool and die manufacturing
What are pneumoconioses?
Interstitial lung diseases resulting form long-term occupational exposure to substances that cause pulmonary inflammation
Describe asbestosis: exposure, labs, rad, complications
Exposure: Working with insulation, construction, demolition, building maintenance, automobiles
Labs: PFT shows restrictive pattern, asbestos fibers seen on pleural biopsy but not required for Dx
Rad: multinodular opacities, pleural effusion, blurring of heart/diaphragm, chest CT shows linear/parenchymal fibrosis
Complications: risk of malignant mesothelioma and lung cancer, worse with tobacco
Describe silicosis: exposure, labs, rad, complications
Exposure: mining, pottery making, sandlblasting, cutting granite
Labs: PFT restrictive pattern
Rad: small apical nodular opacities, hilar adenopathy
Complications: increased risk of TB, progressive fibrosis
Describe coal worker disease: exposure, labs, rad, complications
Exposure: coal mining
Labs: PFT restrictive pattern
Rad: small apical nodular opacities
Complication: progressive fibrosis
Describe berylliosis: exposure, labs, rad, complications
Exposure: electronics, ceramics, tool and die manufacturing
Labs: Pulmonary edema, diffuse granuloma formation
Rad: diffuse infiltrates, hilar adenopathy
Complications: increased risk of lung cancer, may need chronic corticosteroid treatment to maintain respiratory function
Describe primary features of Goodpasture’s syndrome
Progressive autoimmune disease of lungs and kidneys caused by anitglomerular basement membrane antibody leading to intraalveolar hemorrhage and glomerulonephritis
H/P: hemoptysis, dyspnea, recent respiratory infection
Labs: anti-GBM antibodies, PFT restrictive pattern but increased DLco, renal biopsy shows crescenteric glomerulonephritis and IgG deposits along glomerular capillaries
Tx: plasmaphoresis to remove antibodies, corticosteroids and immunosuppressive agents
What is the diagnostic approach for suspected PE?
Well’s criteria to asses pretest probability
D-dimer which is effective in ruling out PE
Definitive imaging involving CT pulm angio if stable and bedside echo and vein compression if unstable
V/Q scan is not used as often, but is an option if CT is inconclusive
What is treatment for PE?
O2
Treat hypotension
Anticoagulate with heparin
Discharge on either LMWH or warfarin for 3-6 months
IVC filter can be placed if anticoagulants contraindicated
Thrombolysis can be used for massive PE and in those without cardiac contraindications, recent trauma, or sugery
What is pulmonary wedge pressure?
Estimate of left atrial pressure
Used to differentiate causes of pulmonary edema
If greater than 18 it is elevated and indicates cardiac cause
If less than 18, ARDS is more likely
What do the findings of cephalization of vessels and Kerley B lines on CXR indicate?
Pulmonary edema
What are the likely causes of pleural effusion based on the fluid being transudative or exudative?
Transudate usually is due to hydrostatic or oncotic changes caused by CHF, Cirrhosis, kidney disease
Exudate is usually due to inflammation and infection, cancer vasculitis
What are the pleural:serum protein ratio and pleural:serum LDH ratio levels that indicate transudate vs exudate?
Pleural:serum protein ratio over 0.5 is exudate
Pleural:serum LDH ratio over 0.6 is exudate
What is next step in treatment for patient with suspected tension pneumothorax?
Do not wait for CXR if tension pneumothorax is suspected. Perform immediate needle decompression by placing needle in 4/5 intercostal space at midaxillary line, or 2/3 space at miclavicular line
What happens if hemothorax is not drained?
Fibrosis can occur
Describe malignant mesothelioma
Uncommon tumor on visceral pleura and pericardium usually due to asbestos exposure more than 20 years prior and made much worse by smoking and has poor prognosis.
Non-small cell lung cancer is more common than this in patients exposed to asbestos
Non-pleuritic chest pain, dyspnea, palpable chest wall lesion and scoliosis can occur
CXR shows pleural thickening, pleural effusion
At what point should an intubated patient be converted to a tracheostomy?
If needed for more than 3 weeks
