Clinical presentations of cancer and Paraneoplastic syndromes

Question 1

Describe the local effects of a tumor

Answer 1

Basically what a tumor is doing to structures nearby:

Tumor destruction of normal tissue

Invasion of/pressure on adjacent structures

Erosion of mucosa, vessels, skin/peripheral nerves

Question 2

Tumor compression on a nerve can result in what symptoms?

What symptoms can result from an intracranial lesion caused by tumor invasion?

Answer 2

Nerve compression >> pain and focal weakness/numbness

Intracranial lesion (think of encephalitis symptoms): swelling, headache, focal weakness/numbness, confusion, seizures

Question 3

What pathology is seen below?

Answer 3

Invasion of bone marrow by malignancy

Question 4

Bleeding can occur as a result of tumor erosion of vessels etc. __, hematemesis, hematuria and __ can all be signs of tumor related bleeding

Answer 4

Bleeding can occur as a result of tumor erosion of vessels etc. melena (dark, tarry stools), hematemesis, hematuria and hemoptysis can all be signs of tumor related bleeding

**note that melena and hematemesis are both indicative of an upper GI bleed**

Question 5

A ___ tumor is a tumor at the apex of the lung that compresses adjacent structures and can lead to Horner’s syndrome

What symptoms would you expect to see if there is brachial plexus involvement with this tumor?

Answer 5

A pancoast (like pan-toast) tumor is a tumor at the apex of the lung that compresses adjacent structures and can lead to Horner’s syndrome

If brachial plexus involvement, expect to see shoulder pain and arm weakness

Question 6

SVC syndrome can result from ___

What are some of the symptoms that can arise in SVC syndrome?

Answer 6

SVC syndrome can result from compression of the SVC by a tumor

Observed symptoms include face, neck & upper extremity edema, facial plethora, shortness of breath, cough, headache

**note that is typically the result of small cell lung cancer but other cancers can do this as well)

Question 7

Cachexia is a common cancer complication and it characterized by ___

Answer 7

Elevated basal metabolic rate

Equal loss of body fat and lean body mass

**note that this is in contrast to starvation where there is a lowering of basal metabolic rate and preferential loss of body fat**

(there are also cytokines that are produced that are involved in this process, namely proteolysis-inducing factor (PIF) which acts directly on muscle & fat to ↑ catabolism, TNFa, IL-1 etc)

Question 8

How is cancer able to influence hormone production?

Answer 8

Tumors of the endocrine glands can cause hormone overproduction (more common in benign tumors) or tumors in non-endocrine organs can produce hormones or hormone like products

Question 9

Describe a paraneoplastic syndrome

Answer 9

Paraneoplastic syndromes are a group of symptoms that are caused by an altered immune response to cancer

**note that these are NOT due to overproduction of hormones indigenous to the tumor’s tissue of origin, and also not caused by local or distant spread of the tumor**

Question 10

Paraneoplastic endocrinopathies are characterized by ectopic hormone production. Name 5 such endocrinopathies

Answer 10

Cushing syndrome (overproduction of ACTH or POMC)

Hypercalcemia

Syndrome of inappropriate ADH secretion (SIADH)

Carcinoid syndrome

Polycythemia

Question 11

Cushing syndrome can result from the ectopic production of __ or ___ by a tumor

Answer 11

Cushing syndrome can result from the ectopic production of ACTH or POMC by a tumor

(about half of folks have lung cancer and for the most part, it’s small cell lung cancer)

Question 12

There are two major causes of hypercalcemia in cancer patients. Name them.

Which one of these is considered a paraneoplastic syndrome?

Answer 12

1. Osteolysis induced by cancer in the bone (primary or metastatic) - not considered paraneoplastic
2. Production of calcemic humoral substances by cancers that ARE NOT in the bone

Question 13

Describe the development of paraneoplastic hypercalcemia

Answer 13

Recall that parathyroid hormone-related peptide is a PTH like peptide that binds to PTH receptor and is secreted in small amounts by normal tissues

In the case of a tumor, this can be secreted in high amounts

(remember, PTH increases calcium levels in the blood)

Question 14

The lab findings to diagnose paraneoplastic hypercalcemia include elevated Ca2+, ___ PTH and ___ PTHrP

What are some of the symptoms of paraneoplastic hypercalcemia?

Answer 14

The lab findings to diagnose paraneoplastic hypercalcemia include elevated Ca2+, low/normal PTH and elevated PTHrP

Symptoms (pretty much just hypercalcemia symptoms)

Altered mental status or confusion

Constipation

Nausea/vomiting

Fatigue/lethargy

Excessive thirst and urination

Question 15

SIADH results from ___ and can occur in which types of cancer?

Answer 15

SIADH results from ectopic ADH secretion >> impaired water excretion/excessive water resorption >> hyponatremia

Occurs in small cell lung cancer and intracranial cancers >> leads to cerebral edema and neurologic dysfunction

Question 16

What will the levels of serum sodium, serum osmolality and urine concentration look like with SIADH?

Symptoms of SIADH include___

Answer 16

Lab findings for SIADH include: low serum sodium level, low serum osmolality and concentrated urine

Symptoms (again, resemble encephalitis): confusion, altered mental status, seizures, generalized muscle weakness, hyporeflexia, ataxia, tremors, etc

Question 17

___ syndrome results from excess secretion of serotonin or ___ and is characterized by ___

Answer 17

Carcinoid syndrome results from excess secretion of serotonin or bradykinin and is characterized by flushing, diarrhea, wheezing +/- cardiomyopathy

**occurs in GI or lung neuroendocrine tumors**

Question 18

Describe polycythemia and what it results from

Answer 18

Polycythemia is red blood cell overproduction and it results from ectopic production of EPO from a tumor (mainly renal cell carcinoma or liver tumor - the kidney makes EPO anyway so don’t know how renal cell carcinoma-induced polycythemia would be paraneoplastic)

**EPO usually increased in a state of hypoxia; so here EPO is being produced by the tumor, not in response to hypoxia**

Question 19

Name a dermatologic syndrome that can result from malignancy (hint: name of condition literally means black thickening of the skin)

How does this condition develop?

Answer 19

Acanthosis nigricans: gray-black patches of velvety thickening along the skin

This condition results from abnormal secretion of epidermal growth factor by tumor (can result from gastric, lung, uterine cancers)

**note that this can also happen in non-malignant conditions**

Question 20

___ is an osseous/sof tissue paraneoplastic syndrome that affects the distal ends of long bones

What features clue you into this syndrome?

Answer 20

Hypertrophic osteoarthropathy

Features of hypertrophic osteoarthropathy:

Periosteal new bone formation (at distal ends of long bones)

Arthritis of adjacent joints

Clubbing of the digits **significant if it is a new finding**

Question 21

What is a vascular syndrome that can occur from malignancy?

Answer 21

Migratory thrombophlebitis/Trosseau syndrome

Characterized by repeated episodes of thrombophlebitis (inflammation of superficial veins involving different sites) resulting from mucins that activate clotting cascade

**normally seen in pancreatic and lung cancers**

Question 22

Another hematologic/vascular syndrome that can arise from malignancy is __, aka Marantic endocarditis

How does this condition develop?

Answer 22

Another hematologic/vascular syndrome that can arise from malignancy is non-bacterial endocarditis, aka Marantic endocarditis

The condition results from hypercoagulability and is characterized by the formation of sterile vegetations on cardiac calve leaflets

**more often seen in advanced cancers i.e. mucin producing adenocarcinomas**