path respiratory - formatted Flashcards
- 1.APRIL02 Which of the following best describes the most common macroscopic’ appearance of bronchioalveolar carcinoma of the lung?
- Central hilar mass
- Peripheral solitary mass favouring the upper lobes
- Peripheral mass, usually as multiple diffuse nodules with tendency to coalescence
- Central area of ill-defined consolidation
- Bilateral ill-defined unresolving multifocal consolidation
- LW: Robbins states “BAC involve peripheral parts of lung as either single nodule, or more often as multiple diffuse nodules that may coalesce to produce pneumonia like consolidation” hence answer 3 is preferred.
2. Peripheral solitary mass favouring the upper lobes 3. Peripheral mass, usually as multiple diffuse nodules with tendency to coalescence Adenocarcinomas in situ (AIS) of the lung refer to a relatively new entity for a pre-invasive lesion in the lung. This entity partly replaces the noninvasive end of the previous term bronchoalveolar carcinoma. Adenocarcinoma in situ is defined as a localised adenocarcinoma of <3 cm that exhibits a lepidic growth pattern, with neoplastic cells along the alveolar structures but without stromal, vascular, or pleural invasion 1.- < 3 cm- no invasion- lepidic growth
- 2.APRIL02 Lung carcinomas are associated with the following paraneoplastic syndromes, with the EXCEPTION of:
- Lambert-Eaton syndrome (a myasthenia like syndrome)
- Hypocalcaemia
- Gynaecomastia.
- Low serum sodium
- Horner syndrome
- Horner syndrome (not paraneoplastic syndrome)
- LW:
- cushing syndrome –> ACTH
- carcinoid syndrome –> serotinin and bradykinin
- Hypocalceamia –> calcitonin
- hypoglycaemia
- PTHrP –>hypercalcaemia
- SIADH –> low Na++
- Eaton Lambert syndrome
- limbic encephalitis
- gynacomasteia –> gonadotrophins.
APRIL02 Concerning mesothelioma, Which of the following statements IS INCORRECT:
- Asbestos workers who smoke have a greater risk of developing mesothelioma than those who do not smoke
- The epithelial form has a better prognosis than the sarcomatous form
- Tumour characteristically extends into the fissures
- Tumour can arise from the parietal or the visceral pleura
- There is a greater risk of developing the tumour with the crocidolite-type of asbestos fibre than anthophyllite.
- Asbestos workers who smoke have a greater risk of developing mesothelioma than those who do not smoke
* *Does not increase risk of mesothelioma in smokers, but smoking+asbestos= 55x lung cancer.**
Mesothelioma, also known as malignant mesothelioma, is an aggressive malignant tumour of the mesothelium. Pleura (visceral and parietal) .
Given the presence of the mesothelium in different parts of the body, mesothelioma can arise in various locations pleural mesothelioma (~90%) peritoneal mesothelioma (~10%) pericardial mesothelioma (<1%) cystic/multicystic mesothelioma, tunica vaginalis, testis mesothelioma (<1%)
Risk factors for mesothelioma:
- Asbestos-fibre exposure: causes majority of cases erionite-fibre exposure: naturally occurring mineral used in building, particularly in Turkey
- simian virus 40 (SV40)
- radiation exposure
Amphibole fibres (needle like): CrocidoLITE (most hazardous), anthophylLITE
Serpentine (curly, more soluble and gets impacted upper airway): ChrysoTILE.
Histology: epithelial: 60%, sarcomatoid: 20% mixed: 20% (or slightly more)
Histologic subtype has significant implications for prognosis, with the poorest outcomes observed for sarcomatoid tumors.
Ddx: Fibrous solitary tumour
- 4.APRIL02 Concerning bronchogenic carcinoma, which of the following statements is correct?
- Adenocarcinoma has the strongest correlation with smoking.
- Squamous cell carcinoma is the histologic sub-type that most often produce para-neoplastic syndrome
- Small cell carcinoma is most responsive to chemotherapy
- Bronchioloalveolar carcinoma is a sub-type of large cell carcinoma
- There is no increased risk of developing the tumour in asbestos workers
- Small cell carcinoma is most responsive to chemotherapy (Small cell is sensitive to radiotherapy & chemotherapy, with potential cure rates of 15 – 25 % for localized disease)
APRIL02 Concerning bronchogenic carcinoma, which of the following statements is correct?
- Adenocarcinoma has the strongest correlation with smoking. (Small cell > Squamous show strongest association with Smoking)
- Squamous cell carcinoma is the histologic sub-type that most often produce para-neoplastic syndrome (Small cell)
- Small cell carcinoma is most responsive to chemotherapy (Small cell is sensitive to radiotherapy & chemotherapy, with potential cure rates of 15 – 25 % for localized disease. However, most patients with small cell carcinoma have distant metastases at diagnosis. Thus, even with treatment, the mean survival after diagnosis is only about 1 year.)
- Bronchioloalveolar carcinoma is a sub-type of large cell carcinoma (F - adenocarcinoma “in situ”)
- There is no increased risk of developing the tumour in asbestos workers (F- Asbestos exposure also increases the risk for lung cancer development. The latent period before the development of lung cancer is 10 to 30 years. Lung cancer is the most frequent malignancy in individuals exposed to asbestos, particularly when coupled with smoking. Asbestos workers who do not smoke have a five-fold greater risk of developing lung cancer than do nonsmoking control subjects, and those who smoke have a 55-fold greater risk.)
- 13.02.51 The following are not associated with primary TB
- Consolidation
- Lung disease of secondary TB worse than primary
- Ghon complex defined as the pulmonary lesion only
Not assoc with primary TB
3. Ghon complex defined as the pulmonary lesion only
Ghon focus = initial tuberculous granuloma formed during primary infection and is not radiologically visible unless it calcifies - this occurs in up to 15% of cases
Ghon complex = parenchymal granuloma (Ghon focus) + ipsilateral mediastinal LN
Ranke = Calcified Gohn focus + calcified LN (ie a progression of Ghon complex)
ref: Radiopaedia
- 5.APRIL02 Concerning pulmonary tuberculosis, which of the following statements IS INCORRECT?
- Primary infection is usually asymptomatic
- The Ghon focus is characteristic of post-primary (secondary) tuberculosis
- Cavitation is characteristically seen in reactivation of tuberculosis
- In miliary tuberculosis, grey-white nodules are scattered throughout the lung parenchyma and the pleura
- Bronchial stenosis is a complication
- The Ghon focus is characteristic of post-primary (secondary) tuberculosis (Initial focus of 1° infection = Ghon complex)
*LW:
Gohn Focus = primary infection of bacilli causing small inflammatory consolidation focus.
Gohn compex = Combination of parenchymal lung lesion (Gohn focus) and nodal involvement.
Ranke complex = Progressive fibrosis of Gohn complex, becoming radiologically calcified.
- 5.APRIL02 Concerning pulmonary tuberculosis, which of the following statements IS INCORRECT?
- Primary infection is usually asymptomatic (Usually progresses to fibrosis & calcification (asymptomatic)
- The Ghon focus is characteristic of post-primary (secondary) tuberculosis (Initial focus of 1° infection = Ghon complex)
- Cavitation is characteristically seen in reactivation of tuberculosis (Erosion into a bronchiole & drainage of caseous focus → CAVITY)
- In miliary tuberculosis, grey-white nodules are scattered throughout the lung parenchyma and the pleura
- Bronchial stenosis is a complication
- 6.APRIL02 A patient with known coal worker’s pneumoconiosis has a CXR. They have increased risk of all of the following conditions WITH THE EXCEPTION of:
- Tuberculosis
- Bronchogenic carcinoma
- Progressive massive fibrosis
- Chronic bronchitis
- Emphysema
- Bronchogenic carcinoma
Note- increased risk of -> TB-> Copd, emphysema-> PMFdetabatable regarding cancer
**LJS - Robbins 9th ed says no increased risk of TB either
Robbins:
The spectrum of lung findings in coal workers is wide, varying from asymptomatic anthracosis, to simple coal workers’ pneumoconiosis with little to no pulmonary dysfunction, to complicated coal workers’ pneumoconiosis, or progressive massive fibrosis, in which lung function is compromised.
Coal workers may also develop emphysema and chronic bronchitis independent of smoking.
Unlike silicosis, there is no convincing evidence that coal dust increases susceptibility to tuberculosis. There is also no compelling evidence that coal workers’ pneumoconiosis in the absence of smoking predisposes to cancer.
- 7.APRIL02 Concerning bacterial pneumonia, which of the following statements IS INCORRECT?
- Klebsiella pneumoniae causes lobar pneumonia with abundant inflammatory exudate
- Streptococcus pyogenes is the commonest cause of community-acquired pneumonia
- Haemophilus influenzae causes round pneumonia
- Staphylococcus aureus pneumonia is associated with abscess formation
- Haemorrhagic oedema of hilar and mediastinal lymph nodes is characteristic of inhalational anthrax
- Streptococcus pyogenes is the commonest cause of community-acquired pneumonia (46% Pneumococcus pneumoniae, 29% Gram negatives, 23% Staph. Aureus)
- 8.APRIL02 A patient with known asbestos exposure has an abnormal CXR. Which of the following conditions IS NOT asbestos related?
- Pleural effusion
- Non calcified pleural plaques
- Laryngeal carcinoma
- Bronchogenic carcinoma
- Pulmonary microlithiasis
- Pulmonary microlithiasis
- 9.APRIL02 Which of the following statements concerning asbestos exposure IS LEAST correct?
- There is an increased incidence of carcinoma in families of asbestos workers
- Histologically asbestosis is characterised by a diffuse basal pulmonary fibrosis with visible asbestos fibres encased in an ironcontaining proteinaceous coating.
- The pulmonary fibrosis begins around the respiratory bronchioles and alveolar ducts.
- Macroscopic nodule formation may occur in patients with rheumatoid disease
- While the risk is markedly increased the overall lifetime incidence of mesothelioma with heavy asbestos exposure remains low – in the order of 1 in 1000.
- While the risk is markedly increased the overall lifetime incidence of mesothelioma with heavy asbestos exposure remains low – in the order of 1 in 1000. (Lifetime risk with high exposure ~10% i.e. 1 in 10) 10.
- APRIL02 Which of the following statements concerning asbestos exposure IS LEAST correct?
- There is an increased incidence of carcinoma in families of asbestos workers
- Histologically asbestosis is characterised by a diffuse basal pulmonary fibrosis with visible asbestos fibres encased in an ironcontaining proteinaceous coating.(Asbestos bodies = fibres coated with iron-containing proteinaceous material)
- The pulmonary fibrosis begins around the respiratory bronchioles and alveolar ducts.
- Macroscopic nodule formation may occur in patients with rheumatoid disease (Large parenchymal nodules may appear in patients with concurrent rheumatoid arthritis (Caplan syndrome)) *LW varying defintions of Caplan syndrome, originally just CWP with Rh nodules, but recently extended to involve all pneumoconioses inlcuding asbestos, so likely true.
- While the risk is markedly increased the overall lifetime incidence of mesothelioma with heavy asbestos exposure remains low – in the order of 1 in 1000. (Lifetime risk with high exposure ~10% i.e. 1 in 10)
- 10.APRIL02 A 68-year-old man has a suspected primary left bronchogenic carcinoma. Which of the, following aspects of a radiological report HAS NO OR LEAST relevance to staging?
- Tumour size greater or less than 5 cm
- Involvement of regional intrapulmonary nodes (separate to hilar or mediastinal nodes)
- Side of any mediastinal node enlargement
- Distance from the carina
- Presence of lobar collapse
- Involvement of regional intrapulmonary nodes (separate to hilar or mediastinal nodes) +/- involvement means that it goes from N0 to N1 can’ remember this as a part of staging system
**LJS - intrapulmonary nodes = N1, so does have relevance. Old question, previously distance to carina was important, now only involvement of carina is (8th edition staging). If this were asked now, distance from carina would be least true
- 13.02.06 Coal workers pneumoconiosis on 6 months follow up chest x-ray least likely finding ? Rob p269
- TB
- PMF
- Bronchial Ca
- Caplan’s syndrome
- Pulmonary HT
- TB: *LW: robbins states unlike silicosis, there is no convincing evidence that coal dust increases susceptibility to TB: so this is also false
- Bronchial Ca (No ↑ risk of lung cancer)
* LW agrees. - 13.02.06 Coal workers pneumoconiosis on 6 months follow up chest x-ray least likely finding ? Rob p269
Previous answers:
1. TB (Incidence of TB increased)
- PMF
- Bronchial Ca (No ↑ risk of lung cancer)
- Caplan’s syndrome (Occurs in patients with Rheumatoid Arthritis & pneumoconiosis)
- Pulmonary HT (Involvement of pulmonary vasculature by scarring → pulmonary hypertension & cor pulmonale)
- 13.03.02 Patient with suspected C. psittacosis for HRCT ? Rob p310-311, 483
- Inflammation – histiocytes/lymphocytes confined to alveolar walls
- Neutrophilic exudate within alveoli
- Grey/white slough on bronchial walls
- Mucous plugging and areas of atelectasis
- Inflammation – histiocytes/lymphocytes confined to alveolar walls
- C. psittaci is excreted from infected birds and inhaled with dust particles.
- Although human infection may be asymptomatic or mild, C. psittaci also causes a severe pneumonia, also known as ornithosis.
- Lethal generalized disease, most frequent during epidemics, is marked by focal areas of necrosis in the liver and spleen and diffuse mononuclear infiltrates in the kidneys, heart, and (sometimes) brain.
- The alveolar septa are widened and edematous and usually have a mononuclear inflammatory infiltrate of lymphocytes, histiocytes, and occasionally plasma cells.
- In acute cases, neutrophils may also be present.
- The alveoli may be free from exudate, but in many patients there are intra-alveolar proteinaceous material, a cellular exudate, and characteristically pink hyaline membranes lining the alveolar walls, similar to those seen in hyaline membrane disease of infants.
- These changes reflect alveolar damage similar to that seen diffusely in ARDS.
- Subsidence of the disease is followed by reconstitution of the native architecture
- 13.03.41 In pure emphysema VS pure chronic bronchitis? Rob p459
- Emphysema occurs younger
- Chronic bronchitis more likely to have cardiomegaly
- Elastic recoil is preserved in emphysema
- bronchitis earlier and more short of breath
- cor pulmonale more common in emphysema
- Chronic bronchitis more likely to have cardiomegaly (Emphysema small heart vs Bronchitis large heart)
- 13.03.41 In pure emphysema VS pure chronic bronchitis? BRob p459
- Emphysema occurs younger (Emphysema 50-75 vs Bronchitis 40-45)
- Chronic bronchitis more likely to have cardiomegaly (Emphysema small heart vs Bronchitis large heart)
- Elastic recoil is preserved in emphysema
- bronchitis earlier and more short of breath (Dyspnoea - Emphysema severe:early vs Bronchitis mild late)
- cor pulmonale more common in emphysema (Emphysema Rare: terminal vs Bronchitis common)
- 13.03.42 DEFINITION of chronic bronchitis is ? Rob p463
1. Productive cough in 3 consecutive months over for 2 consecutive years
- Productive cough in 3 consecutive months over for 2 consecutive years
- 5.03.40 Young female with tufts of capillary formation? Rob p130
- Primary pulmonary hypertension
- Goodpastures
- SLE
- Recurrent thromboemboli
- Primary pulmonary hypertension
• Plexogenic pulmonary arteriopathy in primary pulmonary hypertension.
Plexogenic arteriopathy has been a term used to describe a constellation of vascular changes occurring in those with pulmonary arterial hypertension. It is considered the histologic hallmark of idiopathic pulmonary arterial hypertension; it is seen in approximately 75% of cases
The term for the clinical situation has not been largely replaced by idiopathic pulmonary hypertension.
chest CT, may been seen as small, tortuous peripheral arteries without a significant connection to pulmonary veins.
Features of background pulmonary hypertension may also be present.
features of pulmonary hypertension on CT- dilated pulmonary trunk- peripheral pruning and tortuousity of pulmonary arteries- right ventricular dilation and/ or hypertrophy- interventricular septal flattening/ bowing- right atrial dilation
- 13.02.10 Definition of Bronchiectasis ? Rob 464
- Permanent dilatation bronchus and bronchioles > accompanying arterioles
- Permanent dilatation bronchus and bronchioles > 1.1 accompanying arterioles
- Chronic Permanent dilatation of the bronchi and bronchioles caused by destruction of the muscle and elastic supporting tissue, resulting from or associated with necrotizing infection of bronchus and bronchioles
- Chronic infection of bronchus and bronchioles
- Cylindrical saccular, varicose dilation of bronchus and bronchioles
- Chronic Permanent dilatation of the bronchi and bronchioles caused by destruction of the muscle and elastic supporting tissue, resulting from or associated with necrotizing infection of bronchus and bronchioles
- 13.03.38 ARDS takes a long time to resolve because Rob p466
- Usually associated with bacterial superinfection
- Always goes on to fibrosis
- Abnormality is due to endothelaial damage and increased capillary permeability.
- Takes a long time for Type II pneumocytes to recover
*LW quoting Robbins:
Organising stage, type 2 pnuemocytes undergo proliferation to try and regenerate the alveolar lining damaged. Resolution is unusual, more commonly there is organisation of the fibrin exudate with resultant intra alveolar septa fibrosis, and marked thickening of alveolar septa, due to proliferation of interstitial cells and collagen deposition.
Fatal cases often have superimposed broncho-pneumonia.
Initial injury is to capillary endothelium most commonly, progressing to both endothelium and alveolar epithelium.
Acute consequences of damage to alveolar capillary membrane include increased vascular permeability, and alveolar flooding, loss of difusion capacity, surfactant abnormalities due to type 2 cell injury, Exudate and diffuse tissue destruction cannot be easily resolved, resulting in organisation with scarring –> chronic disease.
Thus:
1. Usually associated with bacterial superinfection: not always (tend to be fatal cases), so less correct
- Always goes on to fibrosis: commonly goes onto fibrosis, so partially correct, but term ‘always’ makes me dubious.
- Abnormality is due to endothelaial damage and increased capillary permeability: TRUE.
- Takes a long time for Type II pneumocytes to recover: semi true.
Previous answer:
• the exudate and diffuse tissue destruction that occur with ARDS cannot be easily resolved, and the result is generally organization with scarring, producing severe chronic changes, in contrast to the transudate of cardiogenic pulmonary edema, which usually resolves
- 7.02.55 Hyaline Membrane Disease (‘mild’ form) Rob p466
- Child typically breathless at birth
- Child becomes breathless a short time after birth
- Various durations for recovery
- Child becomes breathless a short time after birth
- At birth may require resuscitation but usually quickly establishes spontaneous breathing + normal colour
- Shortly after (30mins)develops respiratory distress + cyanosis requiring ventilation
- In uncomplicated cases recovery begins in 3 – 4 days
- 13.02.08 Desquamative interstitial pneumonitis ? Rob p468
- Hamman-Rich syndrome
- Desquamative lymphocytic interstitial pneumonitis
- Chronic interstitial pneumonitis
- Treatable condition and can progress to UIP
- Chronic form of UIP
- Treatable condition and can progress to UIP
* LW: confusing question with terminology used… - Hamman-Rich syndrome: False –> Acute interstitial pneumonitis.
- Desquamative lymphocytic interstitial pneumonitis: False - macrophages predominate = smokers macrophages.
- Chronic interstitial pneumonitis: is a broad umbrella term for interstitial pneumonias of chronic duration, although not radiologically descriptive it tends not to include ground glass appearacnes which DIP is…..
Differing line of thought…symptoms are usually insideous and thus suggest chronicity, and micro shows mild chronic inflammatory changes…. - Treatable condition and can progress to UIP: most correct option (sub set can progress to fibrosis with continued smoking).
- Chronic form of UIP: False, DIP minimal if any fibrosis, and is usually non progressive (subset can progress to fibrosis with continued smoking).
- 13.03.94 Sarcoid – which is TRUE? Rob p470
- Relapsing/ remitting course
- Complete recovery in 60-80%
- Residual pulmonary/ visusal impairment in 30%
- Complete recovery in 60-80%
Course → either
(1) Progressive Chronicity Or
(2) Periods of activity interspersed with remissions
• 70% recover with no/minimal residual manifestations
• 20% have permanent loss of some lung function / visual impairment
• 10% have progressive pulmonary fibrosis & cor pulmonale
- 13.03.31 Sarcoid which is MOST ATYPICAL ? Rob p470
- Afro-american
- South East Asian
- Ashkenzai Jew
- Living in tropics
- Male
- South East Asian (rare in Asians – from B&H)
- 13.03.31 Sarcoid which is MOST ATYPICAL ? Rob p470
- Afro-american (Most common)
- South East Asian (rare in Asians – from B&H)
- Ashkenzai Jew (no mention of this)
- Living in tropics (no mention of this)
- Male (more prevalent in females, but race more important overall)
- 13.02.07 Sarcoid What is true answer? Rob p470
- Hypogammaglobulinemia
- Subpleural interstitial fibrosis
- Bone lesion distal and proximal femur
- 50% affect spleen and liver
- Subpleural interstitial fibrosis true
- 13.02.07 Sarcoid What is true answer? Rob p470
- Hypogammaglobulinemia (Increased ACE level in 2/3, Hypercalciuria 2/3, Hypercalcaemia 2%-15%, hypergammaglobinemia 50%)
- Subpleural interstitial fibrosis true
- Bone lesion distal and proximal femur ( 5%- circumscribed (punched out ) areas of bone resorption in phalanges)
- 50% affect spleen and liver (microscopically involved in 75% of cases)
• microscopically involved in 75% of cases
• splenomegaly in 20% (hepatomegaly less freq. ~5% - scattered granulomas in portal triads)
• Nodules & Nodular thickening in a perilymphatic distribution
o Perihilar bronchovascular
o Subpleural inc. fissures
• nodules 3mm – 1cm
*LW:
Additional facts:
–> Approximately, 50 to 65 percent of patients with sarcoidosis have granulomas on liver biopsy, but symptomatic hepatic sarcoid occurs in 5 to 15 percent
–> The frequency of splenic involvement in sarcoidosis has been reported to be 10% to 50%, depending on whether it is detected on physical examination (5% to 14%), a radiological test (33% to 53%), or a tissue biopsy (24% to 59%)
–> 3 main patterns of sarcoid fibrosis described corresponding to pulmonary function testing results:
1) central bronchial distortion or bronchiectasis featuring air trapping, with predominantly obstructive physiology.
2) peripheral honeycombing, with predominantly restrictive physiology and low DLCO:
usually a minor feature and present only in severe fibrosis, subpleural, mainly the middle and upper lung zones, lower lobes predominance resembling UIP is rare
3) diffuse linear fibrotic pattern, with more mild effect on respiratory function: typically radiate away from hila in all directions
- 13.02.09 Young girl with moderate to several sarcoid presents with sudden death – cause? (Normal Calcium Score) Rob p470
- Renal failure
- Pulmonary HT
- Ruptured berry aneurysm
- Hypertensive cerebral haemorrhage
- Cardiac sarcoid
- Cardiac sarcoid