Pleural Disease and Lung Cancer B&B

Question 1

The lung pleura is lined by ______ which secrete small amounts of pleural fluid for lubrication

Answer 1

mesothelial cells

Question 2

Primary versus secondary spontaneous pneumothorax

Answer 2

Primary – rupture of subpleural bleb, common and tall/thin young males

secondary - older patients with underlying pulmonary disease like COPD

Question 3

patient is an 89-year-old male with a history of COPD presenting with sudden onset dyspnea and pleuritic chest pain. CXR is used to make the diagnosis. What is the most likely diagnosis?

Answer 3

spontaneous pneumothorax - secondary cause, most likely COPD

Question 4

In what medical emergency, usually from trauma, does air enter the pleural space but cannot leave, and the trachea deviates away from the affected side?

Answer 4

tension pneumothorax

Question 5

what are the three general at etiologies of plural effusion?

Answer 5

1. transudative: something driving fluid it pleural space (most often CHF high pressures), mostly fluid in effusion (very little protein)
2. exudative: fluid leaking into pleural space (high vascular permeability) with high protein content, requires drainage
3. lymphatic: from thoracic duct obstruction/injury (malignancy most common cause), milky-appearing fluid high in TAGs

Question 6

what causes transudative pleural effusion? how is it characterized? how is it treated?

Answer 6

Something driving fluid into pleural space (high hydrostatic pressure), most commonly CHF due to high pressures

Can also be due to nephrotic syndrome (low protein) or cirrhosis (low albumin)

mostly fluid in effusion (very little protein)

treat underlying cause (no drainage required)

Question 7

what kind of plural effusion is caused by nephrotic syndrome and cirrhosis?

Answer 7

transudative: Something driving fluid into pleural space (high hydrostatic pressure), most commonly CHF due to high pressures

Can also be due to nephrotic syndrome (low protein) or cirrhosis (low albumin)

mostly fluid in effusion (very little protein)

treat underlying cause (no drainage required)

Question 8

what causes exudative pleural effusion and how is it characterized?

Answer 8

fluid leaks into pleural space due to high vascular permeability - many causes such as malignancy or pneumonia

High protein content in pleural fluid, usually requires drainage

Question 9

how can transudative vs exudative pleural effusion be differentiated in a patient?

Answer 9

transudative: due to high hydrostatic pressure, mostly fluid in effusion, treat underlying cause (no drainage)

exudative: due to high vascular permeability, high protein/LDH content, requires drainage

—> obtain fluid via thoracentesis and test for protein and LDH (Light’s Criteria to analyze fluid)

Question 10

what kind of plural effusion is due to high vascular permeability?

Answer 10

exudative: many causes such as malignancy or pneumonia

High protein content in pleural fluid, usually requires drainage

Question 11

what is the most common cause of the lymphatic plural effusion and how is it characterized?

Answer 11

“chylothorax”: due to thoracic duct obstruction/ injury, most often caused by malignancy

can also be caused by trauma (usually surgical)

milky-appearing fluid high in triglycerides

Question 12

empyema

Answer 12

infected pleural fluid —> pus, putrid odor, positive culture

Question 13

this cancer presents with slow onset symptoms and asbestos is the only known risk factor - what is?

Answer 13

mesothelioma: pleural tumor, slow onset of dyspnea/cough/ chest pain

presents decades after asbestos exposure, poor prognosis

imaging shows pleural thickening and effusion

Question 14

where do polycyclic aromatic hydrocarbons come from and what do they put patients at risk for?

Answer 14

PAH (polycyclic aromatic hydrocarbons) are found in cigarette smoke - carcinogens (lung cancer)

Question 15

hamartoma

Answer 15

Benign pulmonary nodule – lung tissue and cartilage with scattered calcification

Question 16

which two type of fungi and what type of bacteria are known to cause granulomas in the lung?

Answer 16

fungi:
1. Histoplasmosis – patients from Midwest, Mississippi/Ohio river valley.
2. coccidioidomycosis - southwest/ California

bacteria:
Mycobacteria – usually tuberculosis.

Question 17

into what two classes are lung cancers divided, and how do they differ?

Answer 17

small cell – 15%, fast growing and early metastasis, non-amendable to surgical resection, smokers/those treated with chemo, poor prognosis

Non-small cell – 85%, can sometimes be respected, better prognosis, smokers and non-smokers

Question 18

describe the following paraneoplastic syndromes of small cell lung cancer:
a. Cushing syndrome.
b. SIADH
c. Lambert Eaton syndrome.

Answer 18

a. Cushing syndrome: tumor secreting ACTH – progressive obesity and hyperglycemia

b. SIADH: tumor secreting ADH – hyponatremia (—>confusion)

c. Lambert Eaton syndrome: tumor secreting antibodies against presynaptic calcium channels in neurons – block release of acetylcholine, main symptom is weakness

Question 19

what are the five types of non-small cell lung cancer?

Answer 19

1. squamous cell carcinoma.
2. Adenocarcinoma.
3. Large cell carcinoma.
4. Bronchioalveolar carcinoma
5. Carcinoid tumor.

Question 20

describe squamous cell lung carcinoma (include who is usually affected)

Answer 20

hilar mass arising from bronchus, keratin “pearls” produced by tumor cells and “intracellular bridges” between desmosomes

can produce PTH (parathyroid hormone) —> hypercalcemia —> stones, bones, groans, psychiatric overtones (bones/abdominal pain, confusion)

usually male smokers

Question 21

What do squamous cell lung carcinomas sometimes secrete and what is the effect of this?

Answer 21

can produce PTH (parathyroid hormone) —> hypercalcemia —> stones, bones, groans, psychiatric overtones (bones/abdominal pain, confusion)

Question 22

what pathology findings are associated with squamous cell lung carcinoma? (2)

Answer 22

keratin “pearls” produced by tumor cells and “intracellular bridges” between desmosomes

Question 23

What is the most common type of lung cancer in non-smokers and females?

Answer 23

Adenocarcinoma: glandular tumor in the periphery of the lungs

Question 24

This type of lung cancer is poorly differentiated, considered a smoker’s cancer, can be central or peripheral, and has poor prognosis. What is?

Answer 24

Large cell carcinoma

Question 25

Describe the features of bronchioalveolar carcinoma

Answer 25

subtype of adenocarcinoma with many similar features – non-smokers, peripheral

Mucinous (goblet cells) or non-mucinous (Clara/Type II cells) types

Looks like pneumonia on CXR – lobar consolidation

Excellent prognosis

Question 26

what are the two types of bronchioalveolar carcinoma?

Answer 26

Mucinous type: derived from goblet cells

Non-mucinous type: derived from Clara cells or type II pneumocytes

[bronchioalveolar carcinoma is subtype of adenocarcinoma – glandular tumor]

Question 27

patient is a 35-year-old female, presenting with chronic cough and dyspnea. No past history of smoking. CXR shows lobar consolidation which was originally diagnosed as pneumonia, but is now thought to be malignant. What cancer is most likely and what is the most likely prognosis?

Answer 27

bronchoalveolar carcinoma: subtype of adenocarcinoma with many similar features – non-smokers, peripheral

Mucinous (goblet cells) or non-mucinous (Clara/Type II cells) types

Looks like pneumonia on CXR – lobar consolidation

Excellent prognosis

Question 28

describe the features of carcinoid lung tumor?

Answer 28

Neuroendocrine tumor with well differentiated cells – chromogranin positive

Usually in non-smokers

*Rarely causes carcinoid syndrome (secretion of serotonin – flushing/diarrhea)

Question 29

Neuroendocrine lung tumor with well differentiated cells – chromogranin positive

Usually in non-smokers

Answer 29

carcinoid tumor (type of non-small cell lung cancer)

Question 30

describe the symptoms of SVC syndrome, which may be caused by compression by lung masses (NSCLC, SCLC), mediastinal mass (lymphoma), or thrombosis (indwelling catheters, pacemaker wires)?

Answer 30

SVC syndrome: obstruction of blood flow through SVC, caused by compression or thrombosis

—> facial swelling, arm swelling, increased ICP (headaches, confusion, cranial artery rupture)

Question 31

Pancoast tumor

Answer 31

carcinoma at apex of lung, involving superior sulcus (groove is formed by subclavian vessels)

—> arm edema on affected side, shoulder pain, radiating toward axilla/scapula, arm paresthesias/weakness

can compressed sympathetic nerves —> Horner’s syndrome (miosis, ptosis, anhidrosis)

Question 32

what are symptoms associated with a pancoast tumor?

Answer 32

carcinoma at apex of lung, involving superior sulcus (groove is formed by subclavian vessels)

—> arm edema on affected side, shoulder pain, radiating toward axilla/scapula, arm paresthesias/weakness

can compressed sympathetic nerves —> Horner’s syndrome (miosis, ptosis, anhidrosis)

Question 33

This type of tumor may cause arm edema on the affected side, shoulder pain radiating toward axilla/scapula arm, weakness, and Horner syndrome. What is?

Answer 33

Pancoast tumor: carcinoma at apex of lung, involving superior sulcus (groove is formed by subclavian vessels)

can compressed sympathetic nerves —> Horner’s syndrome (miosis, ptosis, anhidrosis)

Question 34

what are four common metastasis sites from lung cancer?

Answer 34

1. adrenal - usually found on imaging without symptoms
2. brain - headache, neurodeficits, seizures
3. bone - pathologic fractures
4. liver - hepatomegaly, jaundice

Question 35

Which cancer is most often metastasized to the lungs?

Answer 35

most commonly from breast or colon cancer

More common for cancer to metastasize to the lung, then primary lung tumors to form

Usually multiple lesions on imaging