Pulmonary/Radiology/Pathology Teaching Cases
A 57 year old female presented with purulent sputum production for one week, then developed streaky hemoptysis. She has a 20 pack year history of smoking. Physical exam was unremarkable. Her chest x-ray is shown below.
Bronchoscopy revealed normal airways, with no endobronchial lesions. Transbronchial biopsies in the right upper lobe were non-diagnostic. Endobronchial brushings in this area were suggestive of poorly differentiated carcinoma. The patient underwent right upper lobe resection, at which time a 5 cm mass was noted in the right upper lobe. A biopsy was performed which is shown below:
Gross Specimen:
Microscopic specimen:
All of the following statements regarding this disease are true except:
A) Lung cancer is the leading cause of cancer mortality in both men and women.
B) The incidence of lung cancer is decreasing.
C) Arsenic has been shown to be a risk factor for the development of lung cancer.
D) Approximately 70 percent of patients present with metastasis.
E) The most common presenting symptom is cough.
The answer is B. The biopsy reveals an example of adenocarcinoma. Unfortunately, the number of new cases of lung cancer has increased every year over the last half century. Lung cancer has long been the leading cause of cancer mortality in men and it has recently passed breast cancer as the leading cause in women in 1977, 66,000 versus 43,900. Other risk factors include haloetheis, second hand tobacco smoke, and nickel. Only 10 percent of patients are asymptomatic at the time of presentation. Although non-specific, the most common presenting symptom is cough.
UAB Division of Pulmonary, Allergy, and Critical Care Medicine
Michael Brunson, M.D.
James H. Strickland, Jr., M.D.
Gary M. Strauss, M.D. UptoDate
A 73 year old female with a history of adenocarcinoma of the uterus presented to clinic. She was first treated three years prior with uterine implants, multiple resections and further external radiation. She developed a perforated uterus after radiation, and cul-de-sac washings were positive for adenocarcinoma. Her physical exam was normal. On routine follow-up, she had the chest x-ray shown below:
Fiberoptic bronchoscopy was performed. The pathologic specimen is shown below:
This lesion most likely represents:
A. Metastatic adenocarcinoma
B. Squamous cell carcinoma of the lung
C. Hamartoma
D. Carcinoid tumor
E. Small cell lung cancer
The answer is A. This specimen reveals metastatic adenocarcinoma. The patient had an abdominal CT which revealed marked lymphadenopathy. No other therapy was given. The pathologic specimen reveals anaplastic epithelium forming glands.
UAB Division of Pulmonary, Allergy, and Critical Care Medicine
Michael Brunson, M.D.
James H. Strickland, Jr., M.D.
The patient is a 38 year old WF with a history of rheumatic valvular heart disease, having undergone Starr Edwards mitral valve replacement in 1971. She had been on chronic anticoagulation, and has had a history of chronic paroxysmal atrial fibrillation. Her illness began in late August 1983 when she had some left-sided pleuritic chest pain, not associated with cough, hemoptysis or fever. She subsequently saw her local physician who did not feel that she had a pulmonary embolus on the basis of blood gases and x-ray. About one month later she began to cough up what appeared to be old blood followed by some streaky bright red hemoptysis, not associated with recurrent chest pain, fever, or SOB. She presented to the Cardiology Clinic with these complaints and was admitted.
On admission her exam was unremarkable except for the Starr Edwards valve. Chest X-ray from February 1983 was normal except for some vascular redistribution and the Starr Edwards valve. Chest x-ray on admission revealed a round well defined opacity in the LLL which on the lateral view was posterior based:
A V/Q scan showed matched ventilation perfusion defects consistent with an infarct. The patient had an exercise gas exchange which showed normal dead space ventilation. It was felt that the findings were most consistent with a pulmonary infarct. However sputum cytology was read as suggestive of squamous cell carcinoma, so the patient underwent a bronchoscopy with biopsies taken of the lesions. There were no endobronchial lesions seen. The biopsies revealed hemosiderin laden macrophages and some mild fibrosis which would be consistent with an infarct but could also be seen in any area of inflammation. They were not diagnostic of an infarct. Brushing and washings were negative for malignancy. It was felt that the clinical course was most consistent with a pulmonary infarct in a nonsmoker.
The patient did well for several weeks however a follow up chest x-ray revealed an enlargement of the mass. The patient then underwent a thoracotomy which revealed a necrotic area of pulmonary parenchyma. The pathology specimens are shown below:
Gross specimen:
Microscopic specimen:
All of the following statements regarding this tumor are true except.
A. second hand tobacco smoke
B. haloetheis
C. nickle exposure
D. radon gas
E. decreased dietary selenium
The answer is E. The pathologic specimen reveals a large cell, poorly differentiated carcinoma. Increased risk for the development of lung cancer include all of the above except dietary selenium. Previous pulmonary parenchymal scarring, familial factors, and dietary factors are suspected to be risk factors but large studies have not been performed.
UAB Division of Pulmonary, Allergy, and Critical Care Medicine
Michael Brunson, M.D.
James H. Strickland, Jr., M.D.
Gary M. Strauss, M.D. Up to Date
A 57 year old male presented with a three month history of hemoptysis and epigastric pain. The patient was a nonsmoker. He has no occupational exposures. His chest x-ray is shown below:
The patient's hemoptysis was scant. The second most common cause of hemoptysis is.
A. Cancer of the lung
B. Bronchiectasis
C. Congestive heart failure
D. Tuberculosis
E. Idiopathic
The answer is A or B. Bronchitis and bronchogenic carcinoma are the two most common causes of hemoptysis depending upon the patient population studies. Hemoptysis was considered pathognomonic for pulmonary tuberculosis as Hippocrates famous aphorism reiterates "the spitting of pus follows the spitting of blood, consumption follows the spitting of this and death follows consumption."
This patient had an abdominal CT which revealed a large pancreatic mass as shown below:
The chest x-ray abnormality shows an enlarged right paratracheal lymph node. A bronchoscopy was performed. This biopsy is shown below revealing an adenocarcinoma, likely metastatic:
UAB Division of Pulmonary, Allergy, and Critical Care Medicine
Michael Brunson, M.D.
James H. Strickland, Jr., M.D.
Steven E. Weinberger, M.D. Up to Date
A 44 year old male presented with increased shortness of breath of three weeks duration. He was a nonsmoker. He had a history of mild cardiomegaly with a negative workup. He had a normal chest x-ray eight years prior. His presenting chest x-ray and a CT scan through his mid trachea are shown below. An arteriogram, also shown, reveals the blood supply of the mass to be in the anterior mediastinum.
The patient underwent a left thoracotomy and a 3 kg well encapsulated mass was removed. Several pathologic specimens are shown below.
Gross specimen:
Microscopic specimens:
The most likely diagnosis is:
A thymoma
B. germ cell tumor
C. lymphoma
D. intrathoracic goiter
E. parathyroid adenoma
The answer is A. The low power view reveals a combined proliferation of lymphoid and epithelioid cells. The epithelioid cells are arranged in solid sheets and slender cords with focal trabecular architecture. They have inconspicuous nucleoli. These features are diagnostic of a thymoma.
UAB Division of Pulmonary, Allergy, and Critical Care Medicine
Michael Brunson, M.D.
James H. Strickland, Jr., M.D.
Robert L. Thurer, M.D. Up to Date
A 64 year old male presented with cough and right sided chest pain. His chest x-ray is shown below. He was treated with two courses of oral antibiotics without relief of his symptoms. He underwent a bronchoscopy which reportedly revealed no endobronchial lesions. Bronchial washings were non-diagnostic. He had no history of occupational exposures. PPD was negative with positive controls. He continued to feel poorly and lost ten pounds over the next two to three weeks. He was transferred to UAB for further evaluation. His exam revealed evidence of consolidation on the right but was otherwise unremarkable. His room air ABG revealed pH 7.35/paCO2 48/paO2 58. PFT's revealed an FEV1 of .750 cc's, DLCO was 40% predicted.
CXR:
The patient underwent bronchoscopy with BAL and TBBX, pleural biopsy, and ultimately thoracoscopic lung biopsy at UAB. The BAL specimen is shown below:
The true statement regarding this tumor is:
A. It is small cell carcinoma and should be treated with chemotherapy.
B. It is an adenocarcinoma which should be treated with XRT.
C. The diagnosis of large cell undifferentiated carcinoma should not be made on small endoscopic or cytologic specimens.
D. The diagnosis is mucoepidermoid tumor and should be confirmed with immunoperoxidase stains.
The answer is C. This specimen represent a group of polygonal cells with prominent nucleoli, vesicular nuclei and abundant eosinophilic cytoplasm. However, the diagnosis of large cell carcinoma is a diagnosis of exclusion and should not be made on small samples such as BAL washings or transbronchial biopsies.
Pleural Biopsy:
TBBX:
Thoracoscopic lung biopsy:
UAB Division of Pulmonary, Allergy, and Critical Care Medicine
Michael Brunson, M.D.
James H. Strickland, Jr., M.D.
Jeffrey L. Myers, M.D. Henry D. Tazelaar, M.D. Up to Date
A 60 year old male presented to the VA with chief complaint of twenty five pound weight loss. No fever, cough, hemoptysis, or night sweats. He had no occupational exposures. He had a thirty pack year history of tobacco use. His physical exam revealed a thin black male. Normal head, eye, ear, nose, and throat exam. Lung exam revealed decreased breath sound in the right upper lobe.
Chest x-ray is shown below:
A fine needle aspiration was performed and the results are shown below:
The most likely diagnosis is:
A) Squamous cell carcinoma
B) Silicosis
C) Aspergillus
D) Abscess
E) Tuberculosis
The answer is A. Squamous cell carcinoma may exhibit the presence of keratin and/or intercellular desmosomes. As in this patient, many tumors may show extensive cavitation from central necrosis.
UAB Division of Pulmonary, Allergy, and Critical Care Medicine
Michael Brunson, M.D.
James H. Strickland, Jr., M.D.
Jeffrey L. Myers, M.D., Henry D. Tazelaar, M.D. Up to Date
A 44 year old male presented with URI symptoms for several weeks. He did not improve on antibiotics. he has a 40 pack year history of tobacco use. He worked as a lead burner in a foundry at Oak Ridge, TN. His physical exam was normal. His chest x-ray is shown below.:
A bronchoscopy was performed and the pathologic specimen is shown below:
All of the following statements regarding this tumor are true except:
A. A small subset of tumors may occur as exophytic, endobronchial papillary lesions.
B. Most lesions arise from the proximal portion of the endobronchial tree.
C. Hypercalcemia is a common paraneoplastic syndrome
D. Five year survival of stage I lesions is 40-50 percent.
E. Initial karnofsky score may predict survival
The answer is D. The pathologic specimen reveals a moderately well differentiated squamous cell carcinoma. 60 to 80 percent of squamous cell carcinoma arise in the proximal airways. Five year survival for stage I lesions of non-small cell carcinoma is 60-70 percent. 69% TINO and 59% T2 NO lesions. The three most powerful determinants of survival are extent of disease at presentation, Karnofsky score, and weight loss in the previous six months.
UAB Division of Pulmonary, Allergy, and Critical Care Medicine
Michael Brunson, M.D.
James H. Strickland, Jr., M.D.
Gary M. Strauss Up to Date
A 52 year old female presented for outpatient treatment for wheezing and shortness of breath unresponsive to antibiotics and bronchodilator therapy. A chest x-ray was performed and is shown below:
Bronchoscopy revealed a vascular left main stem tumor. Biopsies are shown below. Immunoperoxidase stains were positive and suggestive of carcinoid:
True statements concerning this tumor are all of the following except:
A. The most useful initial diagnostic test for the carcinoid syndrome is a measurement of 24 hour urinary excretion of 5-HIAA.
B. Bronchial carcinoids may present with prolonged flushes, hemoptysis, or signs of left heart failure due to valvular disease.
C. Somatostatin receptor scintigraphy is the procedure of choice for the diagnosis and staging of carcinoid tumors.
D. Carcinoid tumors may produce chromogranin A, Bradykinin and substance P.
E. The epinephrine provocation test has low sensitivity and may cause prolonged refractory hypotension.
The answer is E. The pathologic specimen reveals strong immunostaining consistent with carcinoid. The epinephrine provocation test is nearly 100 percent sensitivity. Patients are observed for flushing, hypotension, and tachycardia occurring 34 to 120 seconds after injection. The hypotension is usually not profound and is transient, if it persist phentolamine may reverse the effects.
UAB Division of Pulmonary, Allergy, and Critical Care Medicine
Michael Brunson, M.D.
James H. Strickland, Jr., M.D.
Shanthi Sitarama, M.D., PhD, FRCP Stephen E. Goldfinger, M.D. Up to Date
This is a 35 year old who developed hypertension. A screening chest x-ray revealed a right middle lobe nodular density. Fiberoptic bronchoscopy was performed which revealed a very vascular endobronchial lesion. A thoracotomy was performed with resection of her right middle lobe. Several pathologic specimens are shown below including those for chromogranin and synaptophysin, which are positive:
All of the following are true except:
A. Blood serotonin levels are decreased
B. Patients may present with secretory diarrhea
C. An epinephrine provocation test may be positive
D. Urinary values of 5-HIAA may not be elevated
E. The pentagastrin provocation may induce flushing in patients with foregut or midgut tumors.
The answer is A. The pathologic specimen reveals monotonous cells staining for chromogranin and synaptophysin consistent with carcinoid. Solitary pulmonary carcinoids may not produce elevations in urinary 5-HIAA. If urinary 5-HIAA levels are equivocal, blood serotonin levels may be markedly elevated.
UAB Division of Pulmonary, Allergy, and Critical Care Medicine
Michael Brunson, M.D.
James H. Strickland, Jr., M.D.
Shanthi V. Sitaraman, M.D., PhD, FRCP Stephen E. Goldfinger, M.D. Up to Date