This patient is a 64 year old male with a long history of tobacco use and no known occupational exposures. He presented to the ER complaining of dyspnea on exertion and chest pain. He had noted hemoptysis for 3-4 days. On exam he was wasted and tachypneic. His chest exam revealed rales on the left. He had no lymphadenopathy.
Pertinent lab data revealed a room air arterial blood gas pH 7.50, paCO2, paCO2 of 56. Hct was 31 LDH was 754. His chest x-ray is shown below:
The patient developed hypoxemic respiratory failure. He arrested and was unable to be resuscitated. Pathologic specimens from his lung are shown below:
The most likely represents:
A. Adult respiratory distress syndrome.
B. Wegener's granulomatosis
C. Tumor emboli
D. Pulmonary thromboembolism
E. Churg-Strauss disease
The answer is C. The pathologic specimens reveal a bronchoalveolar cell carcinoma. (left) However, the specimen on the right reveals tumor emboli in a vessel. Therefore this would be classified as a metastatic adenocarcinoma.
UAB Division of Pulmonary, Allergy, and Critical Care Medicine
Michael Brunson, M.D.
James H. Strickland, Jr., M.D.
History: A 39 year old male presented because of increasing dyspnea. He had suffered blunt trauma to his chest several day prior. His chest x-ray is shown below.
The effusion was evacuated and found to be bloody. It had re-accumulated in 3-4 days and the patient was readmitted for chest tube placement. The fluid was evaluated for AFB and cytology. Cells suspicious for adenocarcinoma were found. The patient had a 20 pack year history of tobacco use. PPD was negative with positive controls. He had no known occupational exposures. A pleural biopsy was performed.
This patient most likely has:
A. metastatic carcinoid
B. metastatic adenocarcinoma
C. mesothelioma
D. pulmonary cartusion with normal pleura
E. bronchoalveolar cell carcinoma
The answer is B. The pathologic specimen reveals thickening of the pleura by infiltrating malignant tumor composed of glands. Mucin stain was positive. The blunt trauma the patient suffered was incidental.
UAB Department of Pulmonary and Critical Care Medicine
Michael Brunson, M.D.
A 27 year old white female presented with increased shortness of breath. Her physical exam revealed left axillary adenopathy. Her chest x-ray is below.
A thoracentesis was performed with pleural biopsy. Further examination revealed a dysplastic nevus or the patient's scalp and a soft tissue mobile breast mass. The pleural fluid cell block is shown below with the biopsy of the scalp lesion.
All statements regarding this patient's disease are true except.
A. Metastatic melanoma; four or more lymph nodes; has <5% survival rate.
B. Five year survival of stage I disease is 85%.
C. There is a familial association with development of melanoma.
D. Dark skinned populatrais (Indians, Puerto Ricans) blacks and orientals have rates of 1/7 to 1/10 that of light skinned Caucasians.
E. Metastatic disease to the lung does not occur after 2 years of diagnosis.
The answer is E. The pathologic specimens reveal a pleural fluid cell block (left) and scalp lesion (right). Stage I disease has an excellent 5 year survival rate with local excision, however distal metastasis to lung, gastrointestinal tract, and liver have been described even after 5 years of treatment of the primary tumor.
UAB Department of Pulmonary and Critical Care Medicine
Michael Brunson, M.D.
This patient is a 49 year old white female who presented with fever and shortness of breath. A chest x-ray was interpreted as showing bilateral pneumonia and she was treated with oral antibiotics with equivocal relief of her symptoms. She presented again two months later with increased shortness of breath and cough productive of one to one and a half cups of clear sputum without blood. She has a 30 pack year history of smoking. PPD and controls were anergic. Her chest x-ray is shown below.
A bronchoscopy was performed with transbronchial biopsies. The results are shown below. Her diagnosis is:
A. Bronchoalveolar Cell Carcinoma
B. Large Cell Carcinoma
C. Metastatic Breast Cancer
D. Hypersensitivity pneumonitis
E. CMV pneumonia
A 52 year old male developed a persistent cough of clear sputum. He gives a history of possible aspiration of a chicken bone. His cough persisted for three to four weeks and did not respond to oral antibiotics. Chest x-ray (which revealed no chicken bone) and is shown below:
Fiberoptic bronchoscopy revealed no foreign body. Al of his specimens were non-diagnostic. A thoracotomy was performed. The right lower lobe was rubbery and entirely resected.
The correct statements regarding this tumor is:
A. Often produce paraneoplastic syndromes
B. Radiosensitive
C. Are always associated with tobacco use
D. Are associated with bronchorrhea
E. Never metastasize
The answer is D. The pathologic specimen reveals well differentiated cell lining the alveolar wall. Mucinous broncho-alveolar cell carcinomas may produce copious amounts of sputum; up to 1 1/2 cups per day. Tumors may present localized, diffuse or multinodular. Multifocal disease may be due to aerogenous or lymphatic dissemination, however recent studies suggest multifocal disease may represent synchronous evolution of multiple independent neoplastic clones.
UAB Department of Pulmonary and Critical Care Medicine
Michael Brunson, M.D.
Jeffrey L. Myers, M.D. Henry D. Tazelaar, M.D. Up to Date
A 59 year old male, lifelong smoker presented with a two month history of general malaise and a 20 pound weight loss. He denied cough or known exposure to TB. On physical exam he had a 1.5 centimeter firm left supraclavicular lymph node. Chest exam revealed diffuse fine inspiratory crackles. Pertinent lab data revealed a sodium of 126. Chest x-ray is shown below.
Bronchoscopy was performed which revealed a carinal mass without occlusion of either mainstem bronchus. The biopsy is shown below. With the information given, the stage of this tumor is:
A. Stage III A - non small cell
B. extensive disease - non small cell
C. Stage III B - non small cell
D. limited disease - small cell
E. Stage IV - non small cell
The answer is B. The pathologic specimen reveals atypical cells of small size compatible with small cell carcinoma. Limited disease in small cell is defined as disease in the ipsilateral hemithorax and within a single radiotherapy port (corresponding to TNM staging 1-IIIB)
UAB Department of Pulmonary and Critical Care Medicine
Michael Brunson, M.D.
Anthony Elias, M.D. Up to Date
A 57 year old male with a long history of tobacco use developed nonspecific back and midepigastric pain. Lab test revealed an elevated amylase and he was felt to have pancreatitis. Over several weeks his symptoms resolved, however he presented again with worsening back pain four months later. His physical exam was unremarkable. His chest x-ray is shown below.
A bronchoscopy was performed and the biopsies are shown below. All are true statements regarding the disease except:
A. SIADH is common in small cell carcinoma.
B. 50% of patients with paraneoplastic Cushing's Disease have small cell carcinoma.
C. Humoral hypercalcemia of malignancy is common in small cell carcinoma.
D. The cause of neurologic abnormalities (i.e. Eaton Lambert) frequently is independent of the cause of the underlying tumor.
E. Survival beyond 5 years occurs in only 3-8% of patients.
The answer is C. The biopsy reveals undifferentiated carcinoma composed of intermediate sized spindle shaped cells with hyperchromatic oval shaped nuclei. The cells are arranged in nests and large sheets. The findings are consistent with small cell carcinoma. Humoral hypercalcemia of malignancy is more common in non-small cell carcinoma. The other statements are true.
UAB Department of Pulmonary and Critical Care Medicine
Michael Brunson, M.D.
A 64 year old male presented for surgical repair of longstanding aortic stenosis. His only symptoms were consistent with worsening congestive heart failure. A screening chest x-ray was performed and is shown below.
The right upper lobe was eventually resected. The pathology specimen is shown below. All are true statements regarding this tumor except.
A. Most present as peripheral parenchymal masses.
B. It is the most common cell type associated with Pancoast tumor.
C. Mucin stain may be positive
D. May present with hoarseness
E. Most are found at stage III A, III B, IV.
The correct answer is B. The most common cell type associated with Pancoast tumor is squamous cell, large cell. then adenocarcinoma 52%, 23%, and 23% respectively. The other statements are true.
The pathology specimen reveals a poorly differentiated adenocarcinoma with abundant amphophili cytoplasm and hyperchromatic nuclei.
Johnson D.H. Pancoastis syndrome and small cell lung cancer. Chest 82:602-606,1982.
UAB Department of Pulmonary and Critical Care Medicine
Michael Brunson, M.D.
A 23 year old black female presented to the outpatient clinic complaining of several months of vague chest pains. She was a nonsmoker. She had no previous chest x-rays. Her physical examination was unremarkable. Her PA and lateral chest x-rays are shown below.
A fine needle transthoracic biopsy was non-diagnostic, and the patient underwent a left upper lobectomy. The mass was well circumscribed. The pathology specimen is shown below and reveals relatively bland cells with small nuclei and even chromatin pattern., The last field demonstrates elongated spindle cells set in a myxoid stroma. This most likely represents intrapulmonary neurofibroma.
All of the following are true statements regarding this tumor except.
A. These tumors generally arise in the posterior mediastinum.
B. Gallium scanning assist in staging.
C. These tumors may result in paralysis.
D. MRI is specifically indicated to detect intraspinal "dumbbell" tumor.
E. Alpha feto protein is not generally useful.
The answer is B. Gallium scanning may be used to determine the extent of disease in lymphoma but not neurofibromas. Alpha feto protein and or beta human chorionic gonadotropin levels may be elevated in non-seminomatous germ cell tumors.
UAB Department of Pulmonary and Critical Care Medicine
Michael Brunson, M.D.
Robert L. Thurer, M.D. Up to Date
A 58 year old male presented for evaluation of a persistent left lower lobe pneumonia. He had a 40 pack year history of smoking with mild COPD symptoms. He had no occupational or industrial exposures.
Physical exam revealed decreased breath sounds on the left with a palpable chest wall mass on the left side. He had no lymphadenopathy. His chest x-ray is shown below.
The patient underwent a thoracotomy for diagnosis and was found to have tumor involving the chest wall, pleura, and lung. The pathology specimens reveal a malignant tumor composed of bland cells form glands which are often papillary. Special stains for mucin are negative. This histology is most consistent with malignant mesothelioma. All of the following statements regarding this tumor are true except.
A. 60% of patients have right sided disease. 5% are bilateral
B. Only 20% of patients have radiographic signs of asbestosis.
C. Thoracentesis or pleural biopsy often establishes the diagnosis.
D. There are no definitive serum biomarkers for mesothelioma.
E. Tumor penetrating the diaphragm are stage III.
The answer is C. Thoracentesis or pleural biopsy may establish the diagnosis of malignancy, but video assisted thoracoscopy or open thoracotomy is generally needed to confirm the diagnosis of mesothelioma staging I confined to the "capsule" of parietal pleura II - tumor invading the chest wall or involving mediastinal structures III - lymph nodes outside the chest, penetrating the diaphragm, or involvement of the opposite pleura IV distant blood barine metastasis.
UAB Department of Pulmonary and Critical Care Medicine
Michael Brunson, M.D.
D. H. Sterman, M.D., L. A. Litzky, L. R. Kaiser, M.D., S. M. Albelda, M.D.