These are actual cases to –Stimulate your reading –Test your knowledge of the material Look for the sound icon (often in the upper right hand corner of each slide)

An 88 year old male increasing exertional dyspnea, nonproductive cough over several weeks. Remote smoking history Pipefitter – asbestos prostate cancer diagnosed 2 years ago – hormone therapy Physical exam: VSS, no distress, O2 sats 91% on room air Decreased breath sounds and decreased fremitus from left base to left mid-lung zone. Bloodwork unremarkable, PSA normal (1.2 µg/L). CXR done

Q1: Interpret the CXR Answer (Q1)

Q2: At this point, what are the diagnostic possibilities and your most likely diagnosis? Answer (Q2)

Q3: What is the next best investigation to determine the cause of the effusion? a)Thoracentesis b)Surgical pleural biopsy c)Bronchoscopy d)CT chest Answer (Q3)

Pleural fluid: clear, yellow total protein 46 g/L LDH 259 units/L glucose 5.5 mmol/L WBC 400 x 10 6 /L –poly 27% –lymph 39% –mono 30% –eos 4% gram stain and AFB negative other tests pending Serum: total protein 74 g/L LDH 183 units/L

Pleural fluid (other results) –cytology shows adenocarcinoma. –Staining for PSA negative, morphologic features consistent with lung adenocarcinoma. –bacterial cultures negative. CT chest: 3 cm mass LUL, mildly enlarged mediastinal lymph nodes, tiny nodules on pleura suggesting metastatic deposits.

Q4: What is the most appropriate treatment? a)Surgical resection of the tumor and surgical decortication to prevent recurrence of effusion. b)Chemotherapy to treat the tumor, which will also prevent recurrence of the effusion. c)Radiation therapy for the tumor, which will also prevent recurrence of the effusion. d)None of the above. Answer (Q4)

Q5: The patient and family ask whether the lung cancer is due to his possible asbestos exposure. How would you respond? Answer (Q5)