2. Pre-session Number2 (Trial-2 /// 8July2013)
Case Review Course
Trial-3 / 2Mordad1392
Pre-session Number2 (Trial-2 /// 8July2013)

4. Approach

5. ------------------ Approach -------------------
A 40-year-old man is referred to the clinic with the chief complaint of cough during the past two month. There was no sign of abnormalities in the physical examination, CXR and spirometry. What would be your next step?

7. Case

8. --------------------- Case ----------------------
A 78-year-old man is seen in the doctor’s office for a non- productive cough, 9-kg (20-lb) unintentional weight loss,all occurring within the past 6 months. He has smoked two packs per day for the past 40 years. His past medical history is otherwise unremarkable, and he takes no medications. His temperature is 36.7°C , blood pressure is 125/85 mm Hg, pulse is 68/min and regular, respiratory rate is 15/min, and oxygen saturation is 99% on room air. There are crackles at the left lower lung field and a ridge of symmetric glandular tissue (1 cm in diameter) around the nipple-areolar complexes of both breasts. Lab test shows a WBC count of 6000/mm3 hemoglobin of 14.7 g/dL, platelet count of 210,000/mm3 & high β-hCG . All other laboratory results are normal. Chest X-ray shows a focal 5-cm mass lesion in the left lower lung corroborated by CT scan. What is most likely diagnosis of this patient?
(A) Adenocarcinoma (B) Bronchoalveolar cell carcinoma
(C) Large cell carcinoma (D) Small cell carcinoma (E) Squamous cell carcinoma

9. Answer

10. ------------------------------------------
A) Adenocarcinoma
Answer A is incorrect. Digital clubbing and hypertrophic pulmonary osteoarthropathy can occur with any histologic subtype of lung cancer, but they are most often associated with adenocarcinoma of the lung. Thrombophlebitis and nonbacterial verrucous endocarditis are cardiovascular complications of adenocarcinoma.

11. B) Bronchoalveolar cell carcinoma
Answer B is incorrect. Bronchoalveolar cell carcinoma is a subtype of adenocarcinoma. It is most often associated with multiple nodules on imaging studies, interstitial infiltration, and prolific sputum production.

12. C) Large cell carcinoma
The correct answer is C. Primary lung cancer is the leading cause of cancer death. The most significant risk factor is smoking because it raises the lifetime relative risk of lung cancer 10- to 30-fold when compared with the lifetime risk of nonsmokers. Patients with lung cancer can present with cough, hemoptysis, chest pain, and unintentional weight loss. Physical examination may reveal crackles or atelectasis. Lung cancer is usually first noted as a nodule on x-ray of the chest but is best defined on CT. Fine-needle aspiration under CT guidance or bronchoscopy with biopsy or brushings can usually establish the histologic diagnosis. Gynecomastia, defined as the benign proliferation of glandular tissue in the male breast and seen clinically as a firm mass extending concentrically from the nipple-areolar complex, is a feature of large cell carcinoma. Large cell carcinoma behaves similarly to poorly differentiated non-small cell lung cancer and may produce β-human chorionic gonadotropin (β-hCG), resulting in gynecomastia, milky nipple discharge, and elevated serum concentrations of plasma β-hCG. Large cell carcinoma of the lung carries a poor prognosis (mean survival time of 7–19 months) and has often metastasized at time of diagnosis.

13. D) Small cell carcinoma
Answer D is incorrect. A variety of syndromes associated with ectopic hormone production are seen with small cell carcinoma, the subtype of lung cancer highly associated with smoking. These include the syndrome of inappropriate secretion of antidiuretic hormone and the syndrome of ectopic ACTH production.

14. E) Squamous cell carcinoma
Answer E is incorrect. The paraneoplastic syndrome associated with squamous cell carcinoma is hypercalcemia, due to the ectopic production of parathyroid hormone–related peptide (PTHrP). Pathologic fractures and kidney stones are also commonly seen as a result of PTHrP production.

15. Mini-cases

16. 1
Differential diagnoses
Workup

17. 2
Differential diagnoses
Workup

18. 3
Differential diagnoses
Workup

19. The End
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