Lung Cancer

Infections with pneumonia send a substantial number of older adults to the hospital, much more than younger adults. Researchers are calling for new rapid diagnostic tests.

I was “foggy” on when and how to apply screens for lung cancer with low-dose CT, but a perfect model for a 3-question template provided answers.

Congestive heart failure and cirrhosis are the most common causes of transudative pleural effusions, while pneumonia and malignancy are responsible for the majority of exudative effusions. Plain chest films are valuable in confirming the presence of an effusion, providing clues to the cause, and directing the method of pleural fluid sampling. Thoracentesis is safe and simple, and it is diagnostic in about 75% of cases. Pleural biopsy is indicated for unexplained exudative effusions, most of which are found to result from malignancy or tuberculosis. Medical thoracoscopy, if available, is the procedure of choice for patients with these effusions. Thoracoscopy permits visually directed pleural biopsies and allows for therapeutic intervention at the time of diagnosis, obviating the need for subsequent invasive procedures.

A 57-year-old man requests an extensive medical evaluation as part of a transition in the ownership of his business. He is generally healthy, although he reports that his capacity for physical exertion has diminished over the past several years. He denies chest pain with effort, dyspnea at night or on exertion, cough, and sputum production.

abstract: Hemoptysis has many causes, including bronchiectasis, lung cancer, and bronchitis. The initial goals of the history and physical examination are to differentiate hemoptysis from epistaxis and hematemesis and then to establish its severity. A variety of signs and symptoms may suggest the underlying cause. For example, hematuria suggests vasculitis or an immunologically mediated disease, such as Wegener granulomatosis or systemic lupus erythematosus. The workup includes chest radiography and measurement of hemoglobin and hematocrit levels, platelet count, international normalized ratio, activated partial thromboplastin time, and creatinine level. Chest CT scanning often identifies sources of bleeding that are not apparent on radiographs and sometimes can be used in conjunction with bronchoscopy. Patients with massive hemoptysis should be hospitalized for rapid evaluation and intervention; treatment may include interventional bronchoscopy, angiography, or embolization. (J Respir Dis. 2007;28(4):139-148)

A 57-year-old woman presents with swelling of the hands that began several weeks earlier and is now worsening. She denies joint pain, and she has no history of trauma or significant vascular disease. She has had pneumonia several times; each episode was successfully treated with antibiotics. She has smoked 2 packs of cigarettes a day for the past 20 years

A 59-year-old woman was evaluated for epigastric discomfort and iron deficiency anemia of 2 months' duration. Two years earlier, she had undergone left upper lung lobectomy and adjuvant radiation for T2 N0 M0 poorly differentiated adenocarcinoma of the lung.

A 58-year-old man presents with exertionaldyspnea of 6 weeks’ duration, adry cough for 2 weeks, and decreasedappetite. He denies fever, chills, sputumproduction, hemoptysis, cigarette smoking,and significant weight loss. Thepatient, a retired electrician, was exposedto asbestos 20 years earlier.

Historically, tuberculosis (TB) was the most commoncause of hemoptysis. Classic operas, such asLa Traviata and La Bohème, featured dramatic scenes ofhemoptysis, often with the heroine dying following episodesof deep passion and coughing.

A 45-year-old man presents with a 1- to2-week history of low-grade fever and nonproductivecough. He has a long history of cigarette and alcoholabuse. The office nurse expresses her concern about thepatients cyanotic nail beds and requests your immediateevaluation.

Alimta (pemetrexed disodium) from Eli Lilly andCompany has received FDA approval for treatmentof malignant pleural mesothelioma. This orphan drug wasapproved under the FDA’s accelerated program for drugsthat treat cancer or life-threatening disease.

A 59-year-old woman presents with generalized facialswelling and dyspnea that has progressed graduallyover the past month. The patient also reports a sensationof pressure in her neck and ears and swelling of the lowereyelids, neck, upper chest, and upper limbs. The bloodvessels on her upper chest are prominent. A dry, irritatingcough has worsened.

A 48-year-old African Americanwoman with HIV infection who hadbeen hospitalized several days earlierfor presumed Pneumocystis cariniipneumonia (PCP) is readmittedbecause of worsening dyspnea and atemperature of 38.8oC (102oF).She also complains of painful swellingand erythema on her right arm.Her symptoms have worseneddespite treatment with trimethoprimsulfamethoxazole.

Several of my patients have asked me about full-body CTscans.

In their case report of a woman withsuperior vena cava syndrome (CONSULTANT,September 15, 2002, page1391), Drs Sonia Arunabh and K.Rauhilla appropriately indicate thatradiation therapy is the primary treatmentwhen the syndrome is caused bysolid malignancies.

A 47-year-old man has had a posterior neck mass for severalmonths. The mass is not painful and has not changed color, but it continues toenlarge.

A chest film obtained as part of a routine insurance evaluation reveals a nodulein the right lower lobe of a 67-year-old man.

A 62-year-old man has had nightsweats and worsening fever andcough for the last 4 days; 2 days agohe had an episode of hemoptysis. Hedenies trauma or travel to a foreigncountry but has a 30-pack-year smokinghistory. The medical history isotherwise noncontributory.

Breast cancer causesmore deaths than anycancer except lung cancer inwomen of all ages. In womenbetween the ages of 40and 59 years, it is the leadingcause of cancer death.1

For 6 months, a 69-year-old man has experiencedpain in his right shoulder; hetakes NSAIDs for relief. During the lastmonth, the pain has worsened, weaknessand tingling have developed in his righthand, and the skin on the right side ofhis face has become dry. The patient alsoreports a 1-month history of melanoticstools. He had smoked 1 pack of cigarettesa day for 50 years before quittinglast year

A 60-year-old woman reportsthat she has felt intermittent“fullness” in her face for the past day.This sensation is present when sheis supine on the examination table.She denies shortness of breath, dysphagia,and chest discomfort. Thepatient has a 25 pack-year history ofcigarette smoking.

Q:Which patients with chronic respiratory disorders are good candidatesfor pulmonary rehabilitation? When is it a better option than surgery?

A 22-year-old man presents to theemergency department with a2-week history of a worsening nonproductive,irritating dry cough andexertional dyspnea. The patient hasbeen otherwise healthy. He deniesfever, rigors, night sweats, hemoptysis,chest pain, palpitations, orthopnea,paroxysmal nocturnal dyspnea,ankle edema, and lymphadenopathy.

Approximately 90% of cases of lung cancer are attributable to smoking-either directly or as a result of passive exposure. Fifty percent of smokersdie of a smoking-related disease. The 4 most common causes of death-heartattack, lung cancer, chronic obstructive pulmonary disease, and stroke-areall associated with smoking. More lung cancer is diagnosed in former than incurrent smokers.1 The risk of lung cancer decreases each year following smokingcessation, but former heavy smokers will always have a higher risk thannonsmokers.

Abstract: Because of recent advances, more patients may potentially benefit from a variety of interventional bronchoscopic techniques. Nd:YAG laser phototherapy is the most widely used modality and is the treatment of choice for patients with endobronchial malignancies who have large-central airway obstruction. Cryotherapy may be superior to Nd:YAG phototherapy for more distal airways lesions because of the lower risk of airway perforation, but it may be suboptimal for bulky airways disease that requires quick relief of obstruction. Brachytherapy relieves symptoms, such as cough, dyspnea, and hemoptysis, in many patients who have locally invasive airway malignancies. Endobronchial ultrasonography appears to be a safe and sensitive method for staging lung cancer. In select patients with emphysema, a 1-way endobronchial valve can be used to reduce lung volumes. Bronchial thermoplasty is being studied as a potential treatment for asthma. (J Respir Dis. 2006;27(10):415-428)

A 65-year-old woman presented to her primary care physician with a 3-month history of worsening cough, now productive of copious blood-tinged secretions. She also reported a recent onset of fever and dyspnea. She denied any chest pain, chills, night sweats, and weight loss.

The authors present a case that demonstrates the diagnostic challenge of mediastinal tumors. They describe the clinical presentation of a patient who had a central endobronchial tumor that was identified as a primary mediastinal spindle cell neoplasm.

A 49-year-old man presented to theemergency department (ED) andcomplained of fever and cough thatproduced bloody sputum for 1 day.He had AIDS and recently receiveda diagnosis of large B-cell lymphoma.His most recent CD4+ cellcount was 24/µL. He had optedagainst receiving highly active antiretroviraltherapy and prophylaxisfor opportunistic infection.

A 43-year-old woman presents to the emergency departmentwith fatigue, dyspnea, and intermittent chest painof 3 days’ duration. Her symptoms have worsened sinceshe arose, and 2 hours ago palpitations developed. She describesthe chest pain as a heavy pressure under her sternumthat does not radiate; she denies fever, nausea, vomiting,and diaphoresis.

A 77-year-old woman who had hadanorexia and weakness for 3 monthswas seen after a syncopal episode. Sheappeared pale but alert. Heart rate was110 beats per minute; respiration rate,22 breaths per minute; and blood pressure,170/70 mm Hg. Her hematologicindices were: hemoglobin level, 4.3 g/dL;mean corpuscular volume (MCV), 60fL; mean corpuscular hemoglobin concentration(MCHC), 29 g/dL; red bloodcell count, 1.6 million/μL; white bloodcell count, 7500/μL; and platelet count,452,000/μL.