A 34-year-old male presented to the emergency department (ED) with a chief complaint of hemoptysis. His past medical history (PMH) was notable for recurrent pneumonias. Chest x-ray (CXR) demonstrated a right middle lobe infiltrate. Chest computed tomoghraphy (CT) revealed an endobronchial lesion at the level of the bronchus intermedius. Flexible bronchoscopy was notable for bloody secretions, and a broad-based lesion in the bronchus intermedius is shown in the figure below:
What is the next most appropriate step in management?
Correct Answer: B
This patient likely has a bronchial carcinoid tumor. Carcinoid tumors of the lung are rare neuroendocrine tumors accounting for less than 1% of all lung tumors. The lung, however, is the second most common presenting site (after the gut) for carcinoid tumor. Typical presenting symptoms include cough, hemoptysis, and/or symptoms of bronchial obstruction. Carcinoid tumors are far more common in the larger airways. The tumors are highly vascular and grow intraluminally as well as extraluminally and are mostly covered by bronchial epithelium. Definitive treatment is with surgical resection, which typically carries an excellent prognosis. Historically there has been concern for massive hemorrhage following forceps biopsy secondary to the highly vascular nature of the tumor . While this complication is actually fairly rare, it is common to sample suspected carcinoid tumors via rigid bronchoscopy, so that any bleeding may be more effectively controlled. Cryobiopsy has also been reported to be preferable to forceps biopsy. IR embolization would not allow for the tissue sampling needed to make the diagnosis of carcinoid. Pulmonary Kaposi sarcoma is characterized by violaceous endobronchial lesions but is typically a late manifestation of HIV and more likely to present with other constitutional symptoms. In addition, the bronchoscopic appearance in this case is far more typical of carcinoid.
A 59-year-old female presents to her primary care doctor with a chief complaint of progressive shortness of breath and nonproductive cough. She denies chest pain, palpitations, or wheezing. Her PMH is notable only for right-sided inflammatory breast cancer, diagnosed 1 year prior to presentation and treated with doxorubicin/cyclophosphamide/paclitaxel followed by x-ray telescope (XRT) and mastectomy. At rest, her room air saturation is 95% and other vital signs are normal. Chest CT is negative for pulmonary embolus but notable for patchy consolidation and ground glass opacities in the right lung as well as traction bronchiectasis. Her WBC is normal and sputum gram stain shows no organisms.
What is the most appropriate treatment?
Correct Answer: C
This patient with a PMH of inflammatory breast cancer and recent (<1 year) radiation to the chest is likely presenting with radiation-induced pneumonitis. Inflammatory breast cancer is a rare but aggressive form of breast cancer that classically presents with a finding of “peau d’orange”— warm, thickened, firm skin over the affected breast. Treatment, as in this case, is multimodal with neoadjuvant chemo, surgery, and radiation. Patients who undergo thoracic radiation are at risk for radiation pneumonitis, which can present weeks to months after therapy. Radiation pneumonitis is thought to result from radiation-induced injury to type II penumocytes and endothelial cells. It typically presents with shortness of breath and dry cough. Chest CT findings include patchy consolidation, fibrotic changes, and ground glass that does not respect lobar borders. Newer radiation techniques make the classic radiographic finding of a portal line marking the boundary of the radiation field less likely. The mainstay of treatment of high-dose prednisone. Ceftriaxone and azithromycin would be appropriate treatment for CAP but the subacute onset, negative gram stain, and lack of other infectious signs and symptoms make that diagnosis less likely here. Similarly, vancomycin and cefepime would not be the most appropriate therapy. Obstructive lung disease (asthma and COPD) can present with dyspnea and would be appropriately treated with bronchodilators such as albuterol, but there are no physical examination findings or history to support that diagnosis here.
A 46-year-old male with a remote history of resected stage IIA non– small-cell lung cancer presents to the emergency room with dyspnea and chest pain. He is tachycardic, tachypneic, and hypotensive. CXR shows mediastinal lymphadenopathy and bilateral pleural effusions. Bedside transthoracic echocardiogram (TTE) was performed and an image is shown below.
The subcostal view image from the TTE demonstrates a large pericardial effusion and right ventricular compression. Given the history and findings on CXR, this is highly likely to be a malignant pericardial effusion. Malignant pericardial effusion has a high probability of recurrence often requiring pericardial window for definitive management. Drainage of the effusion and subsequent referral for definitive management is also a reasonable approach, but that option is not given here. Malignant pericardial effusion can be seen in numerous tumor types, with lung being the most common. In lung cancer, it is thought to occur via spread from local lymphatics rather than direct pericardial invasion. It is associated with a very poor prognosis, although long-term survival is occasionally seen in the current era of targeted therapeutics. Prognosis is most strongly related to treatability of the underlying malignancy rather than any details of the tamponade. Heparin would be appropriate therapy for pulmonary embolus, which can present with shortness of breath and chest pain, but that diagnosis would not explain the echo findings. Aspirin, clopidogrel, and heparin could be a reasonable step in management of an acute coronary syndrome, but that diagnosis is again not consistent with the echo. Fluid resuscitation is mainstay of therapy for hypotension, but, in this case, there is a readily reversible cause of low blood pressure and intervention should be carried out without delay.
A 47-year-old male with a PMH of lung cancer presents with confusion and lethargy. He has postural hypotension and low central venous pressure on examination. There is no fever, cough, sputum, or rash. The remainder of the examination is notable only for tachycardia. CXR shows a right upper lobe mass similar to prior films and mediastinal lymphadenopathy and left lower lobe nodules. Serum creatinine is 2 mg/dL. Serum calcium is 18 mg/dL and electrocardiogram EKG is shown in the figure below:
This patient with advanced lung cancer (lymphadenopathy and contralateral nodules on CXR, in addition to the presumably primary lung mass) is presenting with severe hypercalcemia, which is a medical emergency. Hypercalcemia of malignancy is a late complication in a number of tumors and is associated with poor outcomes. Up to one-half of all patients diagnosed with malignancy-associated hypercalcemia will die within a month of diagnosis. Serum calcium levels are regulated by a balance between bone resorption, intestinal absorption, and renal excretion. Parathyroid hormone (PTH) modulates all of these processes by increasing bone resorption, decreasing renal calcium excretion, and increasing intestinal excretion by converting calcidiol to calcitriol. Hypercalcemia can occur in malignancy via direct osteolysis in the case of bony metastasis, ectopic PTH secretion, or the action of PTH-related proteins. Therapy for hypercalcemia includes aggressive volume repletion, loop diuretics to maintain high urine output, and bisphosphonates such as pamidronate to decrease bone resorption. While pamidronate should be initiated as soon as hypercalcemia is diagnosed, the peak effect is not achieved for 2 to 4 days making other supportive measures, such as fluid resuscitation, important. Serum calcium measurements can be affected by albumin, and there exist formulas for the correction of measured calcium for hypoalbuminemia. However, this patient has classic signs of hypercalcemia (including shortened QT interval of EKG, altered mental status, and hypovolemia) as well as very elevated uncorrected calcium. Head CT is an important part of the workup of altered mental status, but there is adequate evidence to support a diagnosis of hypercalcemia, and treatment should be initiated as soon as possible.
A 60-year-old female was diagnosed with right-sided proximal bronchogenic carcinoma and underwent right-sided pneumonectomy 8 months ago. She presents to the ED with a 1- month history of progressive dyspnea, cough, stridor, and occasional low-grade fevers. A CT chest was performed and shown in the two figures below:
What should be the next step in management?
Correct Answer: D
The image demonstrates stretching of the left main bronchus between the pulmonary artery and vertebral body which can occur in postpneumonectomy syndrome. Postpneumonectomy syndrome is a rare complication that typically occurs 6 months or later after pneumonectomy. It is characterized by extreme shift of the mediastinum, and common symptoms include increasing dyspnea, cough, stridor, and recurrent pulmonary infections. The syndrome is more common after right-sided pneumonectomy as there is greater volume loss with removal of the right lung. Treatment for postpneumonectomy syndrome involves shifting the mediastinum closer to the midline to remove the compression on the airway and vessels. This procedure is typically performed by inserting saline-filled prostheses on the side of the pneumonectomy. A chest tube would be an appropriate next step for empyema formation, which can be a late complication of pneumonectomy. On imaging, this could be characterized by air fluid levels or a loculated pleural effusion on the side of the surgery which was not visualized in this patient. A barium swallow would be helpful in diagnosing an esophagopleural fistula. An esophagopleural fistula in the late stages is typically caused by residual tumor burden eroding into the esophagus. It will typically present with an empyema, and a barium swallow will demonstrate the spilling of contrast into the airway. Finally IV steroids can be used for pulmonary edema that can occur post pneumonectomy. This is typically an early complication within 72 hours of surgery, therefore would not fit with this patient’s delayed time course.
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