Vascular and other pulmonary disorders and Carcinoma of the Lung

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Where do pulmonary emboli normally arise

veins in the legs - their significance depends upon the size and the basic health of the patient

What is a saddle embolus

large embolus that straddles the bifurcation of the pulmonary artery - it is typically fatal
-Clinically they will have chest pain, dsypnea, faint or absent pulse, low BP, and tachycardia

What is a paradoxical embolus

embolus that travels through a cardiac defect and embolizes to organs supplied by the systemic circulation
-patent with a probe patent foramen ovale

PE rarely cause an infract but if they do what is the typical pattern

wedge-shaped and hemorrhagic

What factors predispose a patient to a PE

bed rest, recent surgery, trauma, estrogen, disorders of hyper coagulability, cancer

Define pulmonary hypertension

elevated pulmonary artery pressure (greater than 25% of systolic)

What type of patient typically has primary (idiopathic) pulmonary hypertension

mostly a disease of young women (20-40)
-causes is unknown (some anti-obesity drugs cause this), hypertrophy of pulmonary vessels

What is the cause of secondary pulmonary hypertension

cardiac disease (Left ventricular failure, mitral valve disease, congenital malformations), or pulmonary disease (COPD, fibrosis, or recurrent pulmonary emboli)

CLASSICALLY how does Goodpasture's present

combination of hemoptosis and hematuria
-disease is due to an increase in circulating antibody against the collagen basement membrane

What is the other pulmonary/renal disease

Wegner's Granulomatosis

Define Wegner's granulomatosis

disease of airway/lung and kidney
-vasculitis
involves the ANCAs -

What is atelectasis

collapse of the lungs

What is the implications of atelectasis

creates a shunting of blood which can lead to a V/Q mismatch

What are the three types of atelectasis

resorption - caused by airway obstruction and absorption of DISTAL airspaces
compression - extrinsic compression such as pleural fluid
contraction - peripheral pleural scarring

Left sided heart failure is

leads to left sided pressures - resulting in pulmonary edema which can DAMAGE the pulmonary capillaries
-can lead to the creation of hemosiderin-filled MACs

What is a pleural effusion

common in heart failure and any condition where fluid accumulates in the body

What is pleuritis

common in lobar pneumonia - friction generated by the involved pleura and is felt by the patient as pain with every breath taken

Pneumothorax

abnormal collection of air and gas in the pleural space - typically causes a collapse of the lung due to air in the pleural space

What is the leading cause of cancer death in the US

lung cancer - prostate and breast are more common, but they have better treatment options therefore lung cancer causes more deaths

What gas is associated with lung cancer

Radon

Does asbestos have a higher risk of lung cancer

yes 5X increased risk and this is even more if this patient smokes

What other factors are associated with lung cancer

TB, fibrotic lung disease, metal exposure, air pollution

Lung cancer is classified as either

central or peripheral

Central lung cancer arises from

bronchogenic - arises in the LARGE bronchus
-typically the result of SMOKING

Peripheral lung cancer arises from

the more distal small bronchioles
-often associated with a scar

What are the two "cell" types of cancer

large or small

What are the types of large cell cancer

adenocarcinoma, squamous cell carcinoma, undifferentiated

What are the features of large cell adenocarcinoma

most common
-most common non-smoking woman
-many are PERIPHERAL tumors
frequently DESMOPLASTIC - 'scar cancer" - can also arise from a preexisting scar (TB, fibrotic lung)

Squamous cell carcinoma

high incidence with cigarette smoking
-CENTRAL tumor
-COMMONLY associated with PTH and hyperCALCEMIA

Squamous cell carcinoma is associated with

Keritinization and/or intercellular bridges

Large cell undifferentiated carcinoma

mostly smokers, AGGRESSIVE tumor, large tumor with frequent necrosis

Small cell carcinoma

highly correlated with cigarette smoking
surgery DOES NOT improve surival
chemotherapy is can improve mortality (but only 20% survive to five-years)
tumors are usually CENTRAL

What cells are associated with small cell carcinoma

small oval or fusiform cells
-cells probably originate from Kulchitsky cell - a neuroendocrine cell

What ectopic hormones are associated with small cell carcinoma

ADH and ACTH

Lung metastatic disease is more common than primary, what cancer are the usual suspects

breast, colon, and renal cancer

What are the carcinoid tumors

-oid means "like" - serotonin producing
no relation to cigarette smoking or other causative factors

Carcinoid tumors clinical features

Neuroepithelial tumor with biogenic amine and polypeptide production (ACTH); carcinoid syndrome (5-HT)

Are carcinoid tumors malignant

typically, they are benign (90%)
-atypical carcinoids are aggressive variant

What is the pathology of carcinoid tumors

obstruct the bronchus -

What are the clinical features of mesothelioma

symptoms are gradual, pain, dyspnea, pleural effusions
-median survival is 1 years - lymph nodes and blood borne metastases occur late

What is the pathology of mesothelioma

Pleural plaques that encase the lung
-may mimic either adenocarcinoma or fibroblastic lesions
-ferruginous bodies (asbestos bodies) occur in lung

What is the epidemiology of mesothelioma

80% occur in the pleura
-relation to asbestos exposure
-small asbestos fibers go deep into the lung tissue and produce fibrosis of lungs and pleura

What are the BENIGN pulmonary lesions

Hamartoma, Sarcoidosis, Vascular anomalies, Infectious processes

How do you detect and diagnose Lung cancer

Silent disease, cough (75%), weight loss, chest pain, dyspnea, Pneumonia that fails to heal, hemoptysis, and hoarseness

What lymph nodes are involved in the spread of pulmonary disease

PERIHILAR(1ST), paratracheal nodes, supraclavicular nodes, and other organs

What does paraneoplastic syndromes mean? what are they in relation to pulmonary carcinoma

substances from a distance
-cushings (ACTH) and SIADH -small cell carcinoma
-hypercalcemia (PTH production) - Squamous cell carcinoma

Where are some of the CLASSIC locations of spread in pulmonary carcinoma

Superior vena caval, Pancoast (apex), Horner's syndrome (Ptosis, miosis)

Which cancers have the highest association with smoking? weaker association?

squamous cell and small cell (oat cell) - highest correlation
adenocarcinoma has a weaker association

Which cancers have a central location

squamous and small cell (oat cell)

Which cancer has peripheral location

adenocarcinoma

Which cancers do you try and resect surgically

all the large cell types - squamous cell, undifferentiated large cell, and adenocarcinoma

Which cancers is your only treatment option for small cell carcinoma

chemotherapy

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