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Chapter 32. Lung Cancer

A 75-year-old woman presents with confusion, dehydration, and constipation. She is found to have hypercalcemia and is admitted for observation and further testing. A new chest x-ray reveals a right hilar mass. A whole body PET-CT scan reveals no evidence of mediastinal lymph node involvement or distant metastasis. What is the most likely explanation for hypercalcemia in this patient?

a. Hypertrophic pulmonary osteoarthropathy secondary to adenocarcinoma of the lung

b. Paraneoplastic syndrome secondary to small cell lung carcinoma

c. Paraneoplastic syndrome secondary to squamous cell lung carcinoma

d. Osteolytic bony lesions secondary to adenocarcinoma of the lung

e. Recent emergence of Cushing syndrome

The most correct answer is c, paraneoplastic syndrome secondary to squamous cell carcinoma of the lung.

Answer a is incorrect, inasmuch as hypertrophic pulmonary osteo-arthropathy secondary to adenocarcinoma of the lung is generally not associated with hypercalcemia even though osseous structures are involved by periostitis and digital clubbing. Answer b is unlikely because unlike most paraneoplastic syndromes that are associated with small cell lung carcinomas, hypercalcemia is most common among patients with squamous cell lung cancer. Answer d is incorrect here because metastatic disease to the bones has already been excluded by the PET-CT scan findings. Answer e is not applicable here because the spectrum of laboratory abnormalities in Cushing syndrome generally does not include hypercalcemia.

A 75-year-old man with a 60-pack year history of tobacco abuse presents with progressive dyspnea of 4 weeks. He has a history of nonproductive cough, anorexia, and 8 kg weight loss, but denies fever, chills, or night sweats. On physical exam, he has normal vital signs; jugular venous pressure is normal. There is no lymphadenopathy. Cardiac exam shows decreased heart sounds but no other abnormality. On pulmonary exam, the patient has dullness over the left lower lung field, decreased tactile fremitus, and decreased breath sounds. The right lung examination is normal. Chest x-ray shows consolidation in the left lung with moderate pleural effusion. What is the most appropriate management of this patient at this point?

a. Bronchoscopy

b. CT guided needle biopsy

c. Inhaled bronchodilators

d. Intravenous antibiotics

e. Thoracentesis

The most correct answer is e, thoracentesis.

This patient with a long-standing history of exposure to tobacco products and thereby at risk for pulmonary malignancy is symptomatic with shortness of breath and physical findings consistent with his radiographically demonstrable left-sided pleural effusion. Answer ...

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