Lung Cancer

Chest be able to differentiate it. What is the probability that it will be a solitary

lung

nodule and then you will have a differential in the head? Could it be benign if it is benign? What are the things to think about about what the likelihood is of it being benign? What is the probability that it is malignant if it is benign? It's evil, what kind of thing could it be? The first thing we're going to have here is a

lung

nodule, so here we're going to have a nodule of tissue that definitely looks abnormal compared to the surrounding lung tissue, how do we define a lung? nodule, one of the key things is that it is less than three centimeters, that is something important.

The second thing is that all the tissue surrounding the actual lung nodule is normal lung tissue, so the normal lung surrounding the lung nodule is huge, and the last thing is that there is no lymphadenopathy, so there are no lymph nodes nearby that are involved by the tumor, okay, these are key things to be able to think about whenever you suspect that this is a benign finding, a benign solitary lung nodule, okay, less than three centimeters of normal surrounding lung tissue and no lymphadenopathy, now that we think about it. about lung nodules we have the idea that it is a type of malignant or benign tumor and, therefore, one can often rest assured because it is likely that 70 of the time it is benign and when they think it is benign, they have a differential. so the things that you're potentially going to evaluate if you're going to go down the path of doing a bronchoscopy, doing a biopsy, whatever it is, the most important thing is if you see a lung nodule and it somehow fits into the category of less than three centimeters of normal surrounding lung tissue, no lymphadenopathy, think granulomatous diseases, so granulomas can definitely cause this type of nodular appearance, so think about the things that cause granulomas, one of the big ones would be tuberculosis, so that tuberculosis could be a particular disease, another. would be your fungal infection, so this will definitely show up on your test, so it may be histohistoplasmosis or coccidiomycosis, so these are important things to think about, histo or coccidiomycosis, so those fungal infections that You remember the ones we talked about before, okay. so granulominus diseases 80 percent of the time are likely to be something like tuberculosis fungal infections, the other times it may be 10 of the time attacked by homeless people, so they are like an abnormal collection or a mixture of abnormal tissue that is a benign type of like a nodule, ten percent of the time it could be Hammer Thomas, as long as they say okay, you think it's benign, it definitely has the characteristics to suggest a benign type of mass, What are the differences, you say granulominus diseases most of the time, tuberculosis, histo or coccidium, the other 10? probably hamartoma and then for the remaining 10 because we had 80 10 there is something missing here, it would be any kind of other miscellaneous causes that are not worth even mentioning in this video, okay, now the next thing is it could be malignant, could it be malignant? what is the chance that it could be malignant, there is a chance, so there are 70 left, one percentage is 30, so there is still a chance that you have to be alert for that now, if you think it is malignant, we will talk about things that are more suspicious of malignancy, such as What is the patient's age?

Has the nodule changed in the last two years? Maybe two years. Does it have uneven edges? Do you have asymmetrical calcifications? Are there other particular types of things that are very concerning for malignancy and we will discuss that later in this article? diagnostic section but for now you have a suspicion that it could be potentially malignant or you are thinking about your deferential guess what is relatively easy if there is a nodule that you suspect is malignant returns to all of those we just talked about unlikely that it is small cell because when people find small cell it's usually too late, they have about a two year survival rate at that point because it's usually extensive, so think about all the bronchogenic carcinomas that we talk about, like squamous cell carcinoma, adenocarcinoma, large cell carcinoma. maybe also bronchial alveolar carcinoma, but again, these are the important things to think about. 75 of the time, it's actually one of these malignancies and then, could it be metastatic?

Could it have come from breast

cancer

? Could it have come from some type of

cancer

? Colorectal cancer could have come from somewhere else and spread to the lungs many times if it is metastatic it is less likely because you will have multiple lung nodules, if it is metastatic it is usually not just a solitary nodule so those are the important things in the to think about, so we have a lung nodule as part of our other types cause pathophy for this type of thoracic or respiratory neoplasms that I want you to remember less than three centimeters of normal surrounding lung tissue no lymphadenopathy could be benign think granulomas TB histococcidium Hammer Tomas is the remaining one if you have a suspicion that it is malignant, we will talk about what things are suspicious for malignancy for lung nodules, think about the lung cancers that we just talked about, with the unlikely exception of small cell because of the extensive than the disease is or less likely to be metastatic because usually if it is metastatic, it has multiple nodules all over, it is more of a kind of distant spread and usually more than one nodule is beautiful and covers the types, the causes and pathology of our real respiratory or thoracic neoplasms.

Now let's review what's really key. The important thing here is the characteristics and complications, so when we talk about the characteristics and complications, we are going to talk mainly about lung cancer. The most important thing for us to discuss is that often solitary pulmonary nodules that are asymptomatic are incidental mediastinal findings. Masses are often due to compression, so you may get some of the similar effects you'll see in lung cancer, but we're not going to dwell on that too much. I just want us to focus primarily on the characteristics and complications of The lung cancers that we discuss are small cell and non-small cell lung cancer and then carcinoid tumors, so the general characteristics that you can see in all of these cancers is They may have a general feeling of maybe low fevers. loss and some fatigue or general malaise, why that could be a couple of reasons, one of the reasons the tumor may actually gain the ability to produce specific types of cytokines, perhaps things like tumor necrotic factor alpha. interleukin-1 and stimulate the hypothalamus and when it stimulates the hypothalamus, it can actually cause the temperature center, the thermal regulation center within the hypothalamus and our hunger centers and our hypothalamus, to undergo a dysregulation process, so it What it can do is increase our temperature because it controls our thermoregulation, so if our temperature increases it can cause these mild fevers, it can also affect our hunger center, which can decrease the ability or desire to want to eat, so there is a decrease in appetite, leading to weight loss.

Here's the other thing, because cancer is increasing a lot. Similar types of blood flow, there is a lot of blood flow for these real bad boys, what happens is that these cancer cells consume massive amounts of oxygen and glucose, so they are simply chewing up our energy reserves if we chew up the energies or reserves that actually can lead to a large type of calorie deficit, as well as leading to weight loss and since your tumor consumes a lot of oxygen and glucose instead of the muscles and other tissues that need to use it to perform normal daily functions, it is possible who has a generalized caloric deficit. fatigue and weakness, so these are two of the theories behind why these patients develop.

This is due to a release of cytokines that tells the hypothalamus to change the thermoregulation center and the hunger center, which causes us to develop fever and weight loss. The other theory. is that this could be because the tumor consumes a lot of oxygen and nutrients that other tissues in the body are supposed to consume, but has less because it consumes most of that energy. What are some other features that are really important? big deal when you have a tumor that is centrally located you know most of these tumors are centrally located do you remember what would be small cell lung cancer, squamous cell lung cancer and maybe even a carcinoid tumor or a bronchial alveolar carcinoma that has a central location? and peripheral the only ones that we said were not quite central would be adenocarcinomas and large cell carcinomas, as they have tumors that are more centrally located, they may be present within the bronchioles or they may be outside the bronchi and compressing. the actual bronchioles nearby so you can get an endobronchial growth which can lead to these features or you can have a tumor on the outside that is compressing the bronchial system in the same way as if there was a tumor inside the lumen, then you guys get the point. , there is a tumor in the lumen or there is a tumor outside of it compressing the lumen.

What are some features you can see with that? Think about this if you have cancer. How does it happen? This can cause some localized inflammation. and increased blood vessel flow whenever there is localized inflammation, guess what stimulates these nearby cough receptors and these cough receptors when they are agitated or activated by inflammation, what do you think they produce a cough reflex? So often, these patients may present with a cough. because of the localized inflammation caused by the actual neoplasm, the second thing is that these neoplasms imagine that here there is some kind of real bronchial tissue here and then you know that it is in the bronchial tissue, here we are going to have, let's say, the tumor is endobronchial , so here's our tumor now, what happens is we know there's a lot of blood supply.

Neoples definitely increase the angiogenesis process so they can get more blood supply so they can get more oxygen, more nutrients to continue to grow. What happens now is that sometimes there may be an erosion of some of these vessels within the bronchial wall and then these blood vessels may begin to flow directly into the actual lumen of the bronchial system and then you may cough, as it is called when coughing, blood hemoptysis. so we have the cough reflex activated by local activation, we have neoplasms with increased vascularization that chew up the actual vessels, sometimes it can cause blood to move towards the lumen, causing hemoptysis, what else do you imagine this tumor obstructing the lumen, What is supposed to move through air?

It's supposed to move in and out, but now you have an obstruction that will decrease the flow of air through this bronchial system, decreasing the flow of air through this bronchial system, if I can't get a good amount of air in. What am I going to try? What to do to increase the fact that I am not contributing adequate running volumes. I will try to breathe faster or deeper, which makes patients appear very short of breath because they are working so hard to inhale. deeper breaths because they have an obstruction within their airway and they may have this.

The other thing is that when you exhale, if you have a tumor here, it's not completely obstructing the lumen, but you have a tumor here and you're trying to exhale now. the air has to move through that small area of ​​the lumen during exhalation, when the air comes out during exhalation, it can cause a wheezing type response, so think again about activated inflammation, the cough reflex, a increasing the vascular supply enough that it really starts to be pushed. In the light of hemoptysis, the third thing is that less airflow comes in due to airway obstruction, causing dyspnea, and then less air comes out during expiration, causing wheezing.

Another thing is that normally, if I have a blockage within the bronchial system, there is usually mucus. It's supposed to go up through the bronchi and be coughed out, but if I have some kind of large blockage that's preventing this mucus from being able to be expelled out because it's blocking it, now the bacteria can multiply and thrive in this bacteria-rich area. mucus and then Now I create an opportunity for an infection called pneumonia, so we call this post-obstructive pneumonia. The great things inWhat I want you to think about is that this is more common with central tumors, so central tumors, remember why I insisted on that, okay, so cough, hemoptysis, dyspnea, wheezing, post-obstructive pneumonia.

I hope that part makes sense. The second thing is near compression, so if I have a tumor that again is more centrally located and what it starts to do is it starts to build up around the mediastinum. and compress the structures near the mediastinum, what are some of the effects I can start to see? Well, the same as central tumors. Think central tumors with actual close compression of structures in the mediastinum. Well, one has this nerve called the recurrent laryngeal nerve. You know if you compress it, it can actually cause hoarseness. You can also compress the esophagus.

If you compress the esophagus, there is now difficulty swallowing. This causes dysphagia and then you can compress it over this large structure. here, bringing venous blood from above the diaphragm, this can compress the super vena cava, the latest SVC syndrome where they have upper extremity edema, chest wall edema discoloration, massive discoloration. nearby tumors mediastinal compression central tumors these are the important things that I need you to think about well, now let's move on and talk about a couple of other features that you can see with these and one of the important things that I want you to think about are the things that can be seen with peripheral tumors, so the next thing we have to talk about is we said that generally there are known plural disorders that will be close to the periphery, so when we talk about pleural disorders associated with lung cancer We would be associating this more with peripheral lung cancers or peripheral lung tumors, so pleural disorders think about these more particularly those peripheral types of lung tumors, so think again about what those were that we said. adenocarcinoma large cell and then technically you could even consider a little bit of carcinoid, a little bit of bronchial alveolar, but not squamous cell or small cell.

He is fine now with these in general, since he has a tumor that is close to the actual visceral and parietal. In plural, which can lead to a pleural effusion, secondly, it can lead to a pneumothorax. Brief discussion because we will go over these impleural disorders and talk about them in a separate lecture, but when you have a malignant disease, obviously, there will be a cause. an increase in inflammation, so malignancies can release certain types of chemicals that can increase nearby inflammation and cause blood vessels to become very permeable. If the blood vessels become very leaky, they can lose a lot of that fluid, some of the plasma fluid and proteins. and different cells in the actual pleural cavity and lead to a pleural effusion, so think about that with these patients, they are more likely to have peripheral tumors now in the same situation if you had a tumor that is close to the actual visceral parietal pleura and It is trying to grow and grow and it grows and what it does is that it has the opportunity to start eating away at the visceral pleura, then it can be created as a fistula if you want between the parenchyma and the pleural cavity and then air will easily enter the pleura. pleural cavity and As air enters the pleural cavity, this is known as a pneumothorax, so think about these two types of disorders that you would probably see more with peripheral lung tumors, plural fusions, plus a type of exudative effusion due to increased of capillary permeability or you know what else.

The lymphatic vessels can compress the lymphatic vessels. You know that you have lymphatic vessels that are actually located inside the pleural cavity and they are supposed to sometimes remove some of the fluid if you have a large enough tumor that is actually compressing this lymphatic vessel. It can actually do what decreases the drainage of pleural fluid and that can also lead to this problem, so it could be due to oxidation due to increased capillary permeability or decreased fluid clearance due to compression of the vessels. lymphatics. Okay, that would cover the pleural disorders. associated with lung tumors now let's talk about a special type of appearance that you can see with two types of tumors pancos tumors you can see this with two types and we'll talk about that in just a second one is adenocarcinoma and the other is squamous cell so This is probably as expected, I thought there is usually a central peripheral.

This one is very interesting, so obviously we know that squamous cells are more centrally located and then adenocarcinoma, which we know is more peripherally located, when we look at Pankos, Pankos tumors. Tumors are tumors that can develop right at the apex of the lung, so usually if you see a Pankos tumor, it will be right here at the apices or apices of the lungs and technically, if it is located more centrally, it will definitely be close of the apices and again peripheral, you see adenocarcinoma, so important things to think about with pankos tumors, usually tumors near the apices of the lungs associated with adenocarcinoma and squamous cell that used to be primarily squamous cell, but we have seen a higher incidence with adenocarcinoma, let's talk about the presentation of Pankos tumors now are okay, so if you remember when we talked about the apices that we have, they usually have their serum here, but they will have a rib here, this would be their first rib and right around the area of ​​the On the first rib you will have the apices of the lungs, but you know what else you have, you have a lot of neurovascular bundle, so you have a lot of nerves that will run in this vicinity.

There are a lot of nerves here. running within this neighborhood here and then you will also have a lot of blood vessels that will be running within this neighborhood here, so definitely a lot of blood vessels and a good neurovascular bundle if you run near the apes use the lungs near the first one. rib, if this tumor grows near the apices, it can compress on these blood vessels and compress on these neural bundles, what would be the characteristics that we would see if it compresses the nerves and compresses the vasculature? Great question if it is compressing the nerves. you need to know what nerves are in that vicinity of the lung apices, one is the recurrent laryngeal nerve, you compress it and you get hoarseness with The Voice, the other is the phrenic nerve, the Frederick nerve surprisingly innervates the diaphragm, so if you had a right pankos You had paralysis of the right hemidiaphragm.

If the right hemidiaphragm doesn't work, you can't. Dome down, you won't get as good chest expansion on the right side, so you have unilateral. decreased chest expansion on that right side, the other thing is if you look at the chest x-ray because it can contract and lower, his diaphragm is very elevated on that affected side, so look for elevation of the hemidiaphragm and decrease chest expansion on the affected side. the other thing is that it can compress the sympathetic nerves. You know, the sympathetic plexus specifically supplies the upper eyelid, helps to be able to irrigate the pupil, and supplies the sweat glands around the actual head, face, and neck area.

Guess what happens if you compress it? Allow them to dilate the pupil. Guess what they will do. Constrain. This is called meiosis. They will not be able to keep the upper eyelid elevated. Will fall. This is called ptosis. And they won't be able to sweat. on the forehead and near the face, that is called anhidrosis. This is a triad for sympathetic plexus compression called Horner syndrome. Well, the last thing is that there is the brachial plexus near this area. Guess what happens if you hit that brachial plexus that is supposed to innervate the muscles and also provide sensation to the upper extremities, you can develop paresthesias, you could even develop pain if it's really intense, and on top of that upper extremity muscle weakness, These are important things to think about on the nerve compression aspect, what about vascular compression? it could compress the artery, so if it compresses like the subclavian artery or near the axillary artery, you could develop reduced perfusion to the skin.

So lowering the pulses on the affected side is a possibility, but you're more likely to see venous compression because it's easier to collapse them and then you have the brachiocephalic vein that runs in this area and the superior vena cava just at the tip, so you can compress these two bad boys if you can compress the brachiocephalic vein or potentially the top of the superior vena cava. will not drain into the right atrium, so all blood flow will return to the upper extremities, neck, chest and develop the upper extremity, neck, chest, while edema, discoloration and a significant increase from jvd are fine, there are important things to think about with panko.

The temperatures, you see, with Adeno squamosus used to be scaly, it's the most common adenos and it's becoming the most common one that we see. The next thing we have to talk about is perineoplastic syndromes. Okay my friend, perineoplastic syndrome is a big deal now. that you will definitely probably be tested at the exam, so you have to know it well, so the first thing we want to think about is if we have a patient that we suspect that he has some type of lung cancer, we look at the potential etiology of it. they definitely smoke a lot of cigarettes have some type of lung mass on their pictures and are you worried that they may have perineoplastic syndrome, what are the things they should think about and what lung cancer is it associated with, so squamous cell carcinoma it was really?

It's interesting that it gains the ability to produce a very special type of hormone called parathyroid hormone-related peptide, it acts just like parathyroid hormone, so what it does is it helps to act on the kidney and actually cause the kidney increases the reabsorption of calcium in the blood and excretes phosphate in the urine, that is one thing and another, since it will also act on the bone tissue and cause the activation of osteoclasts in order to increase osteoclastic activity. the bone release more calcium and release more phosphate from the bone, the end result is that you are now pushing a lot of calcium into the blood through reabsorption or through bone resorption, if that happens what happens to the levels of calcium in the blood? increases, so if you have a patient, you order a routine blood test and you notice that they have hypercalcemia.

Consider whether you have a lung mass. Check a pthrp level as well as a normal pth level to tell if it is hypercalcemia due to hyperparathyroidism elevated Pth or is it malignant hypercalcemia due to squamous cell carcinoma. Alright, next is an adenocarcinoma. The main one I want you to remember is this one above. Here it acquires the ability to produce a very specific type of hormone that activates fibroblasts. you know, fibroblasts love to respond to transforming growth factor beta, that's why we have tissue in our bone that has fibroblasts or dense connective tissue, the periosteum around the bone that has a lot of fibroblast tissue, these fibroblasts are activated when fibroblasts are activated, they start increasing periosteal deposition making the actual thickness around the bones much thicker, especially near the fingers, and what you see is some hypertrophic osteoarthropathy.

I'll show you a picture of this of patients' fingers sometimes, what they really look like. whenever you have significant hypertrophic osteoarthropathy it looks like this, okay, that's something important that I really want you to remember, adenocarcinoma, the second thing we've looked at, I don't want you to go too crazy and remember these last two, but think about it, possibly if they present on the exam with adenocarcinoma, it also has the ability to increase the production of procoagulants, so they are actual molecules that want to induce coagulation, so if I increase procoagulants, I will increase clot formation. if I increase clot formation, this can create a hypercoagulable state that puts the patient at risk for things like an acute ischemic stroke, which puts them at risk for an acute myocardial infarction, which puts them at risk from suffering from acute limb ischemia, acute mesenteric ischemia, etc., these are important things.

You have to think about it as well as maybe even DVT PE DVT, which is actually very important to consider. The last thing is that they can actually increase the activation of plasma cells to increase the production of antibodies and antibodies that will actually attack skeletal muscle tissue as well. like skin tissues and this can cause something called inflammatory myopathies, this is specifically dermatomyositis, so you develop inflammation of your actual skeletal muscle cells and a lot of weakness of the proximal muscles, so you'll usually see weakness particularly in the shoulder joint and the hip joint, but alsoAnd, if that's the case, how can I go? on how to do that, you can do a bronchoscopy with a transbronchial biopsy and you can also do a needle aspiration of the lymph node through the ebus so we can throw it into a bronchus, we actually go down through the actual bronchi and then we can take a piece . of tissue from the actual lumen of the bronchus, if the tumor is in the actual lumen of the bronchus and then if it has spread to the nearby lymph node just outside the bronchial system, then what you could use, you could actually use a needle and then through ultrasound guidance, I guide myself to the actual lymph node and suction some of the actual tumor out of it as well, so those are the ways we could do it if it's essentially a localized tumor.

Now we see a CT scan here to give us a better idea of ​​the tumor and its central presentation and then we can also do things called pet scans or CT scans to really help us stage the adenocarcinoma, so to see if it has spread anywhere, if it has metastasized, I could do a panoramic CT scan so I can scan your head, your chest, your abdomen, your pelvis and look for distant Mets or I can do a PET scan to see if I see any hot spots where spread. I don't think that's important when I do it.

I think what may come up on the exam is where these lung cancers actually spread, and if they spread, they usually spread to the brain, the liver, and then the adrenals and the bones, so think about that, my friends, How do we treat this patient? I think it's important to remember if this tumor is actually located in the periphery, towards the pleura, how do we approach it? It's usually a fine needle aspiration, but it can be done using CT guidance or you can do what's called video-assisted toroscopy. There is also a similar surgery there, so you can do a Vats, either way, using fine needle aspiration of the tumor of the peripheral type of the plural area or the peripheral area of ​​the plural parenchyma, we can do a fine needle by tomography guidance computerized or you can do Video assisted as a kind of toroscopic tumor removal.

What if they had a plural effusion that was actually related to their malignancy? What could I do? You could then do a thoracentesis and send the pleural fluid for cytology to look for. see what kind of malignancy actually shows up there too, okay let's move on to the next case here, we have a 45 year old woman with no relevant medical history who presents to nerdy ninja hospital for a deep chest laceration that she receives. A chest x-ray and, by the way, it shows a coin-shaped nodule in the right upper lobe, very interesting, so I think this is trying to point us towards a lung nodule versus a true lung mass which is a type of cancer, So is it benign or malignant?

The question we are trying to solve here is that when we look at the vital signs we see that everything is relatively normal, no type of abnormality appears. We're going to look at the chess x-ray and when we look at it, this is what we notice. We noticed a small 1.5 centimeter circular nodule with dense central calcification which is good and compared to the previous films from two years ago, he actually never had this nodule, which is interesting, when we see a new nodule. a little worrying, but just because it's new doesn't mean it's actually malignant, it could still be benign, so I think one of the most important things to think about is how we can continue to follow up on this nodule.

I really think a CT scan of the chest. This will be the best situation with thin cuts to be able to see this nodule well if it is a new nodule, so let's say we do that when we do it, what we see are the nodules present here, they are about 1.6. centimeter circular nodule with dense central calcification and then there is no lymphadenopathy nearby and the whole actual lung during lung window examination does not show any abnormal lung parenchyma, that is super critical my friends so I think it is very important think about it. Would you say? that this lung nodule is suspicious of malignancy or that it is benign.

I think it's benign and how do we think about this again? Look at the age you are under 50, so it's one thing if you smoke. He has no medical history of smoking. the size is 1.6 centimeters that means it measures less than two centimeters the edges are irregular or regular he said it was actually decently regular gene was its central or asymmetrical calcification was located centrally that is good and there was a change in size no, but it was there was a new, if you want to say technically yes, there was a new nodule, so one of these factors was potentially concerning, but everything else here definitely does not appear to be malignant.

I think the best thing to consider here is to really follow up in a couple of months and have another low dose CT scan and make sure it hasn't gotten any bigger or any new nodules formed, so I would repeat the CT scan in about three months to see what it looks like now and I think the next question is what could it be if we think it's benign what's the responsibility to think about what else it could be, it could be a granuloma like sarcoidosis or a hammertona, so those are things in which What to think about and if it is rare Sometimes it could be like a histo or coccidiomycosis, but it is not very common.

I would think of things like sarcoid or you know Hammer Tomas is probably the likely cause. Here it is okay, let's move on to the next case. Here we have a 70 year old man. to engineering hospital with this neopluritic chest pain horse voice numbness and weakness of right arm no relevant medical history here so we look at his vitals everything looks good nothing really stands out as worrisome except for one thing the spo2 It is a little low then, the spo2 is a little low, which shows us a mild hypoxemia when we examine them, we notice that they have less breath sounds on the right side, they are fine with a decrease in the tactile thrill and dullness to percussion, for which every time we hear decreased sinus noises, that means no By inflating part of the lung well, we have decreased tactile firmness, which means there is usually fluid in the pleural fluid and dullness is likely. to percussion.

Pleural fluid, so there is most likely pleural fusion as an etiology here. When we also examined the patient, we noticed that he has ptosis of his right eye, we noticed meiosis of his right eye and we noticed anhidrosis on his forehead on his right side, we noticed edema and discoloration of his upper extremities, his trunk and he has a bulbous jugular vein that is distended. They also have weakness of their right upper extremity and less sensation to light touch in their right upper extremity and then you notice that their fingers became swollen and spoon-like in appearance, which is very interesting, so the things that we are starting to understand see here they are really The really strange thing is that we see that they probably have a pleural effusion, Horner's syndrome, SVC syndrome, brachial plexus compression and some kind of strange curling of the fingers that could be like what is called hypertrophic osteoarthropathy.

It's very interesting, so I think we need to look at that. chest x-ray or CT scan and really look at the apex and the right lung to make sure they don't have something called a pankos tumor, so let's go ahead and check that, so look at that right apex large horn tumor here, so it would be right in the vicinity of where the brachial plexus is, this would be in the vicinity of the sympathetic like fibers, this would be in the vicinity of the superior vena cava, so we're and we're also looking at here, look at this pleural effusion here as well, so they had pleural effusion, they had a big old pankos tumor, they have a lot of the symptoms.

I think that would explain them having a pankos tumor, so I think back to pankos tumor and usually the two types of tumors that will cause this are squamous cell. Carcinomas are generally more centrally located, but they can also be near the apex or adenocarcinomas, so I think one of the most important things to think about is what are some of the other characteristics that this patient has with the panchose of which we talked. about this, but they have horns because you are compressing their sympathetic plexus, they have hoarseness due to compression of the recurrent laryngeal nerve, we actually see that here they also have some degree of swelling in the upper extremities, jvd discoloration due to compression of the vena cava upper and probably also We see some Horner syndrome as we talked about due to compression of the sympathetic fibers and plexus and then we also see compression of the brachial plexus, which is causing some weakness in the upper right and decreased sensation in the right upper extremity. well, and then here's the thing: this is actually probably the cause of the toes falling off, this is called hypertrophic osteoarthropathy and it's usually seen with adenocarcinoma, so we're probably going to see it as a potential effect here and such maybe more likely to support Adeno, but again you need to do a biopsy to really see if that's really the case, and again we also see that they have that heavy pleural effusion there, so I think it's important to remember which tumors we're talking about. which are centrally located and which are usually small cells, which are usually carcinoid, which are usually squamous, which are more peripherally located, which will usually be like an adenocarcinoma, usually like a large cell carcinoma, is another one I would also think of , so I think that's one of the big questions that What you can really see on the exam is which of all the tumors, small cell, squamous cell, large cell carcinoid, Adeno, is not associated with smoking and is adenocarcinoma, and then how do I test its addition?

Keep in mind you had a biopsy and this is actually, it's located more peripherally so I would like a CT guided fine needle aspiration or a Vats as the potential opportunity here and if you have any pleural fluid I can remove , it is likely due to its malignancy, it could go. go ahead and do a thoracentesis and then send some cytology there as well and then again staging. I think it's important to remember to look for any Met, so scan his head, his chest, his abdomen, and his pelvis. You can even do a pet scan to search. any hot spots as well and again, I think that's the great location, but remember where they commonly metastasize to talk about the brain, the liver, the adrenal glands and the bones, if this patient had if we were to quickly say that he had stage 3A adenocarcinoma , what does that mean? for your stages that wouldn't work too much in this, I'll show the kind of diagram that we talked about on the board, but stage one will generally be located in a hemithorax if it goes to the hemithorax. and the ipsilateral lymph nodes, that's stage two, if it goes here as well to the other lymph nodes and starts to grow a lot, then we start to see stage 3A and in this case we start to see again as we move up the stage. 3B and then in stage four, we're starting to see it spread into the actual systemic circulation, so I think that's the most important thing to think about here: in this patient, I think what we'll see is what does that mean? stage.

And what would be the treatment? In this case, the mass actually spread to the mediastinum, so it actually went from being in the lung and spread to the nearby lymph nodes and then from the lymph nodes it spread to the actual mediastinum. Well, and then from there we start to see that it actually starts to spread further because we usually have it located in the lymph nodes, then in the lymph nodes and the mediastinum, where it can still potentially be resected, then in the mediastinum of the nearby lymph nodes, where it cannot be resected and then, usually, in the lung parenchyma, the lymph nodes, the middle stem cannot be resected and neither can the systemic metastasis, so in this situation it is still possible to resect it, but you will need a lot of chemo radiation to really reduce it. the tumor too, okay my friends, that would cover these types of lectures and cases on lung masses.

I hope that made sense. I hope you enjoyed it. I love you, thank you and as always, see you next time.