Lung malignancy

An overview of different presentations

Case 1:
History •A 78 years old Saudi man, known to have
• Osteoarthritis
• Treated COVID19 pneumonia 2 months prior to presentation
• Former smoker, 15 pack-year quit 20 years back

•Presented to ER with history of decrease oral intake, weight loss, easy

fatigability for 2 months

•No history of chest pain, cough, SOB, hemoptysis

•No history of palpitation, orthopnea or PND
•No history of change in bowel habits or abdominal pain
•No Hx of night sweats
•Systemic review is unremarkable.
Case 1: • Generally:

Case 1: examination
Examination
• Old man, cachectic looking, lying on bed not seem to be in pain or
respiratory distress
Not pale, jaundiced or cyanosed.
Connected to IV lines and a monitor. He was conscious, alert,
oriented to time, place and person
• Vitals:
T 37 Pulse 99 RR 18 BP 121/86 SpO2 99% RA

•Head: unremarkable
•Neck: no lymphadenopathy JVP not raised, unremarkable thyroid exam
•Chest: decreased air entry over the right middle zone
•CVS: Normal S1, S2 no added sounds
•Abdomen: Soft, lax, no organomegaly.
•LL: No edema or signs of DVT.
•Skin: intact with no ulceration, rash or hyperpigmentation
•Other: unremarkable
Case 1: Labs
CBC WBC 8 Hgb 11 MCV 82 Plt 247
RFT BUN 27 Creat. 1.28 Na 137 K 3.8
LFT Tbili 0.7 Dbili 0.3 Albumin  2.9 Alk phos 107 SGOT 20 SGPT 22 LDH 129
Electrolytes Ca  11.1 PO4 2.7 Mg 2
Coagulation PT 13.8 PTT 31.5
TFT TSH 3.6 T3 0.58 T4 0.81
PTH  0.37

SARS COV-2 Negative

What is the DDx of his hypercalcemia?

Approach to hypercalcemia
Serum Ca > 10.2

Intact PTH

PTH mediated Non PTH mediated

Primary hyperparathyroidism (sporadic) 1, 25 25
SPEP
Inherited variants Dihydroxyvitam Dihydroxyvitami UPEP
Multiple endocrine neoplasia (MEN) syndromes
PTHrP in D nD Serum free light
Familial isolated hyperparathyroidism chain essay
Multip
Hyperparathyroidism-jaw tumor syndrome le
Lymphoma, myelo
Familial hypocalciuric hypercalcemia Granulomatous Vitamin D
Humoral intoxication ma
Tertiary hyperparathyroidism (renal failure) hypercalcemia disease
of malignancy
Paraneoplastic syndromes in lung malignancy
 Lambert-Eaton
 PTHrP  ADH  ACTH  TGFβ1
syndrome

Ca release from  Cortisol release  Extracellular Autoantibodies

SIADH
bones and production matrix proteins against Ca channels

Hypercalcemia Hyponatremia Cushing syndrome Clubbing Muscle weakness

 • A 43 years old male from Tunisia

Case 2: • a smoker for more than 20 years, 20 pack a year.

• Not known to have any medical condition
History
Presented to ED with:

• 2 weeks history of right sided chest pain mild to moderated in severity not
radiating aggravating by cough and relieved by itself associated with mild
productive cough and whitish sputum in the morning only

• Patient also reported left shoulder pain with localized tenderness started 2
months ago moderate in severity aggravating by movement.

•No recent travel last time came from Tunisia 2016

•No fever, weight loss, hemoptysis or contact to sick people
•No dysphagia, hoarseness, facial swelling or headache
•No GI or genitourinary symptoms
•No family history for malignancy
 • Generally:
Middle aged man, well nourished, lying on bed not seem to be in
Case 2: pain or respiratory distress
Not pale, jaundiced or cyanosed.

Examination Connected to IV lines and a monitor. He was conscious, alert,

oriented to time, place and person
• Vitals:
T 37.3 Pulse 76 bpm RR 22 BP 90/60 SpO2 99 RA

•Head: unremarkable
•Neck:
•Chest: EBAE no added sonds
•CVS: Normal S1, S2 no added sounds
•Abdomen: Soft, lax, no organomegaly.
•LL: No edema or signs of DVT.
•Shoulders:
•Other: unremarkable
Case 2: Labs

CBC WBC 15.1 Hgb 13.9 MCV 90 Plt 414

RFT BUN 10 Creat. 0.64 Na 137 K 4.5
LFT Tbili 0.2 Dbili 0.1 Albumin 4.1 Alk phos 123 SGOT 17 SGPT 22 LDH 264

Electrolytes Ca 9.4 PO4 3.3 Mg 1.9

Coagulation PT 14.2 INR 0.99 PTT 43
TFT TSH 2.26 T3 2.75 T4 1.13
inflammatory CRP  4.90 Proc 0.04 ESR  39
SARS COV-2 Negative
pathology
• Adenocarcinoma
Metastatic lung cancer
 This is a 68 years old Indian male
Case 3: • Works as driver
• Medically free, nonsmoker.
History Presented to ER complaining of

•productive cough for the last 10-15 days, increasing in the last days with
whitish moderate amount of sputum.
•Associated with SOB for 5 days duration with minimal exertion.

•No history of fever, night sweat, weight loss

•No history of hemoptysis, chest pain, palpitation, orthopnea or PND.
•No history contact with sick patient or COVID-19 patient
•No nasal congestion, throat pain of other URTI symptoms.
•No history of contact TB patient
•Other systematic review unremarkable
•No similar complain before.
 • Generally:
Case 3: • Old man, lying on bed not seem to be in pain but in respiratory

Examination distress
Not pale, jaundiced or cyanosed.
Connected to IV lines and a monitor. He was conscious, alert,
oriented to time, place and person
• Vitals:
T 36.7 Pulse 72 bpm RR 22 BP 113/77 SpO2 94% RA

•Head: unremarkable
•Neck: no lymphadenopathy JVP not raised, unremarkable thyroid exam
•Chest: decreased chest expansion and air entry on the right side
•CVS: Normal S1, S2 no added sounds
•Abdomen: Soft, lax, no tenderness or organomegaly.
•LL: No edema or signs of DVT.
•Other: unremarkable
Case 3: Labs
CBC WBC 8.4 Hgb 14.4 MCV 82 Plt 285
RFT BUN 21 Creat. 1 Na 134 K 4
LFT Tbili 0.5 Dbili 0.2 Albumin 3.9 Alk phos 73 SGOT 21 SGPT 22 LDH 249
Electrolytes Ca 9.1 PO4 3.6 Mg 2.16
Coagulation PT 13.8 INR 0.96 PTT 38.6
inflammatory CRP 0.53 Proc 0.04 ESR 4
SARS COV-2 Negative
Pleural fluid Pleural Protein 4.7 Serum Protein 6.2
analysis Pleural LDH 296 Serum LDH 310
Pleural Glucose 66 Serum Glucose 88
Cytology: Atypical cells with nuclear atypia, suspicious for malignancy
AFB Stain –ve
Pleural fluid culture: No growth, PCR: -ve BAL AFB stain, culture and PCR: -ve
Malignant pleural effusion
Lung cancer: Classifications