Case #1 Answers:
Answer 1
In
this case, lung cancer is far and away the leading diagnosis. Perhaps, lymphoma
and other metastatic cancer could be considered. Less likely considerations
would include fungal disease, and sarcoid.
Answer 2
A. Focal wheeze
Endobronchial cancer resulting in airway narrowing.
B. Hoarseness
Recurrent Laryngeal Nerve involvement with AP window lymphadenopathy.
C. Cough and/or Hemoptysis
Suggests endobronchial pathology raising the likelihood that bronchoscopy will
visualize the suspected lesion and yield a diagnosis.
D. Myosis, Anhydrosis, and Lid Lag
Suggests a Pancoast tumor.
E. Hyponatremia
Suggests SIADH which is most common with small cell carcinoma.
F. Hypercalcemia
Suggests squamous cell carcinoma in which hypercalcemia may result from direct
bone involvement or the production of a parathyroid-like hormone.
Answer 3
Fine needle aspiration of the supra-clavicular lymph node. While bronchoscopy
would have a high yield for identifying the primary endobronchial lesion, FNA of
the supraclavicular lymph node could not only establish the diagnosis of
malignance but would also stage the patient as well. If positive, the patient
would be staged as N3 disease and as such would not be a candidate for surgery
and no further invasive procedures would be indicated.
Answer 4
Stage 3b, T2N3M0. Prognosis would obviously be poor with 5 year survival
estimated at between 3 and 7 %.
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