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Case (67)
Dr.Habiib:
A 52- year old heavy smoker consulted his physician about an alteration of his voice, severe loss of weight, persistent cough and blood stain sputum. A distorted tracheal carina was observed during bronchoscopy. The radiograph in chest revealed carcinoma in the upper lobe of left lung.
1. What is your diagnosis of this case?
2. What are the predisposing factors of this case?
3. How this cancer spread?
4. What are superficial lymph nodes would be enlarged and palpated?
5. Clarify the bronchopulmonary segments of the upper lobe of left lung?
6. What would be the cause of alteration of voice?
7. What caused distortion carina of trachea?
8. What are the complications of this case?
Dr. Acromion:
1.What is your diagnosis of this case?
It would be the wise to say as already indicated in the case that the diagnosis is Carcinoma in the upper lobe of the left lung ( Lung cancer).
2. What are the predisposing factors of this case?
The principal predisposing factor is cigarette smoking including second hand smoking, the risk of lung cancer increases with the number of cigarettes each day and the number years smoked. Quitting smoking at any time can significantly decrease one's chances of developing lung cancer in the future.
Exposure to certain chemicals like asbestos, radon gas can increase the risks of Lung cancer.
There is also the so called " non-modifiable risk factors" such as heredity, age , sex and race may play role in lung cancer development.
Certain chronic lung diseases , for example Chronic Obstructive Pulmonary Disease (COPD) may also increase the risks of developing lung cancer.
3. How this cancer spread?
The cancer cells spread via the bloodstream , the lymphatic vessels or by means of direct contact to the adjacent body structures.
4. What are superficial lymph nodes would be enlarged and palpated?
Supraclaviculer lymph nodes are the most important, however a complete physical examinations should include palpation for the anterior cervical, posterior cervical , axillary, tonsilar, submental and submandibular lymph nodes and in advanced stages of the cancer as far as the inguinal region.
5. Clarify the bronchopulmonary segments of the upper lobe of left lung?
Left upper lobe;
1 and 2. Apicoposterior bronchus
3. Anterior bronchus
Lingula
4. Superior bronchus (lingular)
5. Inferior bronchus (lingular)
6.What would be the cause of alteration of voice?
Alteration of the voice also known as hoarse voice is do to compression of the left recurrent laryngeal nerve by the cancerous (pancoast) tumor.
7.What caused distortion carina of trachea?
The growing cancerous tumor compresses and pushes the immediate structures such us the trachea, great blood vessels, mediastinum , th ribs leading to distortion of the carina of trachea.
8.What are the complications of this case?
If the cancer spreads throughout the lungs the level of oxygen in blood drops causing shortness of breath.
Blockage of air way by the tumor may lead to the collapse of the part of the lung that the airway supplies, a condition called Atelectasis,
Accumulation of fluid between the lung and the chest wall...........pleural Effusion may also occur leading to sensation of breathlessness.
The cancer may also encroach into certain nerves in the neck , causing a droopy eyelid , small pupil, Sunken eye and reduced perspiration on one sid of the face..........this is called Horner's Syndrome.
The Esophagus my be affected by the growing cancer causind difficult in swallowin food or pain while swallowing.
The heart may be affected by the lung cancer leading to arrhythmias, reduced blood flow to the heart due to obstruction of the superior vena cava by the tumor causing facial swelling , cyanosis and dilatation of the veins of the face and neck......known as the Superior vena cava syndrome and ultimately heart failure.
Dr.Habiib:
Thank you Dr. Acromion for you trying.
we wait another try the answer is still ......................
مستنيكم محاولة ثانية علشان لسه الحل ما كملش
Dr. Acromion:
Thank you Dr. Habib! looking forward to the right answers.
Dr.Habiib:
Thank you very much Dr. Acromion. You are nearest to the answer in more than one way.
I respect your answer really be because most of your answers are correct, but the roles of cases the most of answer depends on first to diagnosis because if you diagnosis is not clear you will lose all of the case mark.
Possible to say some of our members why you say most of answers are correct and problem in diagnosis?
To be kind the case is near to dr answered and they have common factors here we need the best diagnosis, another factor part of questions not need to diagnosis because they are anatomy not pathology
ANSWERs:
1. A part of diagnosis in the case (carcinoma) but we want only complete this into more clear term.
Probably diagnosis is bronchogenic carcinoma.
- First definition of carcinoma: is a malignant tumor of epithelium.
-Second it becomes in old age smoking there is metaplasia in bronchial mucosa which may lead to squamous metaplasia and for long time into bronchogenic carcinoma.
- yes the bronchi are start at bifurcation of trachea in two main bronchi which enters the lung may be part of them, but if we back to the normal histology the lung contains alveoli not has epithelium mucosa, so term carcinoma is exactly bronchogenic carcinoma.
2. Predisposing factors of this case (bronchogenic carcinoma):
► Tobacco smoking (aromatic hydrocarbons and phenol derivatives). Mainly.
► Air pollution with exhaust fumes of tar and diesel.
►Silicosis asbestosis and industrial chemicals as arsenic and nickel.
►Bronchiectasis.
►Irradiation.
►Genetic factors.
3. Spread:
a. Direct with lung, to the pleura and mediastinum.
b. Lymphatic spread to hilar, mediastinal and supraclavicular lymph nodes.
c. Blood spread:
- Through pulmanry artery → metastasis in lungs.
- Through the pulmonary veins → metastasis liver brain, bones( systemic).
4. The supraclavicular lymph nodes would be enlarged and palpated.
5. The bronchopulmonary segments of upper lobe of left lung are:
- Apicoposterior.
- Superior lingular.
- Inferior lingual.
6. The alteration of voice was probably due to enlargement of left bronchomediastinal lymph nodes which caused compression of left recurrent laryngeal nerve affecting the left vocal cord.
7. Spread of cancer cells from bronchomediastinal lymph nodes to tracheobronchial lymph nodes (which lie at bifurcation of trachea) caused distortion of the trachea carina observed during bronchoscopy.
8. Complications:
a. Haemoptysis: is coughing of blood which appears frothy (mixed with air).
b. Pleural effusion: fluid accumulating in pleural sac.
c. Bronchial obstruction.
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