Quiz 1

(Ref: Harrison 20th edition, p 514; Felson's principles of Radiology: 4th edition, page 205)
 Phantom/ vanishing tumour is a term used for a localized transudative inter-lobar pleural fluid collection in congestive heart failure.
 The name originates from its frequent resemblance to a tumor on the CXR and from its tendency to vanish after appropriate management of heart failure.

(Ref: Harrison 20th edition, p 1848; Harrison 19th p 289e)
 Most common tumor of heart valves in papillary fibroelastoma.
 PF are generally small and single, occur most often on valvular surfaces, and may be mobile, resulting in embolization. Because of the potential for embolic events, symptomatic patients, patients undergoing cardiac surgery for other lesions, and those with highly mobile and large PF should be considered for surgical excision.

(Ref: Harrison 19th p 511/609)
 Paraneoplastic syndromes are common in patients with lung cancer, especially those with SCLC, and may be the presenting finding or the first sign of recurrence.
Endocrinological Profiles of Lung Cancer Patients
1. Hypercalcernia resulting from ectopic production of parathyroid hormone (PTH)
2. Hyponatremia may be caused by the Syndrome of Inappropriate Secretion of Anti Diuretic Hormone (SIADH) or possibly Atrial Natriuretic Peptide (ANP).
3. Ectopic secretion of ACTH by SCLC and pulmonary carcinoids usually results in additional electrolyte disturbances, especially hypokalemia, rather than the changes in body habitus that occur in Cushing's syndrome from a pituitary adenoma.
4. Clubbing in 30% of cases (usually NSCLCs)
5. Hypertrophic primary osteoarthropathy (usually adeno-carcinomas).
Neurologic-Myopathic Syndromes Include
1. Myasthenic Eaton-Lambert syndrome
2. Retinal blindness with SCLC
3. Peripheral neuropathies
4. Subacute cerebellar degeneration
5. Cortical degeneration
6. Polymyositis
7. Paraneoplastic encephalomyelitis and sensory neurop-athies, cerebellar degeneration, limbic encephalitis, and brainstem encephalitis occur in SCLC
Coagulation, Thrombotic, or other Hematologic Manifestations
1. Migratory venous thrombophlebitis (Trousseau's syndrome)
2. Nonbacterial thrombotic (marantic) endocarditis with arterial emboli
3. Disseminated intravascular coagulation with hemorrhage
4. Anemia
5. Granulocytosis
Cutaneous Manifestations such as
1. Dermatomyositis
2. Acanthosis nigricans
Renal Manifestations
1. Nephrotic syndrome
2. Glomerulonephritis

(Ref: Harrison 20th edition, p 2924-5; 2930 Harrison 19th p 2469/247)
 Squamous cell carcinoma is associated with release of PTH-rp leading to hypercalcemia.
 Acute hypercalcemia crisis can present with delirium
 QT interval in ECG is inversely related to calcium values.
 Endocrine syndromes are seen in 12% of patients; Hypercalcemia resulting from ectopic production of parathyroid hormone (PTH), or more commonly, PTH-related peptide, is the most common life-threatening metabolic complication of malignancy.
 Hyponatremia is ruled out as ECG findings are not seen with it.

(Ref: Harrison 20th edition, p 668, Table 90-2; Harrison 19th p 614; Table 122-2)
 Antibodies associated with the stiff-person syndrome target proteins (GAD, amphiphysin) involved in the function of inhibitory synapses utilizing gamma-aminobutyric acid (GABA) or glycine as neurotransmitters.
 Paraneoplastic stiff-person syndrome and amphiphysin antibodies are often related to SCLC and breast cancer.
 This disorder is characterized by progressive muscle rigidity, stiffness, and painful spasms triggered by auditory, sensory, or emotional stimuli. Rigidity mainly involves the lower trunk and legs, but it can affect the upper extremities and neck.
 Symptoms improve with sleep and general anesthetics.
 Electro-physiological studies demonstrate continuous motor unit activity.

(Ref: Harrison 20th edition, p 570)
 Primary lymphoma of the stomach is relatively uncommon, accounting for <15% of gastric malignancies and < 2% of all lymphomas.
 The stomach is, however, the most frequent extranodal site for lymphoma, and gastric lymphoma has increased in frequency during the past 30 years

(Ref: Harrison 20th edition, p 603; Harrison 19th p 563)
 Flushing episodes are characterized by red to violet discoloration of face and neck with feeling of warmth and associated with pruritus, lacrimation, Diarrhea.
 It is mostly seen with midgut carcinoid, and toregut carcinoids.
 Diarrhea and flushing occur together in 85 % of cases

(Ref: Nelson 18th edition ch. 498, Neurohlastoma)
Tumor markers, including homovanillic acid (HVA) and vanillylmandelic acid (VMA) in urine, are elevated in 95% of neuroblastoma cases and help to confirm the diagnosis. A pathologic diagnosis is established from tumor tissue obtained by biopsy. NB can be
diagnosed in a typical presentation without a primary tumor biopsy if the patient has neuroblasts observed in bone marrow and elevated VMA or HVA in the urine

(Ref: Harrison's 17th edition pg 2604)
Gliomatosis cerebri is a rare form of astrocytoma in which there is a diffuse infiltration of brain by malignant astrocytes without focal enchancing mass.
 It presents with dementia, seizures and personality changes
 CT/MRI are not useful and biopsy is used to confirm diagnosis
 Management is by whole brain radiation and Temozolomide