Quiz 2

(Ref: Harrison 20th edition, p 502; Harrison 19th p 484)
 The most common causes of death in patients with cancer are infection (leading to circulatory failure), respiratory failure, hepatic failure, and renal failure. Intestinal blockage may lead to inanition and starvation.
 Central nervous system disease may lead to seizures, coma, and central hypoventilation. About 70% of patients develop dyspnea preterminally.
 However, many months usually pass between the diagnosis of cancer and the occurrence of these complications, and during this period the patient is severely affected by the possibility of death

(Ref: Harrison 20th edition, p 542; Harrison 19th p 511)
 Skeletal-connective tissue syndromes include clubbing in 30% of cases (usually NSCLCs) and hypertrophic primary osteoarthropathy in 1-10% of cases (usually adenocarcinomas).
 Clubbing is not seen with the most aggressive lung cancer i.e. small cell lung cancer.

(Ref: Harrison 19th p 511)
 Para- neoplastic syndromes are common in patients with lung cancer, especially those with SCLC, and may be the presenting finding or the first sign of recurrence.
 The ectopic ACTH production can lead to development of Cushing syndrome and resultant hyperglycemia.
 In addition, paraneoplastic syndromes may mimic metastatic disease and, unless detected, lead to inappropriate palliative rather than curative treatment

(Ref: Harrison 20th edition, p 541; Harrison 19th p 510-511)
Pancoast Syndrome Results from
1. Local extension of a tumor growing in the apex of the lung
2. Involvement of the eighth cervical and first and second thoracic nerves, with shoulder pain that characteristically radiates in the ulnar distribution of the arm
3. Radiologic destruction of the first and second ribs.
 Pancoast tumors typically present as an insidious onset of pain in the upper arm, sensory disturbance in the medial aspect of the forearm and hand, and weakness and atrophy of the intrinsic hand muscles along with an ipsilateral Horner syndrome.
 Chest CT scans or MRI can demonstrate extension of the tumor into the plexus. Metastatic involvement of the brachial plexus may occur with spread of breast cancer into the axillary lymph nodes with local spread into the nearby nerves.

(Ref: Harrison 20th edition, p 617; Harrison 19th p 578)
 The classic triad in RCC is seen in 10-20% cases only and consists of hematuria, abdominal pain and abdominal mass
 Fever weight loss and anemia are associated features but not included in triad
 Anemia is more common than eythrocytosis as paraneo-plastic manifestation.

(Ref: Harrison 20th edition, p 590)
The fibrolamellar variant of HCC has a quite different biology than adult-type HCC.
 It is multifocal in the liver, and therefore not resectable, metastases are common, especially to lungs and locoregional lymph nodes, but survival is often much better than with adult-type HCC. Resectable tumors are associated with 5-year survival > 50%

(Ref: Harrison 20th edition, p 576)
Cancers of the large bowel generally spread to regional lymph nodes or to the liver via the portal venous circulation. The liver represents the most frequent visceral site of metastasis; it is the initial site of distant spread in one-third of recurring colorectal cancers and is involved in more than two-thirds of such patients at the time of death.

(Ref: Harrison 19th p 566)
 The most accurate imaging technique is somatostatin receptor scintigraphy.
 The technique can aid diagnosis by localizing primary and metastatic sites of gastro-enteropancreatic endocrine tumors. The degree of radionuclide uptake is related to somatostatin receptor density. In gastrointestinal carcinoids, the concentration at the receptor sites is high (90%).
 Chromogranin A levels correlate with tumour bulk
 Neuron specific enolase is less sensitive than chromogranin A.

(Ref: Harrison 20th edition, p 514)
Thoracic cord is most commonly affected presenting with weakness, sensory loss, Autonomic insufficiency with urinary incontinence and sexual impotence in men.