Carcinoid lung tumors are a rare pulmonary malignancy and have classic, characteristics signs and symptoms associated with them.
What are the PULMONARY specific symptoms?
What are the classic SYSTEMIC symptoms of carcinoid syndrome?
Answer
Carcinoid lung tumors typically arise in the proximal airways and patienta can have obstructing symptoms such as dyspnea, cough, wheezing, chest pain, and recurrent pneumonia due to impaired sputum clearance. These tumors are also hypervascular and hemoptysis is also common.
Since carcinoid tumors are neuroendocrine tumors they produce and secrete a host of vasoactive substances that can cause a host of specific signs and symptoms. The classic presentation for carcinoid syndrome include flushing, telangiectasias, diarrhea, and bronchospasm
Definition – oscillating, crescendo-decrescendo pattern of progressive deeper and faster breathing followed a gradual decrease culminating in a period of apnea
Clinical Significance – this pattern is theorized to be a delay in changes to ventilation after detection of PaCO2 changes. This lag causes the classic respiratory pattern. Conditions associated with this include cardiac disease, neurologic disease, sedation, acid-base disturbances, prematurity in infancy, and rapid altitude changes.
History – Named after John Cheyne (1777-1836) , who was a British surgeon and received his medical doctorate at the age of 18 from Edinburgh University. He would serve as a military surgeon for several years before joining his father’s medical practice and ultimately, moving to Dublin for the majority of his career. Some have credited him as “The Father of Medicine in Ireland”. He would describe his eponymous findings in his 1818 article entitled ” A case of apoplexy in which the fleshy part of the heart was converted to fat”
William Stokes (1804-1878), was an Irish physician and received his medical doctorate from the University of Edinbugh in 1825. He was a leader and pioneer in the adaptation of the Parisian school of anatomical diagnosis and helped introduce the stethoscope to clinical practice in Ireland. He would note his eponymous findings in his 1854 textbook entitled ” The Diseases of the Heart and Aorta” and cited Dr. Cheyne as observing this first.
References
Firkin BG and Whitwirth JA. Dictionary of Medical Eponyms. 2nd ed. New York, NY; Parthenon Publishing Group. 1996.
Bartolucci S, Forbis P. Stedman’s Medical Eponyms. 2nd ed. Baltimore, MD; LWW. 2005.
Yee AJ, Pfiffner P. (2012). Medical Eponyms (Version 1.4.2) [Mobile Application Software]. Retrieved http://itunes.apple.com.
Holes between the mesothelial and subpleural layers that allow for drainage into the lymphatic system
Contains intercostal microvessels
Produce interpleural fluid
Visceral pleura
Which covers the lung parenchyma
20-80 micrometers thick
Contain bronchial microvessels
Arise from pulmonary veins and produce interpleural fluid
The interpleural space is between them and produces 0.1-0.2 mL/kg (10-20 mL per hemithorax) of fluid to keep these pleura from adhering to each other and maintain lubrication
This fluid is constantly produced (0.01 mL/kg/hr) and absorbed
Originates from the systemic pleural microvessels
Theorized that parietal is more important
Intercostal microvessels are closer to the interpleural space
Higher filtration pressure than pulmonary veins
Dependent on balance of hydrostatic pressure opposed by the counterbalancing osmotic pressure and membrane permeability
Transudative fluid collection
Increased hydrostatic pressure
Decreased oncotic pressure
Exudative fluid collection
Decreased pleural membrane permeability
Lymphatic blockage
Associated Diseases and Causes
Clinical Presentation
Symptoms
Patients can be asymptomatic, have fluid specific symptoms, and have disease specific symptoms
Moskowitz H, Platt RT, Schachar R, Mellins H. Roentgen visualization of minute pleural effusion. An experimental study to determine the minimum amount of pleural fluid visible on a radiograph. Radiology. 1973; 109(1):33-5. [pubmed]
Gonlugur U, Gonlugur TE. The distinction between transudates and exudates. J Biomed Sci. 2005; 12(6):985-90. [pubmed]
Heffner JE, Brown LK, Barbieri CA. Diagnostic value of tests that discriminate between exudative and transudative pleural effusions. Primary Study Investigators. Chest. 1997; 111(4):970-80. [pubmed]
Steger V, Mika U, Toomes H, et al. Who gains most? A 10-year experience with 611 thoracoscopic talc pleurodeses. Ann Thorac Surg. 2007; 83(6):1940-5. [pubmed]
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Feller-Kopman DJ, Reddy CB, DeCamp MM, et al. Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guideline. Am J Respir Crit Care Med. 2018; 198(7):839-849. [pubmed]
Bibby AC, Dorn P, Psallidas I, et al. ERS/EACTS statement on the management of malignant pleural effusions. Eur Respir J. 2018; 52(1):. [pubmed]
Definition – set of laboratory findings in pleural effusions that helps differentiate the fluid as transudative or exudative
Clinical Significance – after performing a diagnostic thoracentesis, the fluid can be sent to the lab for biochemical analysis. The results of this analysis can tell the medical team the whether the fluid is transudative or exudative, which can narrow down the causes and provide a diagnostic schema for management.
History – Named after Richard W. Light, a practicing pulmonologist from Vanderbilt University in Nashville, TN. He received his medical doctorate from Johns Hopkins University in 1968 and completed his residency and fellowship there in 1972. He would spend the next 20 years at UC-Irvine building his international reputation as an expert on pleural diseases. He is the author and editor for 16 current textbooks, including the gold standard textbooks Pleural Diseases and The Textbook of Pleural Diseases, as well as authored more than 450 peer reviewed articles. His eponymous criteria were first introduced in 1972 in an article he published as a fellow in the Annals of Internal Medicine….his very first paper as a physician.
References
Firkin BG and Whitwirth JA. Dictionary of Medical Eponyms. 2nd ed. New York, NY; Parthenon Publishing Group. 1996.
Bartolucci S, Forbis P. Stedman’s Medical Eponyms. 2nd ed. Baltimore, MD; LWW. 2005.
Yee AJ, Pfiffner P. (2012). Medical Eponyms (Version 1.4.2) [Mobile Application Software]. Retrieved http://itunes.apple.com.
Light RW, Macgregor MI, Luchsinger PC, Ball WC Jr. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med. 1972; 77(4):507-13. [pubmed]
Surgery is a major physiologic stress and often is accompanied by biochemical derangements that effect homeostasis in the post-operative period. Describe the most common clinical scenarios that can cause each of the four main acid-base imbalances in a post-surgical patient.
Other Known Aliases – end-to-end surgical anastomosis
Definition – gastrointestinal tract is divided into two limbs (proximal, Roux limb and a distal limb) and are re-anastomosed farther down the GI tract, typically in the jejunum
Clinical Significance – this type of surgery is the traditional form of gastric bypass, where the proximal, Roux limb serves as the food reservoir and somach and the distal limb allows for physiologic drainage of gastric, hepatic, and pancreatic enzymes to aid in digestion. Other conditions it can be used is are chronic pancreatitis, alkaline gastritis, and various GI substitution procedures.
History – Named after César Roux (1857-1934), who was a Swiss surgeon and received his medical doctorate from the University of Bern 1880. He would stay on at his alma mater and assist Theodor Kocher until 1887, when he became chief of surgery at cantonal hospital of Lausanne. He would go on to have a modest career in surgery notable for two historical accomplishments. In 1893, he performed his eponymous procedure on a patient with gastric strictures from peptic ulcer disease to alleviate his obstruction symptoms. In 1926, the year of his retirement, he was the first surgeon to successfully remove a pheochromocytoma….7 months before Charles Mayo performed the same operation in the United States. Harvey Cushing visited his clinic in 1900 and said “he is a rough diamond-looks like Kipling-does excellent work and comes nearer to being the kind of man I am looking for than anyone else I have seen”.
References
Firkin BG and Whitwirth JA. Dictionary of Medical Eponyms. 2nd ed. New York, NY; Parthenon Publishing Group. 1996.
Bartolucci S, Forbis P. Stedman’s Medical Eponyms. 2nd ed. Baltimore, MD; LWW. 2005.
Yee AJ, Pfiffner P. (2012). Medical Eponyms (Version 1.4.2) [Mobile Application Software]. Retrieved http://itunes.apple.com.
Surgery is a major physiologic stress and often is accompanied by biochemical derangements that effect homeostasis in the post-operative period. Describe the most common clinical scenarios that can cause each of the four main acid-base imbalances in a post-surgical patient.
Definition – pancreaticoduodenectomy cholecystectomy, choledochojejunostomy, pancreaticojejunostomy, and gastrojejunostomy
Clinical Significance – this type of surgery is performed to resect pancreatic head tumors. It generally performed at large, high-volume medical centers as this has been shown to reduce mortality to less than 5%. An experienced surgeon can complete this surgery in < 6 hours with < 500mL of blood loss. Barring any postoperative complications, most patients are discharged from the hospital in 7-10 days.
History – Named after Allen Oldfather Whipple (1881-1963), who was an American surgeon and received his medical doctorate from Columbia University College of Physicians and Surgeons in 1908. He was appointed faculty at Columbia and Presbyterian Medical Centers before going on to become professor of surgery at his alma mater for the next 25 years. He published the report of his eponymous surgery in 1935 and only performed it 37 times in his lifetime. He also supervised Virginia Apgar and advised her to pursue a career in anesthesiology because he saw an “energy and ability to make significant contributions” that would advance both fields. Other notable accomplishments include helping establish the American Board of Surgery and establishing another eponymous diagnostic triad for insulinoma.
References
Firkin BG and Whitwirth JA. Dictionary of Medical Eponyms. 2nd ed. New York, NY; Parthenon Publishing Group. 1996.
Bartolucci S, Forbis P. Stedman’s Medical Eponyms. 2nd ed. Baltimore, MD; LWW. 2005.
Yee AJ, Pfiffner P. (2012). Medical Eponyms (Version 1.4.2) [Mobile Application Software]. Retrieved http://itunes.apple.com.
Haubrich WS. Calot of the triangle of Calot. Gastroenterology. 2002; 123(5):1440. [pubmed]
Singer AJ, McCracken G, Henry MC, Thode HC Jr, Cabahug CJ. Correlation among clinical, laboratory, and hepatobiliary scanning findings in patients with suspected acute cholecystitis. Ann Emerg Med. 1996; 28(3):267-72. [pubmed]
Shea JA, Berlin JA, Escarce JJ, et al. Revised estimates of diagnostic test sensitivity and specificity in suspected biliary tract disease. Arch Intern Med. 1994; 154(22):2573-81. [pubmed]
Park MS, Yu JS, Kim YH, et al. Acute cholecystitis: comparison of MR cholangiography and US. Radiology. 1998; 209(3):781-5. [pubmed]
Thompson DR. Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis. Am J Gastroenterol. 2001; 96(4):1266-72. [pubmed]
Okamoto K, Suzuki K, Takada T, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018; 25(1):55-72. [pubmed]
Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50(2):133-64. [pubmed]
Hatzidakis AA, Prassopoulos P, Petinarakis I, et al. Acute cholecystitis in high-risk patients: percutaneous cholecystostomy vs conservative treatment. Eur Radiol. 2002; 12(7):1778-84. [pubmed]
