DIAGNOSIS & TREATMENT - PART 6 potx

Thyroid Cancer ■ Essentials of Diagnosis • History of irradiation to neck in some patients • Often hard, painless nodule; dysphagia or hoarseness occasionally • Cervical lymphadenopathy when local metastases present • Thyroid function tests normal; nodule is characteristically stip- pled with calcium on x-ray, cold by radioiodine scan, and solid by ultrasound; does not regress with thyroid hormone administration ■ Differential Diagnosis • Thyroiditis • Other neck masses and other causes of lymphadenopathy • Thyroglossal duct cyst • Benign thyroid nodules ■ Treatment • Fine-needle aspiration biopsy best differentiates benign from mal- ignant nodules • Total thyroidectomy for carcinoma; radioactive iodine postoper- atively for selected patients with iodine-avid metastases; combi- nation chemotherapy in anaplastic tumors • Prognosis related to cell type and histology; papillary carcinoma offers excellent outlook, anaplastic the worst • Medullary thyroid cancer is typically refractory to chemotherapy and radiation; diagnosable by calcitonin elevation in MEN syn- dromes ■ Pearl In patients who had thymus radiation during childhood—a common practice in past years—a thyroid nodule is malignant until proved other- wise. Reference Rossi RL et al: Thyroid cancer. Surg Clin North Am 2000;80:571. [PMID: 10836007] 256 Essentials of Diagnosis & Treatment 9 Carcinoma of the Prostate ■ Essentials of Diagnosis • More common and seemingly more aggressive in blacks • Exact role of screening uncertain; may prove to be more useful in middle-aged men, especially blacks • Symptoms of prostatism more often absent than present; bone pain (especially back) if metastases present; asymptomatic in many, however • Stony, hard, irregular prostate palpable, usually lateral part of gland • Osteoblastic osseous metastases visible by plain radiograph • Prostate-specific antigen (PSA) is age-dependent and is elevated in older patients with benign prostatic hyperplasia and also acute prostatitis; reliably predicts extent of neoplastic disease and recurrence after prostatectomy ■ Differential Diagnosis • Benign prostatic hyperplasia (may be associated) • Scarring secondary due to tuberculosis or calculi • Urethral stricture • Neurogenic bladder ■ Treatment • Providers must apprise patients of the probability of post- therapeutic erectile dysfunction, urinary incontinence • Radiation therapy (external beam, brachytherapy, or combina- tion) or radical prostatectomy, ideally nerve-sparing for local- ized disease • Radiation or surgical therapy for local nodal metastases in selected patients after prostatectomy • Androgen ablation (chemical or surgical) for metastatic disease, though exact timing of initiation of therapy (at diagnosis or at onset of symptoms) is unclear • Combination chemotherapy may benefit selected patients with hormone-refractory metastatic disease ■ Pearl About 1% of prostate tumors—most of these are small-cell carcinomas— are not adenocarcinoma and thus do not express PSA. Reference Klotz L: Hormone therapy for patients with prostate carcinoma. Cancer 2000;88(12 Suppl):3009. [PMID: 10898345] Chapter 9 Oncologic Diseases 257 9 Tumors of the Testis ■ Essentials of Diagnosis • Painless testicular nodule; peak incidence at age 20–35 • Testis does not transilluminate • Gynecomastia, premature virilization in occasional patients • Tumor markers (AFP, LDH, hCG) useful in diagnosis, monitor- ing response to therapy, and surveillance for relapse • Pure seminoma produces hCG only, while nonseminomatous germ cell tumors may produce hCG and AFP ■ Differential Diagnosis • Genitourinary tuberculosis • Syphilitic orchitis • Hydrocele • Spermatocele • Epididymitis ■ Treatment • Orchiectomy, with lumbar and inguinal lymph nodes examined for staging • Additional radical resection of iliolumbar nodes indicated unless tumor is a seminoma for which radiation therapy is treatment of choice following surgery • Postsurgical radiation therapy also useful for other malignant cell types • Platinum-based chemotherapy curative in appreciable majority of patients with advanced or metastatic disease ■ Pearl One of the great stories in oncology, with remarkable therapies result- ing in many years of life saved. Reference Kinkade S: Testicular cancer. Am Fam Physician 1999;59:2539. [PMID: 10323360] 258 Essentials of Diagnosis & Treatment 9 Carcinoma of the Bladder (Transitional Cell Carcinoma) ■ Essentials of Diagnosis • More common in men over 40 years of age; predisposing factors include smoking and alcohol as well as chronic Schistosoma haematobium infection, exposure to certain industrial toxins, or previous cyclophosphamide therapy • Microscopic or gross hematuria with no other symptoms is the most common presentation • Suprapubic pain, urgency, and frequency when concurrent infec- tion present • Occasional uremia if both ureterovesical orifices obstructed • Tumor visible by cystoscopy ■ Differential Diagnosis • Other urinary tract tumor • Acute cystitis • Renal tuberculosis • Urinary calculi • Glomerulonephritis or interstitial nephritis ■ Treatment • Endoscopic transurethral resection for superficial or submucosal tumors; intravesical chemotherapy reduces the likelihood of re- currence • Radical cystectomy standard with muscle-invasive tumors, though less morbid procedures with intensive follow-up may provide sim- ilar outcomes • Role of adjuvant chemotherapy or radiation for completely re- sected patients unclear, but generally offered to those at high risk of recurrence • Combination chemotherapy for metastatic disease has a high re- sponse rate and may be curative in a small percentage of patients ■ Pearl Remember Kaposi’s sarcoma of the bladder in an AIDS patient with a urinary catheter and gross hematuria; it usually (not always) presents in association with cutaneous disease. Reference van der Meijden AP: Bladder cancer. BMJ 1998;317:1366. [PMID: 99030215] Chapter 9 Oncologic Diseases 259 9 Adenocarcinoma of the Kidney (Renal Cell Carcinoma; Hypernephroma) ■ Essentials of Diagnosis • Dubbed the internist’s tumor because of its pleomorphic clinical manifestations • Gross or microscopic hematuria, back pain, fever, weight loss, night sweats • Flank or abdominal mass may be palpable • When flank pain, hematuria, and palpable mass—the “too-late triad”—are present, only 15% are curable • Anemia in 30%, erythrocytosis in 3%; hypercalcemia, hypo- glycemia sometimes seen • Frequent tumor or tumor thrombus invasion of renal vein and ascending inferior vena cava, on occasion causing superior vena cava syndrome • Renal ultrasound, CT, or MRI reveals characteristic lesion ■ Differential Diagnosis • Simple cyst • Polycystic kidney disease • Single complex renal cyst; but 70% of these are malignant • Renal tuberculosis • Renal calculi • Renal infarction • Endocarditis ■ Treatment • Nephrectomy curative for patients with early stage lesions • Poor response to chemotherapy or radiation in metastatic disease • Small response rate to combination bio-chemotherapy (inter- leukin 2 plus cytotoxic agents), though very toxic • Resection of primary lesion has been documented to result in regression of metastases on rare occasions • Nonmyeloablating allogeneic bone marrow transplantation has significant response rate in highly selected patients ■ Pearl A small proportion of patients have a nonmetastatic hepatopathy, with elevation of alkaline phosphatase; this abnormality does not imply in- operability and disappears with resection of the tumor. Reference Motzer RJ et al: Renal-cell carcinoma. N Engl J Med 1996;335:865. [PMID: 8778606] 260 Essentials of Diagnosis & Treatment 9 Malignant Tumors of the Esophagus ■ Essentials of Diagnosis • Progressive dysphagia—initially during ingestion of solid foods, later with liquids; progressive weight loss and inanition ominous • Smoking, alcoholism, chronic esophageal reflux with Barrett’s esophagus, achalasia, caustic injury, and asbestos are risk factors • Noninvasive imaging (barium swallow, CT scan) suggestive, diagnosis confirmed by endoscopy and biopsy • Staging of disease aided by endoscopic ultrasound • Squamous histology more common, though incidence of adeno- carcinoma increasing rapidly in Western countries for unclear reasons ■ Differential Diagnosis • Benign tumors of the esophagus • Benign esophageal stricture or achalasia • Esophageal diverticulum • Esophageal webs • Achalasia (may be associated) • Globus hystericus ■ Treatment • Combination chemotherapy and radiotherapy or surgery for lo- calized disease, though long-term remission or cure is achieved in only 10–15% • Dilation or esophageal stenting may palliate advanced disease; little role for chemotherapy or radiation in advanced or metasta- tic disease ■ Pearl Dysphagia is one of the few symptoms in medicine for which anatomic correlation always exists—too often it represents carcinoma. Reference Lerut T et al: Treatment of esophageal carcinoma. Chest 1999;116(6 Suppl):463S. [PMID: 10619509] Chapter 9 Oncologic Diseases 261 9 Carcinoma of the Stomach ■ Essentials of Diagnosis • Few early symptoms, but abdominal pain not unusual; late com- plaints include dyspepsia, anorexia, nausea, early satiety, weight loss • Palpable abdominal mass (late) • Iron deficiency anemia, fecal occult blood positive; achlorhydria present in minority of patients • Mass or ulcer visualized radiographically; endoscopic biopsy and cytologic examination diagnostic • Associated with atrophic gastritis, Helicobacter pylori; role of diet, previous partial gastrectomy controversial ■ Differential Diagnosis • Benign gastric ulcer • Gastritis • Functional or irritable bowel syndrome • Other gastric tumors, eg, leiomyosarcoma, lymphoma ■ Treatment • Resection for cure; palliative resection with gastroenterostomy in selected cases • Adjuvant chemotherapy may improve long-term survival in high- risk patients post surgery and may achieve remission in a minor- ity of patients with metastatic disease ■ Pearl A gastric ulcer with histamine-fast achlorhydria is adenocarcinoma in 100% of cases. Reference Scheiman JM et al: Helicobacter pylori and gastric cancer. Am J Med 1999;106:222. [PMID: 10230753] 262 Essentials of Diagnosis & Treatment 9 Bronchogenic Carcinoma ■ Essentials of Diagnosis • Smoking most important cause, concomitant asbestos exposure synergistic; also associated with second-hand smoke • Chronic cough, dyspnea; chest pain, hoarseness, hemoptysis, weight loss; may be asymptomatic, however • Examination depends on disease stage; localized wheezing, club- bing, superior vena cava syndrome in some • Enlarging mass, infiltrate, atelectasis, pleural effusion, or cavita- tion by chest x-ray; peripheral coin lesions in a minority • Diagnostic: presence of malignant cells by sputum or pleural fluid cytology or on histologic examination of tissue biopsy • Metastases to other organs or paraneoplastic effects may produce the initial symptoms • Central nervous system metastases at time of diagnosis common with small cell histology ■ Differential Diagnosis • Tuberculosis • Pulmonary mycoses • Pyogenic lung abscess • Metastasis from extrapulmonary primary tumor • Benign lung tumor, eg, hamartoma • Noninfectious granulomatous disease ■ Treatment • Resection for appropriate non-small-cell carcinomas and all coin lesions, assuming no evidence of spread or other primary • Combination chemotherapy and radiation for limited-stage small- cell carcinoma; may be curative • Prophylactic cranial radiation probably beneficial for those achiev- ing complete remission or excellent response with initial therapy • Palliative chemotherapy and radiation for metastatic non-small-cell carcinoma ■ Pearl Of nonsmokers who develop this disorder, middle-aged women with non-small cell cancer are the most common; take pulmonary symptoms very seriously in this group. Reference Hoffman PC et al: Lung cancer. Lancet 2000;355:479. [PMID: 10841143] Chapter 9 Oncologic Diseases 263 9 Pleural Mesothelioma ■ Essentials of Diagnosis • Insidious dyspnea, nonpleuritic chest pain, weight loss • Dullness to percussion, diminished breath sounds, pleural friction rub, clubbing • Nodular or irregular unilateral pleural thickening, often with ef- fusion by chest radiograph; CT scan often helpful • Pleural biopsy usually necessary for diagnosis, though malignant nature of tumor only confirmed by natural history; pleural fluid exudative and usually hemorrhagic • Strong association with asbestos exposure, with usual latency from time of exposure 20 years or more ■ Differential Diagnosis • Primary pulmonary parenchymal malignancy • Empyema • Benign pleural inflammatory conditions (posttraumatic, asbestosis) ■ Treatment • No consistently effective therapy currently available, though inves- tigations with combination surgery, radiotherapy, and chemo- therapy are under way • One-year mortality rate > 75% ■ Pearl Consider this when empyema develops in patients irradiated for malig- nancy years earlier—it’s a rare complication. Reference Sterman DH et al: Advances in the treatment of malignant pleural mesothelioma. Chest 1999;116:504. [PMID: 10453882] 264 Essentials of Diagnosis & Treatment 9 Primary Intracranial Tumors ■ Essentials of Diagnosis • Many different cell types; prognosis upon which one; half are gliomas • Most present with generalized or focal disturbances of cerebral function: generalized symptoms include nocturnal headache, seizures, and projectile vomiting; focal deficits relate to location of the tumor • CT or MRI with gadolinium enhancement defines the lesion; pos- terior fossa tumors are better visualized by MRI • Biopsy is the definitive diagnostic procedure, distinguishes pri- mary brain tumors from brain abscess and other intracranial space- occupying lesions such as metastases Specific types: • Glioblastoma multiforme: in strictest sense an astrocytoma, but rapidly progressive with a poor prognosis • Astrocytoma: More chronic course than glioblastoma, with a variable prognosis • Medulloblastoma: seen primarily in children and arises from roof of fourth ventricle • Cerebellar hemangioblastoma: patients usually present with dis- equilibrium and ataxia, and occasional erythrocytosis • Meningioma: compresses rather than invades adjacent neural structures; usually benign • Primary cerebral lymphoma: usually in AIDS and other immun- odeficient states, though may occur rarely in immunocompetent individuals ■ Treatment • Treatment depends upon the type and site of the tumor and the condition of the patient • Resection to maximal extent possible is important predictor of outcome in most central nervous system malignancies • Radiation post surgery is mainstay of therapy • Herniation treated with intravenous corticosteroids, mannitol, and surgical decompression if possible • Prophylactic anticonvulsants are also commonly given ■ Pearl A headache that awakens a patient from sleep should put this diagno- sis at the top of the list. Reference DeAngelis LM: Brain tumors. N Engl J Med 2001;344:114. [PMID: 11150363] Chapter 9 Oncologic Diseases 265 9 [...]... about recent upper respiratory infections; anticholinergic medications in over-the-counter remedies may be the answer Reference Ramsey EW: Office treatment of benign prostatic hyperplasia Urol Clin North Am 1998;25:571 [PMID: 100 267 66] 288 Essentials of Diagnosis & Treatment RENAL DISORDERS Acute Renal Failure I Essentials of Diagnosis • When not otherwise qualified, usually synonymous with acute tubular... HIV Reference National guideline for the management of epididymo-orchitis Clinical Effectiveness Group (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases) Sex Transm Infect 1999; 75(Suppl 1):S51 [PMID: 1 061 6385] 11 2 86 Essentials of Diagnosis & Treatment Testicular Torsion I Essentials of Diagnosis • Usually occurs in males under 25 years of age; may present... an elevated PCO2; it’s the case in most hypercapnic patients Reference Adrogue HJ et al: Management of life-threatening acid-base disorders First of two parts N Engl J Med 1998;338: 26 [PMID: 9414329] Chapter 10 Fluid, Acid-Base, & Electrolyte Disorders 279 Respiratory Alkalosis I Essentials of Diagnosis • Lightheadedness, numbness or tingling of extremities, circumoral paresthesias • Tachypnea; positive... lowered PCO2 is a dependable early sign of bacteremia and sepsis syndrome Reference Adrogue HJ et al: Management of life-threatening acid-base disorders Second of two parts N Engl J Med 1998;338:107 [PMID: 9420343] 10 280 Essentials of Diagnosis & Treatment Metabolic Acidosis I Essentials of Diagnosis • • • • I Dyspnea, hyperventilation, respiratory fatigue Tachycardia, hypotension, shock (depending on cause)... dehydration Reference Kleiner SM: Water: an essential but overlooked nutrient J Am Diet Assoc 1999;99:200 [PMID: 9972188] 266 Copyright 2002 The McGraw-Hill Companies, Inc Click Here for Terms of Use Chapter 10 Fluid, Acid-Base, & Electrolyte Disorders 267 Shock I Essentials of Diagnosis • History of hemorrhage, myocardial infarction, sepsis, trauma, or anaphylaxis • Tachycardia, hypotension, hypothermia,... without clinical manifestations Reference Subramanian R et al: Severe hypophosphatemia Pathophysiologic implications, clinical presentations, and treatment Medicine 2000;79:1 [PMID: 1 067 0405] 10 2 76 Essentials of Diagnosis & Treatment Hypermagnesemia I Essentials of Diagnosis • Weakness, hyporeflexia, respiratory muscle paralysis • Confusion, altered mentation • Serum magnesium > 3 mg/dL; renal insufficiency... of cerebral edema) • Desmopressin acetate for central diabetes insipidus I Pearl In-patient mortality for a sodium > 150 mg/dL is approximately 50% Reference Adrogue HJ et al: Hypernatremia N Engl J Med 2000;342:1493 [PMID: 108 161 88] Chapter 10 Fluid, Acid-Base, & Electrolyte Disorders 269 Hyponatremia I Essentials of Diagnosis • Nausea, headache, weakness, irritability, mental confusion (especially... of Diagnosis & Treatment Hyperkalemia I Essentials of Diagnosis • Weakness or flaccid paralysis, abdominal distention, diarrhea • Serum potassium > 5 meq/L • Electrocardiographic changes: peaked T waves, loss of P wave with sinoventricular rhythm, QRS widening, ventricular asystole, cardiac arrest I Differential Diagnosis • Renal failure with oliguria • Hypoaldosteronism (hyporeninism, potassium-sparing... ketoacidosis is not the cause of an altered mental status—hyperosmolality is Reference Forsythe SM et al: Sodium bicarbonate for the treatment of lactic acidosis Chest 2000;117: 260 [PMID: 1 063 1227] Chapter 10 Fluid, Acid-Base, & Electrolyte Disorders 281 Metabolic Alkalosis I Essentials of Diagnosis • Weakness, malaise, lethargy; other symptoms depend on cause • Hyporeflexia, tetany, ileus, muscle weakness • Arterial... intraprostatic levels of all antibiotics; an ideal drug for this process Reference Nickel JC: Prostatitis: evolving management strategies Urol Clin North Am 1999; 26: 737 [PMID: 1058 461 5] 11 284 Essentials of Diagnosis & Treatment Urinary Calculi I Essentials of Diagnosis • Most common in the stone belt, extending from central Ohio through mid Florida • Sudden, severe colicky pain localized to the flank, commonly . imply in- operability and disappears with resection of the tumor. Reference Motzer RJ et al: Renal-cell carcinoma. N Engl J Med 19 96; 335: 865 . [PMID: 877 860 6] 260 Essentials of Diagnosis & Treatment 9 Malignant. 1999;1 16( 6 Suppl): 463 S. [PMID: 1 061 9509] Chapter 9 Oncologic Diseases 261 9 Carcinoma of the Stomach ■ Essentials of Diagnosis • Few early symptoms, but abdominal pain not unusual; late com- plaints. this diagno- sis at the top of the list. Reference DeAngelis LM: Brain tumors. N Engl J Med 2001;344:114. [PMID: 11150 363 ] Chapter 9 Oncologic Diseases 265 9 266 10 Fluid, Acid-Base, & Electrolyte