Dyspnea in a patient with cancer

The general approach to the patient with a malignancy who presents with dyspnea is similar to that in a patient without a malignancy, but some considerations are more prominent in this situation. Some issues to think about:

Infections:
-post-obstructive pneumonia
-opportunistics: PCP, especially if on prednisone 20mg for over 2 months (or equivalent).
-nosocomial pneumonia
-fungal esp. if neutropenia.
-TB reactivation
-tachypnea as compensation for lactic acidosis in sepsis

Vascular/lymphatic:
-pulmonary embolism
-lymphangitic carcinomatosis
-tumor emboli syndrome (seen in lung, prostate, breast- micromets plugging pulmonary capillaries. PFTs may show diffusion abn).
-secondary pulmonary HTN

Airway:
-endobronchial lesion
-COPD- esp smoker with lung ca,

Neuromuscular:
-Lambert-Eaton
-phrenic nerve involvement
-steroid myopathy

Parenchymal/interstitial (in addition to infectious items above):
-drug effect
-radiation effect

Pleural:
-pleural effusion
-pneumothorax
-pleural involvement of malignancy itself

Cardiac:
-pumonary edema seconary to cardiomyopathy- chemotherapy toxicity (esp. anthracyclines) -pericardial effusion

Other:
-anemia

No Country for Old ________........

(Does this man have acromegaly?)











Multiple Endocrine Neoplasia (MEN) syndromes can often be a bit confusing. It should be considered in those with....uhhhh....endocrine neoplasia - at multiple sites.

MEN 1: An autosomal dominant disease with mutations in the MENIN gene.
Remember "the 3 P's":

• Pituitary tumors: particularly the anterior pituitary.
• Pancreas: islet cell tumors like Insulinomas, Glucagonomas, and VIPomas.
• Parathyroid hyperplasia, usually in all glands.

MEN 2: Also an autosomal dominant disease. The mutation is in the RET proto-onco gene.

• MEN 2A: aka Sipple Syndrome
  
• Medullary thyroid cancer; typically bilateral. In non-MEN disease this is mostly unilateral.
  
• Pheochromocytoma in about 50%. Also can be bilateral.
• Parathyroid hyperplasia

• Men 2B
• Medullary thyroid cancer: as above.
• Parathyroid hyperplasia: as above.
• Marfanoid habitus: high arched palate, pectus excivatum.