CTS1A Tumours and their anatomico-physiologic complications

Case 1
A 50-year-old man presents with weight-loss and a persistent cough with blood-stained sputum.
His wife has noticed an alteration in his voice. He smokes 2 packets of cigarettes a day.
On examination, the left vocal cord is immobile and lies in the adducted position. A PA chest
Xray shows a large mass in the upper lobe of the left lung with an increase in the width of the
medistinal shadow on the left lung.

Questions
1. What are the signs and symptoms in this case?
Signs (the doctors examination) : immobile left vocal cord lying in adducted position & PA
Chest X-ray
Symptom (the patient complains of):
-

voice alteration
weight-loss
persistent cough with blood- stained sputum.

2. How can you correlate the alteration in the voice with the rest of the symptoms?
- Change in the voice pattern (hoarseness of voice) can be a symptom of lung cancer. This
occurs more commonly with left sided tumors
- happens because of the pressure effect of the tumour on the left recurrent laryngeal
nerve. The outside go to the abductors and the inside of the nerve go to the adductors.
The LRLN gives more to the abductors, therefore it lies in the adductor position. It is
more susceptible to be injured as it is longer.
- The right RLN passes under the arch of the aorta therefore hoarseness of voice does not
occur
- The blood coughing is due to the force of the tumour on the alveolar capillaries which
might cause them breaking and leak blood. These leak back until they enter the trachea
and blood is coughed subsequentially. The mass causes eroding of main blood vessels
- The drop-in weight may also be associated with lung cancer the cancer cells using
energy & reduce apatite
- Cough is due to the fact that he smokes the toxins immobilse the cilia and the patient
will produce secretions and are not able to move. The cigarette smoke causes the
irritation in the mucosa. The tumor causes irritation.

3. What other features would you expect to see in the chest Xray?
- Enlarged lymph nodes in the lungs (Hilar lymph nodes).
- Collapsed lung- If the bronchus grows enough to obstruct bronchus. If tumour completely
blocks the bronchus, from growing in inside, air gets trapped, absorbed in circulation gets absorbed slowly therefore lungs gets collapsed since there is no fresh air keeping
them open.
- Pneumonia can be an option. Accumulation of secretion which may be infectious since
they are not moved around, stagnate and cause infection. Fluid stuck in a particular
place gets stagnant.
- Probably he has obstructive pulmonary disease emphysema- the walls between the
alveoli break down - bullei are present Mostly black on the X-ray
- More air is present in the lung- elasticity decreases due to bursting of alveoli less
surface area less air to be diffused- more air trapped bigger lung
- the diaphragm flattens
- Pleural effusion

4. Would you expect this patient to present with chest pain?

- The cancer can be present without pain. However, the tumor can cause a dull, sharp pain
in the chest sometimes. This would be present in the late stage of the tumour as it starts o
increase pressure in the mediastinum and compress on the nerves which leads to visceral
pain
- Some lung cancers make hormone-like substances that raise blood calcium levels. This
affects nerves and muscles, making the person feel weak and dizzy.
- Lung cancer usually spreads to the bones causing a deep, sharp pain
- No, they do not have somatic nerve supply, but autonomic nerve supply are not
associated with pain
- Brachial plexus- it could be painful
- Pancoast tumor- tumor in the lung present in the apex

5. What anatomical characteristics would determine whether a tumour would present with
pain?
- Nervous Pain: The Nerve pain is caused by pressure on nerves or the spinal cord, or by
damage to nerves caused by the tumor. It is also called neuropathic pain. People often
describe nerve pain as burning, shooting, tingling, or as a feeling of something crawling
under their skin. In this case the tumor may be causing pressure onto the nerves in the
mediastinum namely the phrenic nerve, vagus nerve, thoracic spinal nerves

Bone Pain(Somatic) : Cancer can spread into the bone and cause pain. The cancer cells
within the bone damage the bone tissue and cause the pain. People often describe this
type of pain as aching, dull or throbbing. This has to do with the expendability of the
tissue. Bone is not expandable; thus, the tumor starts to grow pressing onto the nerves
In this case the tumor may spread into the vertebral column as well as sternum or ribs
and surrounding bones

Soft Tissue Pain (visceral pain) : Soft tissue pain means pain from a body organ or
muscle. For example, you may have pain in your chest caused by damage done to the
lungs

6. Give examples of carcinomas which in your opinion would classically present with pain.
-

Bone cancer
Bone cancer describes cancer cells that originate in the bone itself. Bone cancer is
much rarer than metastatic bone cancer. It can cause bone pain when the cancer
disrupts or destroys the bones normal structure. This also grows to put a lot of pressure
on the tissue under somatic control
Back pain is associated with cancer in the colon, rectum or ovary, liver or testicular
cancer
A head ache is associated with cancer in the brain increase in intracranial pressurecausing a head ache
Pancreatic cancer : presses on the nerve, pancreatic juices erode the nearby organ
HOWEVER, most often pain is due to the fact that the cancer has already metastasized,
as tumor in lungs, cavities, and ovaries usually do not cause pain immediately as no
pressure build up on nerves is present.
Metastatic cancer:
This is cancer that started somewhere else in the body but spread to other body parts.
Cancers of the breast, lung, thyroid, kidney, and prostate are among the cancers that
commonly spread to the bones. This grows to put a lot of pressure on the tissue

Case2
A 40 year-old woman goes to her doctor because she has noticed a swelling in her neck which
has grown over several months. She is preoccupied now because she has noticed that her neck
looks swollen all over. On examination you see very distended neck veins and a raised SVC
/jugular vein pressure.
Questions

1. Can you explain the womans clinical features?

Symptom: Swollen Neck which has grown over several months
Sign: Distended Neck vein and raised Superior Vena Cava/ jugular vein pressure
2. What pathology could present in this way?
- Extrinsic
blood cloth within the vena cava
Aneurism of the arteries
- Intrinsic
o A neoplasm that compresses or invades the superior vena cava may be present
such as bronchogenic carcinoma or mediastinal lymphoma.
o Lymph nodes near the neck causing obstruction
o The resulting obstruction produces a characteristic clinical complex consisting of
marked dilation of the veins of the head, neck and arms associated with cyanosis
as well as headaches
o Swelling in the face and upper limbs
o Repeated episodes of nose bleeds
o Collateral veins near face bursting of capillaries- new veins in the skin to form
new unresisting
o Decreases the cardiac output- increases the heart rate
o Tired and breathless and loss of consciousness due to lack of deoxygenated blood
passing through the heart
- This could include:
o bronchogenic carcinoma including small cell and non-small cell lung carcinomatypically a tumor outside the vessel compressing the vessel wall
o Upper lobe of the lung tumour Right compressing the vena cava
o lymphoma (swelling of the lymph nodes of the neck) pressing svc inwards.
o Syphilis and tuberculosis are both associated with the superior vena cava
syndrome
3. What is the name of the syndrome?
- Superior vena cava obstruction syndrome

Case3
A 35-year-old man presents with sudden onset of dropping of the right upper eyelid. On
examination, there is constriction of his pupil (myosis) and enophthalmos.

Questions
1. What is enophthalmos?
- Enophthalmos is the prosterior displacement or sinking in of either one of both eyeballs
over any length of time.

2.
3.
-

What is the clinical term for dropping of the upper eyelid?

Eyelid ptosis
Can you correlate, using your anatomy, the three clincial signs. What is happening?
Cancers of the top part of the lungs sometimes can obstruct and affect the nerves to the
eye and part of the face, causing a group of symptoms called Horner syndrome.
enophthalmus
constricted pupil disruption of sympathetic nerves
superior tarsile muscle drooping of eye lid supplied by a sympathetic nerve & cranial
nerve if a lesion is present in a sympathetic nerve causes partial ptosis
the pupil opens by the sympathetic supply dilator papillary muscle therefore
constantly constricted
Enophthalmos occurs due to the ptosis it is not actually like that

4. What could be the cause of this?

- Apical neoplasms may invade the brachial or cephalic sympathetic plexus to cause
Horner syndrome. Such apical neoplasms are sometimes called Pancoast tumors.
- Pancoast tumor often is accompanied by destruction of the first and second ribs and
sometimes the thoracic vertebrae.
- Enhydrosis inability to sweat the lesion in the sympathetic trunk- before it reached the
sweat gland
- Brain tumor, multiple sclerosis, trauma to the vertebrae can cause the horner s syndrome
- The synapsis ganglion the sympathetic chain in the mediastinum the nerve is also
susceptible
- Goitre
- Lymphoma
- Cervical rib
- Aneurism
- Internal Carotid artery surrounded by sympathetic plexus pain and features of
horners syndrome