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NBME 20 Answers

nbme20/Block 4/Question#13 (52.8 difficulty score)
A 62-year-old woman comes to the physician ...
Bronchogenic carcinoma🔍

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 +6  upvote downvote
submitted by xxabi(224),
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gneonrcciohB riomcaanc = unlg crnaec

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luke.10  why not systemic scleroderma since i did this question wrong and i chose systemic sclerosis scleroderma , can someone explain that ? +1  
kernicterusthefrog  My best guess answer to that @luke.10 is that: a) there's no mention of any skin involvement (which there would be in order to be scleroderma) b) Scleroderma shows pitting in the nails, not clubbing c) There would be collagen deposition with fibrosis, not hypertrophy of the bone at joints Saying that, I also got this wrong! (but put RA...) so I'm not claiming to "get this" Hope my thought process helps, though! +5  
yotsubato  This is in FA 2019 page 229 +8  
larascon  I agree with @kernicterusthefrog on this one, Bronchogenic carcinoma = lung cancer. Squamous cell carcinoma gives you hypercalcemia (new bone formation; maybe?), commonly found in SMOKERS ... +3  
waterloo  the clubbing is the symptom that takes out alot of the answer choices. It's super tricky. +  
jawnmeechell  Plus the patient has an 84 pack-year smoking history, super high risk for lung cancer +  
veryhungrycaterpillar  FA 2019 pg 229 is all paraneoplastic syndromes. There is no mention of bronchogenic carcinoma in any of them. There is adenocarcinoma, but that is most likely in non smokers, not in someone with 84 pack year of smoking history. Why does he have 5 upvotes for referencing first aid here, what am I missing? +2  
jakeisawake  @veryhungrycaterpillar sounds like bronchogenic carcinoma is a general term for lung cancer. You are right that if a non-smoker gets lung cancer it is most likely adenocarcinoma as non-smokers rarely get small cell. However, smokers can get adenocarcinomas as well. The oncologist that I shadow sees this frequently. Adenocarcinoma of the lung causes hypertrophic osteoarthropathy per 229 in FA2019 +1  
mangotango  @verhungrycaterpillar @jakeisawake Adenocarcinoma is the most common tumor in nonsmokers and in female smokers (like this patient), so adenocarcinoma would still be the most likely cancer for this pt over the others. Pathoma Pg. 96. +2  
fatboyslim  Apparently bronchogenic carcinoma is basically an umbrella term for lung cancer. Source: +  

 +3  upvote downvote
submitted by niboonsh(285),

found this online:

Hypertrophic pulmonary osteoarthropathy (HPOA) is a syndrome characterized by the triad of periostitis, digital clubbing and painful arthropathy of the large joints, especially involving the lower limbs. Clubbing is characterized by bulbous enlargement of terminal segments of the fingers and toes due to proliferation of subungual connective tissue.

primary... is a rare hereditary condition.

A majority of cases (>90%) of secondary HPOA are associated with pulmonary malignancies [6] or chronic suppurative pulmonary diseases.

Pulmonary malignancies, including primary [7], metastatic lung cancer and intrathoracic lymphoma, account for 80% of cases of secondary HPOA. Adenocarcinoma of the lung is the most frequent and small cell carcinoma is the least frequent histopathologic type of lung cancer associated with HPOA [7].

other associated extrathoracic malignancies include nasopharyngeal carcinoma, renal cell carcinoma, oesophageal cancer, gastric tumour [8], pancreatic cancer, breast phyllodes tumour [9], melanoma, thyroid cancer, osteosarcoma and intestinal lymphoma.

Various rheumatologic conditions, including RA [10], AS [11], polyarteritis nodosa, SLE [12], Takayasu disease [13], sarcoidosis, APS and Mediterranean fever are known to be associated with this condition as well.

Pulmonary conditions such as cystic fibrosis, tuberculosis, idiopathic pulmonary fibrosis [14] and lung transplantation have also been associated with HPOA.

This patient has hypertrophic osteoarthropathy which is associated with bronchogenic carcinoma. It presents with painful swelling of wrists, fingers, ankles, knees, or elbows. In addition, the ends of long bones show periosteal new bone formation , which can produce digital clubbing and often arthritis of adjacent joints.

Resource: Kaplan Bone Pathology Page 237

 +0  upvote downvote
submitted by tulasi(0),

The presentation of Bronchigenic carcinoma is -Cough and hemptysis The tutor metastasis to Bone,Lung,brain and adrenals. So now the question is mentioning the same points The cough and sputum and also new bone formation on affected bones on Xray and also clubbing represents the lung.

Reference- 100 concepts of anatomy slide 94

tulasi  Also its cell type is squamous cell carcinoma like not adenocarcinoma like. +  
tulasi  Also its cell type is squamous cell carcinoma like not adenocarcinoma like. +  
tulasi  Also its cell type is squamous cell carcinoma like not adenocarcinoma like. +  

 -1  upvote downvote
submitted by step1soon(43),

The reported incidence of Caplan syndrome is 1 in every 100,000 people. This has been a declining number due to lower exposure to coal, asbestos, and silica. Prevalence of Caplan syndrome is higher in patients with silica exposure compared to the other causes. The first epidemiologic study undertaken by the Pneumoconiosis Research Unit observed an increased prevalence of RA amongst men with progressive massive fibrosis (PMF). Miall et al. found no increased prevalence of rheumatoid arthritis in miners when compared to a community where PMF and rheumatoid arthritis were prevalent and therefore concluded that the etiology of RA was not associated with exposure to dust or lung changes of complicated pneumoconiosis. There was a high prevalence rate of PMF and tuberculosis amongst miners and ex-miners with rheumatoid arthritis.[4][5]

Pathophysiology: An autoimmune condition is a phenomenon where one's body has inflammatory cells which attack its own tissue and, in the case of RA, the synovium. It is believed that in these patients, there is an alteration which causes the increased immune response to foreign materials in the lungs. There is immune hyperactivity that is sparked by silica in which monocytes and macrophages release cytokines such as interleukin-1 and granulocyte-macrophage-colony-stimulating factor and tumor necrosis factor alpha. The sharp edges of the silica also cause lysis of lysosomal proteases in macrophages. Lymphocytes are activated by the cytokines released by macrophages. This all leads to an autoimmune phenomenon through exposure to silica which is triggered in genetically predisposed individuals who have RA.

wouldn't the underlying disease be RA which is then causing bronchogenic carcinoma? I'm confused!!

kpjk  i dont think its RA, because they said xray shows new bone formation, where as RA would have erosion +