1. Lesson for today… “Sticks and stones can break my bones…” Grand Rounds Presentation
2. To present a case of a rapidly progressing lung mass To discuss a diagnostic approach to lung carcinoma presenting with effusion Objectives
3. Identifying Data Insert picture Name: S.D. Age: 73 years old Sex: Female Chief Complaint: left shoulder pain “angsakitngkaliwangbalikatko” Sticks and stones can break my bones…
84. Physical Examination Sensory: 80% sensory deficit C7-C8 dermatomal of LUE 5/5 3/5 Motor: 3/5 on LUE, the rest 5/5; inability to flex, extend, abduct adduct fingers, left 5/5 5/5 Sticks and stones can break my bones…
135. No progression of lung findings on PEPassive left atelectasis Pleural effusion Day 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Sticks and stones can break my bones…
140. VS stable, same lung findings on PEMotor: 3/5 LUE; inability to flex and extend fingers, left Day 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 3 PF analysis, exudative; no growth on culture Sticks and stones can break my bones…
141.
142. VS stable, same lung findings on PEInterpretation (Light’s Criteria): Exudative Day 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 3 PF analysis, exudative; no growth on culture Sticks and stones can break my bones…
146. PE: no significant progression or improvement of lung findingsDay 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 3 PF analysis, exudative; no growth on culture Sticks and stones can break my bones…
149. Interval increase of pleural effusion on CXRDay 6 Day 1 S/P Thoracentesis Day 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 3 PF analysis, exudative; no growth on culture Day 6 CT scan –guided biopsy Chest xray Sticks and stones can break my bones…
152. Oncology service called inDay 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 3 PF analysis, exudative; no growth on culture Day 6 CT scan –guided biopsy Chest xray Day 8 Biopsy result: Adenocarcinoma Sticks and stones can break my bones…
155. Oncology service called inDay 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 3 PF analysis, exudative; no growth on culture Day 6 CT scan –guided biopsy Chest xray Day 8 Biopsy result: Adenocarcinoma Sticks and stones can break my bones…
159. Sensory: 50% deficit, right and 75%, left3/5 3/5 - 50% - 75% Day 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 8 Biopsy result: Adenocarcinoma Day 3 PF analysis, exudative; no growth on culture Day 6 CT scan –guided biopsy Chest xray Day 9 Given Bisacodyl Sticks and stones can break my bones…
163. Sensory: 50% deficit, right and 75%, leftDay 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 8 Biopsy result: Adenocarcinoma Day 3 PF analysis, exudative; no growth on culture Day 6 CT scan –guided biopsy Chest xray Day 9 Given Bisacodyl Sticks and stones can break my bones…
166. DRE: lax sphincter tone3/5 0/5 Day 1 Thoracentesis Tramadol Ceftriaxone Day 9 Dexamethasone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 8 Biopsy result: Adenocarcinoma Day 3 PF analysis, exudative; no growth on culture Day 6 CT scan –guided biopsy Chest xray Day 9 Bisacodyl Sticks and stones can break my bones…
169. DRE: lax sphincter toneDay 1 Thoracentesis Tramadol Ceftriaxone Day 9 Dexamethasone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 8 Biopsy result: Adenocarcinoma Day 3 PF analysis, exudative; no growth on culture Day 6 CT scan –guided biopsy Chest xray Day 9 Bisacodyl Sticks and stones can break my bones…
180. Official reading of histopathology: adenocarcinoma, pulmonary in originDay 11 Thoracic MRI: metastatic findings at C7, T7, T8, T9 Ketorolac Sticks and stones can break my bones…
183. First cycle of radiation therapyDay 11 Thoracic MRI: metastatic findings at C7, T7, T8, T9 Ketorolac Sticks and stones can break my bones… Day 14 1st cycle of RT Dulcolax suppository Lactulose Gabapentin
184. Final Diagnosis: Lung Cancer, Adenocarcinoma Stage 4 Pancoast tumor with spinal cord and left brachial plexus compression Sticks and stones can break my bones…
197. Adenocarcinoma Lung Cancer Adenocarcinoma accounts for 40% of non-small-cell lung cancers It usually originates in peripheral lung tissue Most cases of adenocarcinoma are associated with smoking; however, among people who have never smoked ("never-smokers"), adenocarcinoma is the most common form of lung cancer A subtype of adenocarcinoma, the bronchioalveolar carcinoma, is more common in female never smokers, and may have different response to treatment
198. Types of NSCLC on smokers and non-smokers Women & adenocarcinoma Bryant, A; Cerfolio RJ (July 2007).Differences in epidemiology, histology and survival with patients between cigarette smokers and never smokers. Chest 132 (1): 198-
203. Pleural Effusion In a study by Diaz et. Al… 75% likely that it is pleural metastasis! Chest X-rays 7% Pleural Effusion
204. How about the shoulder pain? Later staging… ….Poorer prognosis
205. Pancoast tumor Severe pain in the shoulder region >>> toward the axilla & scapula & ulnar aspect of the muscles of the hand Atrophy of hand and arm muscles Horner syndrome Compression of the blood vessels with edema CLASSIC PANCOAST TUMOR
208. Spinal cord compression Early diagnosis is crucial Arrest the course of the disease 60% in the thoracic spine 30% the lumbosacral region Weakness is the most obvious and problematic manifestation of spinal cord compression Bowel and bladder disturbances tend to be a late occurrence
209. Insert picture Treatment? Lung Cancer Adenocarcinoma Stage IV PLUS Spinal Cord Compression LOM Sticks and stones can break my bones…
210. Risk Factors Protective Smoking passive smoking Diet: cured meat, deep fried cooking, chili Alcohol Occupational exposure: silica, asbestos, radioactive particle exposure Lung cancer susceptibility genes Diet: fruits, vegetables exercise Molina, J, et al (2008). Non–Small Cell Lung Cancer: Epidemiology, Risk Factors, Treatment, and Survivorship. Mayo Clinic Proceedings; 83 (5): 584-594
211. A study from Japan In 1981 Possible importance of passive or indirect smoking as one of the causal factors of lung cancer This explains why women develop lung cancer although they themselves are non-smokers Hirayama, T (1981). Non-smoking wives of heavy smokers have a higher risk of lung cancer: a study from Japan.. British Medical Journal. (183-185)
212. Passive smoking You’re not only killing yourself… you’re killing others too. 3,000 lung cancer deaths per year in U.S. nonsmokers age >35 environmental tobacco smoke 33% of all lung cancer deaths in female never-smokers is attributed to environmental tobacco smoke and 31% of this population are due to spousal environmental tobacco smoke Office of Health and Environmental Assessment, U.S. Environmental Protection Agency (1992). RESPIRATORY HEALTH EFFECTS OF PASSIVE SMOKING: LUNG CANCER AND OTHER DISORDERS
213. Tumor markers TPS (tissue polypeptide specific antigen) and CYFRA 21-2 were found to be useful for the diagnosis of NSCLC NSE (neuron specific enolase) seems to be a useful tumor marker for monitoring course of patients especially in SCLC Combined use of TPS and CYFRA 21-1 may provide additional information for prognosis Mumbarkar, P, et al (2006). Significance of Tumor markers in lung cancer. Indian Journal of Clinical Biochemistry,/ 21 (1) 173-176
214. CYFRA 21-1 Persistently elevated 21-2 level than that before therapy may remind clinicians of tumor recurrence or disease progression Sheng lain, R, et al (1996). Cyfrea 21-2 Enzyme-linked immunoabsorbent assay. Evaluation as a tumor marker in non-small cell lung cancer. American College of Chest Physicians. 109;995-1000
215. Treatment In a Stage IV Lung Cancer, what are our options? Surgery? Radiotherapy? Chemotherapy?
216. Treatment Surgery? For Stage I and II NSCLC (with no evidence of mediastinal disease or invasion of local organs) Stage IIIB or IV tumors are almost never surgical candidates.
217. Treatment In a Stage IV Lung Cancer, what are our options? Surgery? Radiotherapy? Chemotherapy?
219. Chemotherapy, cisplatin-based First-line therapy Good performance status and weight loss less than 10% of their body weight Side effects: Nephrotoxicity Nausea and vomiting Ototoxicity Electrolyre imbalance Treatment
220. Radiation therapy adjunct for operable patients with resectablediseases primary local treatment for patients with medically inoperable or unresectablediseases important palliative modality for patients with incurable diseases Treatment
221. Radiation therapy Side effects Minimal side effects Cytopenia Fatigue and nausea are uncommon Treatment
222. Treatment NCCN 2011 guidelines on NSCLC Commonly Used Doses for Conventionally Fractionated Radiation Therapy
223. 300 cGy/day x 10 days In the patient… reduced to 200 cGy/day x 5 day
228. Lung Cancer has been documented to be the most common type of cancer in the world for several decades. Globocan 2008 (Cancer Incidence and Mortality Worldwide in 2008, WHO-International Agency for Research on Cancer, http://globocan.iarc.fr/ )
230. Among cases of lung cancers, prostate, breast, colorectal, LUNG CANCERhas the lowest 5-year survival rate. Cancer Trends Progress Report 2009/2010 update from the National Cancer Institute, http://progressreport.cancer.gov/doc_detail.asp?pid=1&did=2009&chid=95&coid=927&mid
