OS 213: Human Disease Treatment 3 (Circulationand Respiration) SGD 01: MALIGNANCY Exam 3 | Med Onco Preceptors | August 23, 2012 OUTLINE Case 1 Case 2 Case 3 Case 4 General Notes CASE 1 R.S., 50, M CC: Right lung nodule o o HPI: 2 mo PTC o CXR done for employment purposes revealed a solitary pulmonary nodule measuring approx. 2 cm o Px denied other symptoms except for an occasional dry, non-productive cough o diagnosed with PTB and was given anti-TB meds regularly taken for 2 months After 2 months o repeat chest X-ray was done and revealed an increase in the size of mass to 3cm o chest CT scan revealed 3.5 x 2.8 cm enhancing mass at SUPERIOR SEGMENT OF R UPPER LUNG. o (-) enlarged peribronchial, hilar, mediastinal nodes o still no other symptoms except for occasional dry cough PMHx: Unremarkable (U/R) PSSx: (+) Smoking: 1 pack/day for 20 years (20 pack years) ROS: (-) anorexia, headache, weight loss, back pain, hemoptysis PE: (-) palpable lymph nodes, Clear lung fields, U/R abdomen Diagnosis (Note from the transers: Case 1 contains all general data applicable to lung malignancies. Italicized and underlined phrases are applicable to Case 1.) As with diagnosing any disease condition (in this case, and in all other cases you will encounter), the most crucial initial step is a thorough history and physical examination. By Hx: Sx of lung cancer can arise from 1.Local mass effects and systemic effects Symptoms related to tumor itself: hemoptysis and chest pain Constitutional non-specific symptoms such as: anorexia, weight loss, fevers/night sweats Tumor mass effects such as cough due to nerve irritation, hoarseness due to compression of recurrent laryngeal nerve, and facial/upper extremity syndrome 2.Effects of metastatic disease bone, pleura, brain, liver, and adrenal glands 3.Effects of products produced by the tumor (paraneoplastic syndromes). *Most lung cancers arise in patients with a long smoking history; the symptoms of cough and dyspnea are relatively non-specific. However, an acute change in previously stable symptoms can be a clue to an underlying malignancy. By PE: Classic PE findings associated with lung CAs: Horner’s syndrome (sympathetic ganglion dysfunction with ptosis, miosis, enopthalmos and anhydrosis) CES, MIKKI, JOLO A supraclavicular mass due to a Pancoast tumor (apical tumor involving C8 and T1-2 nerves causing shoulder pain radiating down to the arm) SVC syndrome (upper extremity swelling with or without facial swelling due to vascular obstruction) Clubbing of fingers and adenopathy suggestive (but not pathognomonic) of an underlying malignancy. Table 1. Diagnostic Procedures Chest X-Ray tumor in the lungs enlargement in the mediastinum due to enlarged lymph node opacity or white-out lung may indicate presence of malignancy or tuberculosis other thoracic causes Chest and localizing tumors, especially Abdominal CT central masses not visualized in Scan chest X-ray metastasis (if present) – commonly in the brain and adrenal glands determining the presence of fluid assist in biopsy procedures (CT GAB) Positron Emission visualize tumors <1 cm in Tomography diameter, malignant lesions and (PET) Scan solitary pulmonary nodules aid in staging mediastinal tumors R/O active infection (also take up glucose) Expensive! Usually not recommended Bone Scan detect bone metastasis/es Magnetic determine brain metastasis and Resonance spinal compression Imaging (MRI) rule out (R/O) Potts disease Chest Ultrasound effusion locate lung tumors extent of tumor infiltration guide needle during thoracentesis or biopsy. Histopathology detect cancer cells special stains (acid fast) to R/O TB Thoracentesis drain fluid from pleural effusion collect samples for histologic exam, presence of serosanguinous fluid is indicative of malignancy and to determine if the fluid is a transudate or exudates Fine Needle To collect samples from the Aspiration Biopsy lesions that are too large to (FNAB) excise for cytologic evaluation usually CT-guided Bronchoscopy can also be used if the lesion is centrally located. Excision Biopsy if mass is not too large Pleural Biopsy samples from pleural tissue Bronchoscopy evaluate lung lesions (esp. central) investigate unexplained hemoptysis or adventitious lung sounds obtain materials for microbiologic studies UPCM 2016 B: XVI, Walang Kapantay! 1 of 6 mild difficulty of breathing.8 cm superior RUL. Group Counseling/Therapy Follow-Up Check-up every 2mo post-treatment CA patients should be educated about signs and symptoms of recurrence and potential adverse effects related to therapy Monitoring with: CXR.OS 213: Human Disease Treatment 3 (Circulation and Respiration) SGD 01: MALIGNANCY Exam 3 | Med Onco Preceptors | August 23. acupuncture to relieve pain. decreased breath sounds at the right upper lung field with dullness to percussion. should always be considered to have lung CA unless proven otherwise.main treatment for SCLC. fixed right supraclavicular node. seldomly early) Management Counseling together with the patient’s family 3C’s: Coping. Differentials (Case 2) Disease Reason for R/I SCLC (+) Pulmonary mass (+) Cough (+) Dyspnea (+) Facial swelling (plethora) (+) Weight loss Smoking hx: 95% Reason for R/O (-) ankle edema (-) muscle weakness (-) polyuria.given in patient with SCLC in the ff situations: CES. By FNAB (CT Guided) – Preferred for this Px because of the peripheral location of the lesion 6. lytic bone lesion. and occasional inspiratory wheezing on all lung fields. symptomatic therapy (for difficulty breathing. Communicating. improve 3-year survival rates. massage therapy. M. From operative specimen at the time of definitive surgical resection 4. and progressive hip pain HPI: CXR revealed pulmonary mass at the R upper lung with 2 nodules on the L upper and mid-lung fields. Filipino CC: Cough. 2012 Mediastinoscopy Suprasternal approach to obtain specimens from mediastinal nodes Thoracoscopy visualizing and biopsy of pleural and mediastinal nodes Pulmonary establish if dyspnea is cardiac or Function Test pulmonary in origin (PFT) R/O other differentials CBC establish if pallor is due to anemia determine the patient’s blood type if transfusion is needed (IMPORTANT Note: A patient who is male. TNM Classification: used in staging NSCLC’s Cancer Staging: Using the TNM guideline: T1 N0 M0 Stage IA 3. Diagnosis Table 2. no note of enlarged peribronchial. radiation explaining his condition: natural history of the disease (stage of his disease).) can also be given as necessary. or to reduce the side effects.) Staging (Note: See the Lecture Malignancies for this part. By node biopsy during mediastinoscopy 3.) trans on Overview of Lung Tumor tissue obtained: By bronchial/transbronchial biopsy during FOB 2. aromatherapy. Chest CTSc Liver UTS every 6 months Bone scan every year Cranial CTSc if with frequent headache or signs of inc. especially in patients less than 65 years old o After chemotherapy: kill any small deposits of cancer that may remain Chemotherapy . see the Lecture trans on Overview of Lung Malignancies) Targeted Therapy Complementary Methods and Palliative Care Given after chemotherapy sessions and throughout treatment as an adjunct to therapy. >45 years old. JOLO In combination with chemotherapy: treat the tumor and lymph nodes in the chest.5x2. it UPCM 2016 B: XVI. presenting with a solitary pulmonary nodule. peppermint tea to relieve nausea. anorexia (-) headache. or hemoptysis PE: 2x2 cm hard. exercise Avoid cancer risks: asbestos. prognosis. Help the patient feel better and add to patient's comfort o Ex. Connecting ADVISE TO QUIT SMOKING!!! Good balanced diet. From adequate cell block from a malignant pleural effusion 1. hilar or mediastinal nodes. palliative care. Walang Kapantay! 2 of 6 .preferred operation for SCLC o Segmentectomy Radiation Therapy . PMHx: U/R PSSx: (+) smoking: 40 pack years ROS: (+) facial swelling upon awakening. polydipsia Facial swelling improves (in small cell CA. treatment options Intervention Options Surgery . But needs other modalities to rule out possible metastasis (Note: Patients usually come in late or advanced stages. bone marrow or pleural effusion 5. By percutaneous biopsy of enlarged lymph node. ICP CASE 2 65. yoga.considered if cancer is only small and localized to one tumor nodule o Pneumonectomy o Lobectomy . meditation to reduce stress. with history of smoking. etc. soft tissue mass. Pain medication. weight loss. abdominal pain. o (Note: For more complete lists and details on the drugs used by Lung Cancer patients. MIKKI. Atelectasis (23%). Dyspnea (60%). or painful bony metastases. ABG (to look for hypokalemic alkalosis) CBC BUN-Creatinine Clearance: to check whether or not the kidneys are competent to filter nephrotoxic CA drugs (platinum waste) Staging T4N3M1 Stage IV Lung CA T4 – 2 x 2 cm hard supraclavicular node N3 – involvement of mediastinal and contralateral lymph nodes M1 – presence of metastasis to supraclavicular node and hip Very poor Prognosis Median survival for untreated patients with Stage IV bronchogenic CA: 4-6 months 5-year survival rate: 2% Survival time impkroves with chemotherapy and other targeted therapies Management Counseling (see Case 1 > Management > Counseling) Intervention Options Symptomatic Management o pain: give non-opioids first before moving on to stronger drugs like morphine when the pain is already unbearable o cough (and hemoptysis): can be treated pharmacologically Palliative radiotherapy o FOR: Bronchial obstruction with pneumonitis. docetaxel). nonsmokers Mass is central (vs. M. but again. is more prevalent in women. Vocal cord paralysis (6%) o Also for: cardiac tamponade. improves QOL. dyspnea Common manifestation of pulmonary disease. upper airway or SVC obstruction brain or spinal cord compression (important!). could be due to compression of airway by a mass in this case Facial swelling upon awakening Could be due to the compression of the Superior Vena Cava (SVC syndrome) by the mass on the right upper lung while on supine position (sleeping) Weight loss. with Pulmonary Mass probably malignancy! Cough. squamous cell lung CA 65 yo. o It provides relief of intrathoracic symptoms: o Hemoptysis (84%). 2012 NSCLC (Squamous cell) Adenocarcino ma of CA associated with a chronic smoking Hx is SCLC Presence of nodules at R and mid-upper lung field Hard. painful bony metastasis. JOLO o o o o o o Adenocarcinoma. Adenocarcinoma which is more peripheral) mainly o o Primary Working Impression: non small cell. you will not give Bevacizumab (which is an angiogenesis inhibitor) will cause the patient to bleed out) of UPCM 2016 B: XVI. prevent Complementary Methods and Palliative Care (Note: In squamous cell lung CA. CNS compression. fixed R supraclavicular node (+) Pulmonary mass (+) Cough (+) Dyspnea (+) Facial swelling (+) Weight loss Smoking hx Presence of nodules at R and mid-upper lung field Age. Gemicitabine o Second-line: Docetaxel or pemetrexed Growth factor support is rarely needed EGFR Targeted Therapy: Erlotinib (2nd or 3rd line) o Prolong ssurvival. MIKKI. R/O head and neck primary lesions o for detection Serum ACTH – Cushingoid syndrome. Texane (paclitaxel. the more specimens. expensive! Sputum cytology: if (+). Sex (+) Pulmonary mass (+) Cough (+) Dyspnea (+) Facial swelling (plethora) does not improve due to constant hormone production of the tumor) No reason to rule out yet (histopathologic examination needed for differentiation) Ancillary Tests: paraneoplasms CES. R/O ACTHproducing small cell CA Blood chemistry. hemoptysis. Cough (60%). Smoker.OS 213: Human Disease Treatment 3 (Circulation and Respiration) SGD 01: MALIGNANCY Exam 3 | Med Onco Preceptors | August 23. and improves survival in newly-diagnosed patients o First-line: Cisplatin or Carboplateine. SVC syndrome (80%). the better!) PET scan: detects widespread metastases. Bronchoscopy of mediastinal lymph nodes (for possible metastasis. Bone Scan: detect metastasis Biopsy: FNAB of the supraclavicular node. although more common than squamous cell CA. brachial plexus involvement Chemotherapy: Palliates symptoms. Walang Kapantay! 3 of 6 . anorexia Effect of cancer Two nodules on L upper & mid lung field Metastasis to the L lung Hard. fixed R supraclavicular node Nodal metastasis from R lung Progressive hip pain Metastasis to the hip bone Diagnostic Procedures CXR and Chest CT Scan Abdominal and Cranial CT Scan. Second or Third line therapy o Very expensive Management for Bone Metastasis o Radiotherapy o Bisphosphonates: reduce secondary close. Differentials (Case 3) Disease Reason for R/I Reason for R/O Bronchoge 10 pack-year nic CA smoking (SCLC) (+) unproductive cough for 1 mo (+) occasional pleuritic chest pain (+) Hemoptysis (+) Anorexia. PET Scan Staging TNM Classification is not used in staging SCLC. glucose. Pulmonary 10 pack-year embolism smoking (+) unproductive cough for 1 mo (+) occasional pleuritic chest pain (+) Hemoptysis Pneumonia (+) unproductive cough for 1 mo (+) occasional pleuritic chest pain HPI: 1 mo PTC o Non-productive progressing cough. o Serum LDH is a good marker for response and should be monitored. 2012 CASE 3 52. Mediastinoscopy w/ biopsy. no palpable nodes. (-) headache. 2-year survival rate of 4. Pleural biopsy Ancillary Tests: CBC with platelet count. M CC: non-productive. AST). CT scandirected needle biopsy. adrenal glands and brain Diagnostic Procedures CXR. occasional wheezing at all lung fields CXR: Large bulky mass with hilar adenopathy CT Scan: 3x5 cm tumor invading the R main bronchus. bones. associated with back pain. Instead. o CT scans should be obtained after 2 cycles of therapy to assess response (if afforded) UPCM 2016 B: XVI. Endoscopic esophageal ultrasound w/ biopsy. liver. back pain PE: Slightly cachexic. ECG. 5-year survival rate of 20% Extensive o Spread to other side and/or other distant organs (including pleural/pericardial effusion or hematogenous metastases) o Prognosis: 12 months. CT Scan Biopsy: Bronchoscopy with biopsy. o Renal function should be monitored because of nephrotoxicity from cisplatin. abnormal breath sounds Primary Working Impression: Small cell lung CA Arises in peribronchial locations and infiltrate the bronchial submucosa Usually occurs in the big airways (hilar & central) Very rapid progression and highly malignant Smoking is a risk factor (as well as being male) Common spread is to the mediastinal lymph nodes. 2-year survival rate of 25%. weight loss (+) wheezing in all lung areas on PE Large bulky mass with hilar adenopathy on CXR 3x5 tumor invading R main bronchus Enlarged ipsilateral hilar and mediastinal lymph nodes Atelectasis at hilar region on CT Pulmonary 10 pack-year (-) night sweats. Walang Kapantay! 4 of 6 . assoc. MIKKI. abdominal pain. Anorexia PMHx: U/R PSSx: (+) smoking: 10 pack year ROS: (+) 30 % weight loss. Tuberculosi smoking fever s (+) unproductive no tests done for cough for 1 mo AFB smear/culture (+) occasional pleuritic chest pain (+) Hemoptysis (+) Anorexia. Serum electrolytes. Bone Scan. 3 cm distal to carina Atelectasis at hilar region Enlarged ipsilateral hilar and mediastinal lymph nodes Diagnosis Table 3. we describe the malignancy as Limited or Extensive Limited o Limited to one side of the chest o Can be treated with sufficient radiation therapy o Prognosis: 20 months. pleural chest pain 10 days PTC o (+) Hemoptysis. Open lung biopsy. calcium. weight loss Large bulky mass with hilar adenopathy on CXR CES.OS 213: Human Disease Treatment 3 (Circulation and Respiration) SGD 01: MALIGNANCY Exam 3 | Med Onco Preceptors | August 23. Renal Function Test. JOLO (-) evidence of effusion (transudative or exudative) no reported dyspnea (-) no PE findings of consolidation.6% Confinement to one Hemithorax Limited-Stage Disease Management Counseling (see Case 1 > Management > Counseling) Intervention Options Chemotherapy: o Etopside +cisplatin / carboplatin o CRx doses may be adjusted on the basis of nadir granulocyte counts o Blood work +CBC is needed prior to each cycle of chemotherapy to ensure marrow recovery before the next dose of chemotherapy is administered. Liver Function Tests (ALT. Fatigue. and PND. (-) orthopnea. anorexia. CXR: (+) density at the right apex Chest CT Scan: 5. if cough becomes uncomfortable. Biopsy Sputum Cytology/Examination – if it’s squamous cell CA. CT Scan PET Scan. o PROPHYLACTIC BRAIN RADIATION THERAPY (PBRT) Lung CA can metastasize to the brain – around 60% of controlled lung CA PBRT reduces the chance of metastasis to the brain Px should be advised of the possible cognitive deficits as a result of PBRT Supportive and Other Considerations: Antiemetics. Monitoring for blood counts and blood chemistry. dull on percussion CES. it is likely that it will be detected using this procedure Ancillary tests Staging T2bN2M0 Stage IIA o T2B: Tumor is >5 cm. anorexia.5x6. Bone Scan. which is not yet quantified. Differentials (Case 4) Disease Reasons for R/I Reasons for R/O NSCLC (+) chronic cough No reason to rule (squamous (+) worsening or out yet cell CA) (histopathologic new dyspnea al examination (+) weight loss of biopsy (+) hemoptysis sample needed) (+) pleuritic pain (+) decreased breath sounds. abdominal pain. decreased breath sounds at the right upper lung fields with dullness to percussion over said area. invades visceral pleura UPCM 2016 B: XVI. lymphadenopathy Imaging studies reveal a mass at the right apex History of smoking To rule in: PTB (difficult to rule out unless patient is asked to have sputum AFB and/or culture) Diagnostic Procedures CXR. Fluid support with Cisplatin. use of hemopoietins (treatment for anemia) Complementary Methods and Palliative care CASE 4 55.8 cm mass with right perihilar and subcarinal lymph node enlargement. orthopnea. facial swelling. back pain. Cough suppressants. 30% weight loss. signs of bleeding and infection.possible rich blood supply of tumor) decreased breath sounds at the right upper lung fields with dullness to percussion Signs suggesting the presence of a malignancy: weight loss. dull on percussion Cachexia and weight loss suggest systemic spread Pulmonary Smoking hx (-) night sweating Tuberculosi (+) cough. Cranial and Abdominal CT or MRI. PE: pale palpebral conjunctivae. exertional dyspnea. and an unremarkable abdomen. M CC: Chronic cough and weight loss HPI: 5 mo PTC: chronic cough and weight loss PMHx: Ischemic Heart Disease diagnosed 2 years ago Tx: isosorbide mononitrate and aspirin No recent attacks of chest pain PSSx: (+) smoking. If required. Walang Kapantay! 5 of 6 . no palpable cervical or supraclavicular nodes. s hemoptysis PND (+) chest pain (+) weight loss. does not directly involve carina. MIKKI. alcohol (occasional) ROS: (+) occasional hemoptysis. CT Scan for Adrenals CBC with platelet count: check for hemodynamic stability o patient presented with pale conjunctive and hemoptysis.OS 213: Human Disease Treatment 3 (Circulation and Respiration) SGD 01: MALIGNANCY Exam 3 | Med Onco Preceptors | August 23. 2012 Radiotherapy o In combination with Chemotherapy o Main treatment for our case will consist of combination Chemotherapy and chest irradiation (etoposide plus cisplatin plus 45 Gy chest radiation therapy). Analgesics (for the pleuritic chest pain). Diagnosis Table 4. hemoptysis . occasional right sided pleuritic chest pain (-) headache. Possible Blood Transfusions for the hemoptysis (if massive). dyspnea. JOLO Cachexia and weight loss suggest systemic spread Subcarinal and perihilar lymphadenopathy (bronchogenic CA) Small cell (+) chronic cough Usually presents lung with central (+) worsening or carcinoma endobronchial new dyspnea (SCLC) (+) weight loss tumor (-) headache upon (+) hemoptysis consult (+) pleuritic pain (+) decreased breath sounds. Nutrition therapy for signs of cachexia. anorexia (+) perihilar and subcarinal lymphadenopathy (remember Ranke’s complex) Primary Working Impression: Squamous Cell Carcinoma Presence of respiratory symptoms due to a possible lung tumor (cough. o Px may present with a bleeding mass due to the high vascularity of a carcinoma. At dahil smileys na lang ang greetings nina Mikki at Jolo.OS 213: Human Disease Treatment 3 (Circulation and Respiration) SGD 01: MALIGNANCY Exam 3 | Med Onco Preceptors | August 23. and for men. . always check for CA in other locations.g. ideal = radiographic image of lymph nodes) Management Counseling (see Case 1 > Management > Counseling) Intervention Options Surgical resection with lymph node dissection o may have poor results because of node involvement o Some oncologist conclude that surgery should only be conducted in patients who have clearing of the mediastinal nodes after adjuvant therapy Chemotherapy followed by Radiation Therapy (Tx of choice) o Cisplatin-based combination (with etoposide) o Improved survival compared with sequential therapy but more side effects such as fatigue. esophagitis and neutropenia Supportive Therapy: Pain relief. para purposeful naman ang pagpapaka-OC ko sa trans na ‘to. Combine chemotherapy with other forms of therapy like anti-angiogenesis drugs and radiotherapy. Ondansetron. Kalahati na lang siguro. Leads to a better outcome Others: Sarcoidosis is rarely a viable differential in the Philippines Always get a good history. Walang Kapantay! 6 of 6 . do biopsy instead On Patient Workups: Before doing biopsies.e. On Doing a Biopsy Do a biopsy to check for possible malignant cells then classify what type of cancer. JOLO Sputum cell cytology is seldom used as a diagnostic measure. Not. children) otherwise the patient might die from the treatment Erythropoietin transfusion can increase the risk of stroke and ischemia if given at the wrong dose. Tinoxic ko rin yata ang sarili ko sa pag-aayos ng isang trans na hindi naman babasahin ng mga tao.) Mikki. PTT test to see if there are any bleeding disorders Must have cardiopulmonary clearance (ECG. etc. MIKKI. 2012 o o N2: metastasis to ipsilateral mediastinal and/or subcarinal lymph nodes M0: no distant metastasis (based on PE findings. rectal cancer. Prochloroperazine. Jolo: UPCM 2016 B: XVI. Hello Block B! Kumusta naman ang weekly transing natin? Hello 2016! 2nd place ang EPIMERS sa FATE! XVI: Walang Kapantay! Hello Medchoir 2016! Fun fun fun (and eat eat EAAAAT!) in San Juan! Sana next time makapunta na tayong lahat for more chikahan. etc. Before doing treatment for Lung CA. always opt for the most accessible biopsy (e. Antoxic tuloy magreorganize. tenen! Haay. uubusin ko na lang ang space na ‘to. Haha. usually comes from breast cancer. Kung hindi. Hahaha! Mag-ipon na lang muna tayo ng mga ala-The Buzz na mga tanong sa ngayon. from 9 pages of pure redundancy. the lung malignancy might only be secondary END Ces: Here it is. lymph node) FNAB CT-guided biopsy (CT GAB): for peripheral masses Bronchoscopy-guided biopsy: for central (hilar or mediastinal) masses VATS as a last resort if you're absolutely positive that there's a malignancy but other the methods have failed to give a positive result On Staging and Treatment: Stage dictates treatment Stage 1: Surgery then chemo (Don't do radio) Stage 2: Surgery Stage 3A: Chemotherapy then surgery Stage 4: Chemotherapy and Radiotherapy. Proper regimen is high dose erythropoietin once a week. do PT.) before having a bronchoscopy Platinum-containing anti-cancer drugs are nephrotoxic (also hepatotoxic) . palliative On Other diagnostics: Do a brain CT scan for small cell carcinoma because it is very malignant CES. T___T Sana ganito pa rin ung cases sa future. Emesis therapy.check kidney function via BUN/Creatinine CBC is done to see if the patient has recovered from chemotherapy On Other Treatment: Chemotherapy and Radiotherapy requires good performance status (i. Nutritional intervention Complementary Methods and Palliative Care GENERAL NOTES On History and PE: Getting a good history and PE is important since most CAs metastasize to the lungs. Dexamethasone. ohwell. For women.