Chest Conference
9/20/2011
Matthew Hammar, DO
Pulmonary Critical Care Medicine Fellow
Allegheny General Hospital
JZ
 82 y/o WM prior smoker (40
pack-years, quit age 65) with
PMH of COPD, HTN, HLD,
CAD, PVD, Carotid Stenosis, 4
cm AAA,...
JZ
 Pertinent ROS:
 Admits chronic cough productive
of clear sputum. Increasing DOE
and vague right-sided CP.
 Denies S...
JZ
 CT scan done same day showed a
new (compared to 9/21/2010)
right upper lobe nodule.
 2.3 CM, spiculated RUL nodule.
...
Physical Exam

VS: Afeb, HR 59, BP 105/65, RR 20,
SpO2 98% RA.
GEN: A&A&Ox3. NAD, ASA class II.
HEAD: NC, AT.
EENT: PERRL....
LABS
14.1
5.6

41
INR 1.1

190
CT & Pathology
CT/PET 9/16/2011
 Enlarged (1.5 x 1.4 cm) 2A LN
with increased SUV 6.6.
 RUL nodule (2.4 cm) SUV 14.4.
 Right hilar LN ...
PFT’s 9/7/2011
 FVC: Pre 3.51(102%)

& Post 3.46(101%)

 FEV1: Pre 1.90 (79%) & Post 1.95(81%)
 FVC/FEV1:
Pre (54%)

&
...
NSCLC
 Any type of epithelial lung
cancer other than small cell
lung cancer (SCLC).
 3 most common types of
NSCLC are:
1...
NSCLC
 There are several other
types which occur less
frequently, and all types
can occur in unusual
histologic variants
...
Sarcomatoid carcinomas are a group of
poorly differentiated non-small cell lung
carcinomas that contain a component of
sar...
Sarcomatoid carcinomas
 Rare accounting for ~0.31.3% of all lung
malignancies
 Average age onset 60 y/o
 Male:Female = ...
Sarcomatoid carcinomas
 Sarcomatoid carcinomas can
arise in the central or
peripheral lung, though a
predilection for the...
Sarcomatoid carcinomas
 Signs and symptoms are
related to tumor location
Eg: Central endobronchial
tumors tend to protru...
Sarcomatoid carcinomas
 Signs and symptoms are
related to tumor location
Eg: Peripheral tumors,
(especially pleomorphic
...
Giant Cell Carcinoma
 Characterized as “Very
aggressive” and
metastasize.
 Survival depends on staging.
Place Holder

• Did he have a PET scan…
• I presume serial CT scans…
JZ
 PMH: HTN, HLD, CAD, PVD,
Carotid Stenosis, COPD, 4 cm
AAA, Colon Cancer, TIA, HOH,
BPH
 PSH: CABG 2/19/2007, uretera...
JZ
 Fam: Mother had lung cancer.
Father & brother had colon
cancer.
 SOC: 40 pack-years smoking;
quit age 65. Married. R...
JZ
 Rx: Lopresor, Zocor, Zetia,
ASA, Spiriva, Singulair, Fish
Oil, Rapaflo.
 Allergies: NKDA.
Giant cell chest conference
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  • Note, the pulmonary nodule had been stable since 1/25/2006 thru 9/21/2011 (per report)…
  • Spiriva, Singulair is current regimen. Plan is to add Advair or Symbacort
  • ASA= American Society of Anesthesiologists (ASA) status for pre-op fitness.
  • Adenocarcinoma, arising from the bronchial mucosal glands, is the most frequent non-small cell lung cancer in the United States, representing 35-40% of all lung cancers. It usually occurs in a peripheral location within the lung. Adenocarcinoma is the most common histologic subtype, and may manifest as a “scar carcinoma.” This is the subtype observed most commonly in persons who do not smoke. This type may manifest as multifocal tumors in a bronchoalveolar form.
    SCC accounts for 25-30% of all lung cancers. Whereas adenocarcinoma tumors are peripheral in origin, SCC is found in the central parts of the lung. The classic manifestation is a cavitary lesion in a proximal bronchus. This type is characterized histologically by the presence of keratin pearls and can be detected with cytologic studies because it has a tendency to exfoliate. It is the type most often associated with hypercalcemia.
    Large cell carcinoma accounts for 10-15% of lung cancers, typically manifesting as a large peripheral mass on chest radiograph; it appears to be decreasing in incidence because of improved diagnostic technique. Histologically, this type has sheets of highly atypical cells with focal necrosis, with no evidence of keratinization (typical of SCC) or gland formation (typical of adenocarcinomas).
  • http://www.cancer.gov/cancertopics/pdq/treatment/non-small-cell-lung/healthprofessional/#Section_27: NSCLC arises from the epithelial cells of the lung of the central bronchi to terminal alveoli. The histological type of NSCLC correlates with site of origin, reflecting the variation in respiratory tract epithelium of the bronchi to alveoli. Squamous cell carcinoma usually starts near a central bronchus. Adenocarcinoma and bronchioloalveolar carcinoma usually originate in peripheral lung tissue
  • http://www.iarc.fr/en/publications/pdfs-online/pat-gen/bb10/BB10.pdf
  • Sarcomatoid carcinomas are a group of poorly differentiated non-small cell lung carcinomas that contain a component of sarcoma or sarcoma-like (spindle and/or giant cell) differentiation. Five subgroups representing a morphologic continuum are currently recognized: Pleomorphic carcinoma:, spindle cell carcinoma, giant cell carcinoma, carcinosarcoma and pulmonary blastoma.
  • Carcinogens= second-hand smoke, radon, arsenic, asbestos, chromates, chloromethyl ethers, nickel, polycyclic aromatic hydrocarbons, radon progeny, other agents, and air pollution.
  • A large central endobronchial tumor can occlude the airway causing cough, hemoptysis, SOB and obstructive PNA.
  • The 5-year relative survival rate varies markedly depending on the stage at diagnosis, from 49% to 16% to 2% for patients with local, regional, and distant stage disease, respectively
  • Mallinpati, Supraclavicular adenopathy
  • Rapaflo (silodosin) is BPH Rx.
    Singulair (montelukast) is a leukotriene inhibitor.
  • Rapaflo (silodosin) is BPH Rx.
    Singulair (montelukast) is a leukotriene inhibitor.
  • Giant cell chest conference

    1. 1. Chest Conference 9/20/2011 Matthew Hammar, DO Pulmonary Critical Care Medicine Fellow Allegheny General Hospital
    2. 2. JZ  82 y/o WM prior smoker (40 pack-years, quit age 65) with PMH of COPD, HTN, HLD, CAD, PVD, Carotid Stenosis, 4 cm AAA, Colon Cancer s/p resection 1999 and TIA…  Presented to outpatient pulmonary office 9/7/2011 for ongoing evaluation of COPD & RLL 1 cm pulmonary nodule.
    3. 3. JZ  Pertinent ROS:  Admits chronic cough productive of clear sputum. Increasing DOE and vague right-sided CP.  Denies SOB at rest. Denies hemoptysis, fevers, chills, night-sweats or weight loss.
    4. 4. JZ  CT scan done same day showed a new (compared to 9/21/2010) right upper lobe nodule.  2.3 CM, spiculated RUL nodule.  Scheduled to undergo navigational bronchoscopy 9/13/2011.  PET/CT scheduled 9/16/2011.
    5. 5. Physical Exam VS: Afeb, HR 59, BP 105/65, RR 20, SpO2 98% RA. GEN: A&A&Ox3. NAD, ASA class II. HEAD: NC, AT. EENT: PERRL. Ears/Nose wnl. Edentulous. Mallampati 2. NECK: Supple, full ROM. CV: RRR with grade 2/6 SEM over tricuspid area. LUNGS: Scattered rhonchi, otherwise CTAB with wheezing or rales. ABD: Soft, NT, ND. BS present. NEURO: CN II-XII intact. EXT: No CCE. Radial pulse 1+/4 equal bilaterally
    6. 6. LABS 14.1 5.6 41 INR 1.1 190
    7. 7. CT & Pathology
    8. 8. CT/PET 9/16/2011  Enlarged (1.5 x 1.4 cm) 2A LN with increased SUV 6.6.  RUL nodule (2.4 cm) SUV 14.4.  Right hilar LN SUV 10.5.  Paratracheal LN SUV 6.9.
    9. 9. PFT’s 9/7/2011  FVC: Pre 3.51(102%) & Post 3.46(101%)  FEV1: Pre 1.90 (79%) & Post 1.95(81%)  FVC/FEV1: Pre (54%) & Post (57%)  TLC: 5.86, Ref 5.61 (104%)  DLCO: 11, Ref 17.9 (61%)  “Moderate obstructive disease w/o bronchodilator response”. Decreased diffusion capacity impairment.
    10. 10. NSCLC  Any type of epithelial lung cancer other than small cell lung cancer (SCLC).  3 most common types of NSCLC are: 1) Squamous cell carcinoma 2)Adenocarcinoma 3)Large cell carcinoma, and adenocarcinoma
    11. 11. NSCLC  There are several other types which occur less frequently, and all types can occur in unusual histologic variants  See figure on next slide
    12. 12. Sarcomatoid carcinomas are a group of poorly differentiated non-small cell lung carcinomas that contain a component of sarcoma or sarcoma-like (spindle and/or giant cell) differentiation.
    13. 13. Sarcomatoid carcinomas  Rare accounting for ~0.31.3% of all lung malignancies  Average age onset 60 y/o  Male:Female = nearly 4:1  Etiology ~smoking, carcinogens
    14. 14. Sarcomatoid carcinomas  Sarcomatoid carcinomas can arise in the central or peripheral lung, though a predilection for the upper lobes has been reported
    15. 15. Sarcomatoid carcinomas  Signs and symptoms are related to tumor location Eg: Central endobronchial tumors tend to protrude into the lumen of large airways, causing cough, hemoptysis, progressive dyspnea and postobstructive pneumonia
    16. 16. Sarcomatoid carcinomas  Signs and symptoms are related to tumor location Eg: Peripheral tumors, (especially pleomorphic carcinoma) grow to large sizes and often present with chest pain due to pleural or chest wall invasion
    17. 17. Giant Cell Carcinoma  Characterized as “Very aggressive” and metastasize.  Survival depends on staging.
    18. 18. Place Holder • Did he have a PET scan… • I presume serial CT scans…
    19. 19. JZ  PMH: HTN, HLD, CAD, PVD, Carotid Stenosis, COPD, 4 cm AAA, Colon Cancer, TIA, HOH, BPH  PSH: CABG 2/19/2007, ureteral implant 2/8/2007, Right CEA 10/24/2007, bilateral cataract extraction 2006, LOA 2001, Subtotal colectomy 1999, Right LE arterial stent NOS.
    20. 20. JZ  Fam: Mother had lung cancer. Father & brother had colon cancer.  SOC: 40 pack-years smoking; quit age 65. Married. Retired glass worker. Builds birdhouses as hobby therefore sawdust exposure.
    21. 21. JZ  Rx: Lopresor, Zocor, Zetia, ASA, Spiriva, Singulair, Fish Oil, Rapaflo.  Allergies: NKDA.
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