HEENT: AT/NC, Eyes: EOMI, PERRLA, no icterus. OP: clear, no lesions.
Neck/Thyroid :supple, no LAD or masses.
Cardiac: RRR no m/r/g.
Chest/Lungs: Decreased BS LLL with coarse crackles LLL
Abdominal: soft, NT/ND, BS+, No HSM
Back: no deformities or spinal tenderness to palpation
Extremities: WWP, trace edema, pulses strong and equal bilaterally.
Neurological: Alert and oriented x3, Cranial Nerves II-XII intact. LE strength-proximal and distal 3-4/5 on right. left 5/5. R & LUE 5/5. Mild right pronator drift. Sensation intact to light touch. Patella reflex on right 3+, left 2+. 3 beats of clonus on right. No babinski. Gait-ataxic, unsteady.
Age-adjusted cancer death rates – US Lung CA – 160,000/yr 1.2 million deaths/yr world wide Men Women
Lung Cancer – Clinical Presentation 10 % asymptomatic at presentation
Bone – 20%
Pain, pathological fractures
Liver – 50%
Pain, elevated transaminases
Brain – greatest with adenocarcinoma
HA, vomiting, neurological symptoms, mental status changes
Adrenal glands – 40%
Compression symptoms – pain (96%), motor weakness, autonomic dysfxn, sensory loss
90% lung cancer
85-90% Lung Cancer
Squamous cell carcinoma
25-30% lung cancers
Large cell carcinoma
10% lung cancers
Adenocarcinoma Squamous Cell
Imaging – CXR, CT chest/abd minimum
Symptoms – MRI, bone scan
Sputum – up to 40% false negative
Peripheral - CT guided needle bx
Lymph node bx - Mediastinoscopy/Endobronchial US
Pleural Effusion - thoracentesis
Distant metastases – PET scan
Mediastinal LAD - PET (sens 84%/sp 89%) > CT
No nodes or mets
> 2 cm from carina
Locally advanced disease
Chest wall, diaphragm
Nodes – ipsilateral hilar nodes
No mediastinal involvement
A – mediastinal nodes - ipsilateral
B – Invasion of medistinum
heart, great vessels, trachea, effusions
nodes contralateral or supraclavicular
Stage IV - Distant Metastatic
A 60 yo woman is evaluated for a persistent , non-productive cough of several months. She has a 40 pack-year smoking history, but she quit 10 years ago. Her vital signs are BP 120/80, HR 60, RR 18. Physical exam is entirely normal. CXR and CT scan confirm a 4-cm LUL nodule with irregular borders that was not present on CXR 2 years ago. PET scan shows uptake only in the pulm nodule and no obvious metastasis. Thoracotomy results in left upper lobectomy in which a 4-cm moderately differentiated adenocarcinoma is removed. The margins are clear. Which of the following is the most appropriate next step in management?
No further treatment
A 68 yo man is evaluated for hemoptysis, increasing weakness, and a 13.5 kg weight loss over 4 months. He is WC-bound b/c of severe weakness and has been bedbound for 1 week. He has an 80-pack-year smoking history. PE: BP 120/80, HR 72, RR 18. Abdomen, heart, lung exams are normal. A radiograph and CT scan of head, chest, abdomen, and pelvis show a 10-cm right perihilar lymph node mass with involvement of multiple mediastinal lymph nodes and more than ten 2-3 cm hepatic metastases, but no brain mets. Bone mets are too numerous to count. Squamous cell carcinoma is confirmed by bronchoscopic biopsy. Which of the following is the most appropriate next step in the management of this patient?
Radiation & bisphosphonate
Chemo & bisphosphonate
Chemo, radiation, and bisphosphonate
Lung tumor resection, chemo, radiation, and bisphosphonate