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  • Talked about UMN signs vs. LMN signs.
  • 7/8/09: TWO VIEWS OF THE CHEST ARE COMPARED TO 10/28/2007. IN THE INTERVAL, THERE HAS BEEN DEVELOPMENT OF A LARGE, WELL CIRCUMSCRIBED FLUID AND GAS COLLECTION, WHICH PROJECTS OVER THE SUPERIOR SEGMENT OF THE LEFT LOWER LOBE. THE APPEARANCE IS NONSPECIFIC BUT IS CONCERNING FOR INFECTION, POSSIBLY A PULMONARY ABSCESS OR FLUID FILLING A LARGE PNEUMATOCELE. THIS IS SLIGHTLY LATERAL OF MIDLINE TO REPRESENT A DUPLICATION CYST OR GASTROINTESTINAL DIVERTICULA. THERE IS NO ASSOCIATED PLEURAL EFFUSION OR PNEUMOTHORAX. HEART SIZE IS NORMAL.
  • CT head (non contrast): 9/14/09: There is a high left frontal white matter 4.5 x 4 cm low-attenuation area, most compatible with white matter edema. Further evaluation with MRI of the brain with contrast is advised to rule out a left frontal lobe neoplasm. There is no intracranial hemorrhage. There is no midline shift or hydrocephalous. There is no abnormal extra-axial fluid collection. The basilar cisterns are patent. Mucosal thickening of both ethmoid sinuses.
  • CT chest 7/8/09: 7.8-CM CIRCUMSCRIBED NECROTIC MASS IN THE SUPERIOR SEGMENT OF THE LEFT LOWER LOBE. LESS LIKELY ABSCESS. 3.2-CM LOW DENSITY LEFT ADRENAL MASS. OTHERWISE UNREMARKABLE. REPORT: AXIAL SCANS OF THE CHEST WITH CORONAL RECONSTRUCTIONS WERE OBTAINED USING INTRAVENOUS CONTRAST. THERE IS A 7.8-CM PROBABLE NECROTIC MASS IN THE SUPERIOR SEGMENT OF THE LEFT LOWER LOBE. IT ABUTS THE PLEURA. IT COULD REPRESENT A LUNG ABSCESS BUT THERE IS NO SURROUNDING INFLAMMATORY LUNG CHANGES. NO EFFUSIONS. THERE ARE NO OTHER LUNG NODULES. THERE ARE SMALL MEDIASTINAL AND HILAR LYMPH NODES. NO ENLARGED NODES ARE SEEN. THERE NO PULMONARY EMBOLI. THE THORACIC AORTA IS WITHOUT EVIDENCE OF ANEURYSM OR DISSECTION. THERE IS A 3.2-CM ROUNDED WATER DENSITY LEFT ADRENAL MASS. RIGHT ADRENAL NORMAL. UPPER ABDOMEN OTHERWISE UNREMARKABLE. NO OBVIOUS BONE LESIONS.
  • MRI: 9/15/09: lesion is noted in the left posterior frontal parasagittal lobe with moderate degree of perilesional edema. This could represent metastatic deposit. Differential diagnoses includes infectious etiology.
  • Squamous cell cancer
  • Lung ca – MC cause of cancer mortality, both men and women, Age-adjusted cancer death rates among US men for selected cancers In the United States, in 2007, there will have been an estimated 215,000 new cases of lung cancer and 162,000 deaths [2]. In contrast, colorectal, breast, and prostate cancers combined will have been responsible for only 124,000 deaths. Both the absolute and relative frequency of lung cancer have risen dramatically. As an example, the age-adjusted death rates from lung cancer were similar to that of pancreatic cancer prior to 1930 for men and prior to 1960 for women (show figure 1 and show figure 2) [2].
  • Cough with increasing frequency or severity needs investigation. 10% asymptomatic and found incidentally on imaging. Hoarseness – vocal cord paresis or paralysis when tumors or lymph node metastases compress/invade the recurrent larnyngeal nerve.
  • Most frequent sites of distant metastatsis are liver, adrenal glands, bones, and brain,. Autonomic dysfx (urinary retention, decreased anal sphincter tone). Prostate, breast, lung- mc cause spinal cord compression Visual field loss, hemiparesis, seizures, etc.
  • Synergistic affect with smoking and asbestos
  • Histologically distinct but grouped together b/c similar in presentation, tx, and natural hx. Adenocarcinoma – MC lung cancer in US and MC among never smokers.
  • Common sites of spread of a non-small cell lung cancer include the liver and adrenals; hence, a CT scan of the chest and upper abdomen, to include the liver and adrenals, is the minimum standard for a staging workup for a person newly diagnosed with non-small cell lung cancer. Need to assess for tumor w/in mediastinal lymph nodes, pleural effusion, or distant sites – pushes into higher stage
  • Simplified..I – tumor surrounded by lung or pleural, IIA - ipsilateral node, tumor <3 cm, IIB – w/in 2cm carina, invasion of chest wall, diaphragm, pericardium. Stage III- mediastinum, A and B – B: more invasive – invasion of mediatinum, heart/great vessels, trachea, veretral body or carina, effusion, contralateral nodes
  • Early-stage Non-small Cell Lung Cancer Adjuvant Chemo is a new standard of care Absolute overall survival 4% to 15% at 5 years after adjuvant chemo
  • Poor performance status Widely metastatic NSCLC
  • Stage I and II – goal is cure. Stage III combined modalities. In patients with early-stage resectable non–small-cell lung cancer, the use of adjuvant chemotherapy is a new standard of care replacing the former approach of providing no further therapy.

Nsclc1 Presentation Transcript

  • 1. Morning Report October 27, 2009
  • 2. Physical Exam
    • Vitals: T 98, BP 117/71, P 62, R20 O2 Sat 98% RA
    • General: alert, oriented, appears tired, but NAD.
    • Skin: no rashes.
    • 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.
  • 3. Laboratory
    • WBC 17.1 (71% N, 12% L, 7% B)
    • Hb 11.1 (MCV 80)
    • Plts 300
    • BMP entirely normal
    • CRP 131
    • ESR 58
  • 4.  
  • 5.  
  • 6.  
  • 7.  
  • 8.
    • Diagnosis:
  • 9. Age-adjusted cancer death rates – US Lung CA – 160,000/yr 1.2 million deaths/yr world wide Men Women
  • 10. Lung Cancer – Clinical Presentation 10 % asymptomatic at presentation
  • 11. Metastases
    • Bone – 20%
      • Pain, pathological fractures
      • Hypercalcemia
    • Liver – 50%
      • Pain, elevated transaminases
    • Brain – greatest with adenocarcinoma
      • HA, vomiting, neurological symptoms, mental status changes
    • Adrenal glands – 40%
    • Spinal Cord
      • Compression symptoms – pain (96%), motor weakness, autonomic dysfxn, sensory loss
  • 12. Risk Factors
    • Smoking
      • 90% lung cancer
    • Radiation Tx
    • Environmental
      • Asbestos, radon
    • Pulmonary fibrosis
    • Genetic
  • 13. NSCLC
    • 85-90% Lung Cancer
    • 3 subtypes
      • Adenocarcinoma
        • Most common
        • Peripheral lesion
      • Squamous cell carcinoma
        • 25-30% lung cancers
        • Central lesion
      • Large cell carcinoma
        • 10% lung cancers
    Adenocarcinoma Squamous Cell
  • 14. Diagnosis/Staging
    • Imaging – CXR, CT chest/abd minimum
    • Symptoms – MRI, bone scan
    • Tissue Diagnosis
      • Central
        • Sputum – up to 40% false negative
        • Bronchoscopy
      • Peripheral - CT guided needle bx
      • Lymph node bx - Mediastinoscopy/Endobronchial US
    • Staging –
      • Pleural Effusion - thoracentesis
      • Distant metastases – PET scan
      • Mediastinal LAD - PET (sens 84%/sp 89%) > CT
  • 15. Staging
    • Stage I
      • No nodes or mets
      • > 2 cm from carina
    • Stage II
      • Locally advanced disease
        • Chest wall, diaphragm
        • Nodes – ipsilateral hilar nodes
      • No mediastinal involvement
    • Stage III
      • Mediastinal involvement
      • A – mediastinal nodes - ipsilateral
      • B – Invasion of medistinum
        • heart, great vessels, trachea, effusions
        • nodes contralateral or supraclavicular
    • Stage IV - Distant Metastatic
    5-year survival
  • 16. 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
    • Radiation therapy
    • Chemotherapy
    • Erlotinib
    • Monthly bisphosphonate
  • 17. 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?
    • Hospice referral
    • Radiation & bisphosphonate
    • Chemo & bisphosphonate
    • Chemo, radiation, and bisphosphonate
    • Lung tumor resection, chemo, radiation, and bisphosphonate
  • 18. Treatment
    • Stage I and II – Resection + chemo
    • Stage IIIA – chemo +/- radiation resectable
    • Stage IIIB – unresectable (selected cases surgery)
    • Stage IV – chemo and/or supportive care, palliative radiation
    • Screening – no screening test has been shown to reduce mortality from lung cancer