This document discusses the case of a 75-year-old male former smoker who presented with difficulty breathing, cough, and weight loss. Imaging revealed a left lung mass, and biopsy showed non-small cell lung carcinoma. The patient's cancer was staged as stage IIB and he was diagnosed with lung cancer, which was discussed in terms of epidemiology, risk factors, screening, diagnostics, treatment including surgery and chemotherapy, prognosis, and follow-up. Key learning points included that lung cancer risk increases with age and smoking and prevention through smoking cessation can decrease lung cancer burden.

1. Lung cancer
Nikki Macanas, MD
1st year IM Resident
NDCH

2. Objectives
• To discuss a case of 75 year old male with pulmonary mass
• To discuss the diagnostics and its management
• To discuss Lung cancer through a concept map

4. General Data
• R.C.
• 75/M
• Roman Catholic
• Filipino
• Married
• June 5, 1943 in Pangasinan
• San luis, Baguio city
• January 23, 2020

5. Chief Complaint
Difficulty of
Breathing

6. History of Present Illness
•Easy fatigability especially when climbing 1 flight
of stairs in their home
•Cough, non productive
•No Hemoptysis
•No Colds
•No Fever
•No Chest Pain
•No DOB
•No Orthopnea, No PND
•No Consult done
•No Medications taken
1
month
PTA

7. History of Present Illness
• Productive cough, whitish,
occasionally admixed with blood
• No febrile episode
• Poor oral intake
• With episodes of DOB
• No Orthopnea, No PND
• With easy fatigability
• No chest pain
• No consult
2
weeks
PTA

8. History of Present Illness
• Difficulty of Breathing
• Easy fatigability
• No fever
• No chills
• No colds
Few
Hours
PTA
C
O
N
S
U
L
T
Patient sought consult to her private MD
where xray revealed left upper lobe mass

9. Past Medical History
• Hypertension Stage II (2000)
– Maintained on Amlodipine 5mg1 tab OD and Losartan 50 mg 1 tab OD
• No CVD
• No T2DM
• No PTB
• No bronchial asthma
• No allergies to food or medication
• No surgery
• With previous hospitalization at another institution pneumonia
(2019)

10. Family Medical History
• (+) Hypertension
• (+) Cancer : breast, maternal side
• (+) CVD
• (-) DM
• (-) Bronchial Asthma
• (-) Heart Disease
• (-) Blood Dyscrasia

11. Social and Environmental History
• Retired government employee
• Smoker 40 pack years
• Occasional Alcoholic beverage drinker
• (-) Biofuel exposure
• Diet is composed of mostly rice with meat and veggies
• The patient does not take any vitamins or supplements

12. Review of Systems
• Skin: (-) rashes (-)jaundice (-)cyanosis
• General: (+) Weight Loss from 75kg to 67 kilos in 10 months (-) no weakness
• HEENT: (-) blurring of vision (-) sorethroat (-) no nasal discharge (-) CLAD
• Cardiovascular: No chest pain or heaviness, no palpitation, no orthopnea
• Respiratory: With productive cough, whitish, with dyspnea, no night sweats, no
hemoptysis
• Gastroenterology: (-) abdominal pain, (-) diarrhea, (-) constipation, (-) melena, (-)
hematochazia, (-)nausea (-) vomiting
• GUT: (-) dysuria, (-) oliguria (-)anuria
• Endocrinology: (-) polyuria, polydipsia, polyphagia,
• Musculoskeletal: (-) myalgia
• Hematology: (-)easy brusability
• Neurology: (-) neuropathy, (-)seizures
• Extremities: (-) edema (-)clubbing

13. Physical Examination
• General:
– conscious, coherent, speaks in phrases, ectomorph
– Wt 67 kg Ht 168cm BMI: 23.7 Normal
• Vital Signs:
– BP: 140/70mmHg RR:25 cpm
– CR: 101 bpm, regular T: 36. 1 CSPO2: 93%
• Skin:
– Good skin turgor, no rashes, no jaundice
• HEENT:
– Anicteric sclera, pink palpebral conjunctivae, no tonsillopharyngeal congestion, no
nasoaural discharge, no cervicolymphadenopathy

14. Physical Examination
• Chest and Lung:
– Symmetrical chest expansion, no lagging, no retractions, dull on
percussion over left upper middle lobe, decreased breath sounds
left upper middle lobe, increased tactile fremitus at left upper
middle lobe, bibasal crackles, right lung is resonant on
percussion, basal fine crackles, no wheezes
• Heart:
– PMI at 5th ICS at MCL, Tachycardic, regular rhythm, Distinct heart sounds, no murmur
• Abdomen:
– Flat, soft, normoactive bowel sounds, non-tender, tympanitic No Organomegaly
• Extremities:
– no edema, +2 pulses, equal, extremities with full range of motion

15. Salient Features
• 76M
• DOB
• Cough, productive
• No chest pain
• No fever
• No night sweats
• 40 pack year smoker
• With first degree relative of malignancy
• No exposure to PTB
• No personal hx of PTB
• With significant unintentional weight
loss for the past 10 months
• Who on consult was noted to have left
pulmonary mass
Chest and Lung:
Symmetrical chest expansion, no
lagging, no retractions, dull on
percussion over left upper middle
lobe, decreased breath sounds left
upper middle lobe, increased tactile
fremitus at left upper middle lobe,
bibasal crackles, right lung is
resonant on percussion, basal fine
crackles, no wheezes

16. Admitting Impression
• Pulmonary mass, left probably malignant

17. BASIS: History and PE
• 76M
• Smoker
• Family history of cancer
• Unintentional weight loss
• Fatigue
• Difficulty of breathing
Lung cancer is uncommon below age 40,
with rates increasing until age 80
Cigarette smokers have a 10-fold or greater
increased risk of developing lung cancer
Family history of malignancy probands 2 to 3
fold risk of developing lung cancer in a
susceptible patient.

18. Patient approach, Differential diagnosis
76M, lung mass, weight
loss, DOB
Inflammatory
TB
Weight loss, cough, DOB, night sweats, fever
Neoplastic
Lung cancer
Smoker, DOB,
weight loss,
cough

19. Laboratory done
as OPD
Hilar mass left
Pleural effusion
left

21. Diagnostics
– CXR
– CT SCAN
– CT GUIDED BIOPSY
– CBC
– PTPA
– 12 L ECG
CBC
Hematocrit 0.413
Hemoglobin 141
WBC 10
Neutrophils 87
Lymphocytes 09
Platelet Count 175
• Ff up study revealed
persistence of left
hilar mass
• Hemothorax vs PF
left
• PT 13.6
• INR 1.04
• APTT 26

22. Chest CT
SCAN
Spiculated mass in athe
anterior segment of the
left upper lobe,
consider lung cancer
with mediastinal LAD
and associated mass
effects
Minimal pleural
effusion, left

24. Immunochemical Staining
• The specimen were sent for IHC staining
And the patient was discharged
•primary lung adenocarcinoma (Nap-A positive, TTF-1 positive)
•primary lung squamous cell carcinoma (Nap-A negative, TTF-1 negative)
•primary SCLC (Nap-A negative, TTF-1 positive)

25. Final Diagnosis
• Non small cell carcinoma, Stage IIB T1N1M0
• Hypertension stage 2, controlled

26. staging
ANATOMIC
2.5X2.8 cm upper lobe
mass
Multiple mass and
nodule at prevascular,
paraaortic and
aortopulmo area
PHYSIOLOGIC
COMORBIDITIES
PFT
RECENT INFECTION
• Stage II B
• (T1bN1M0)

27. SHORT DISCUSSION
NSCLC

28. Epidemiology – Lung cancer
• Lung cancer is uncommon below age 40,
• with rates increasing until age 80, after which the rate tapers off.
• The projected lifetime probability of developing lung cancer is estimated to be
~8% among males and ~6% among females.
BTS statement on malignant mesothelioma in the UK, 2007

29. Philippine setting

30. Screening and Diagnostics Imaging for
Lung cancer
• Contrast-enhanced CT
– Primary imaging modality
– In resected cases:
• guidelines recommend a contrasted chest CT scan
every 6 months for the first 3 years after surgery,
followed by yearly CT scans of the chest without
contrast thereafter

31. Treatment strategies
• Treatment Strategy:
– Depends on the staging
Outline of treatment options by stage
Treatment of NSCLC by stage is as follows:
Stage IA - Surgery only; no adjuvant
chemotherapy
Stage IB-IIIA - Surgery followed by adjuvant
chemotherapy with four cycles of a cisplatin-
based regimen
Stage II-IIIB - If surgically unresectable,
chemoradiation plus durvalumab for one
year if chemoradiation results in a partial or
complete response
Stage IV - Treat on the basis of histology
(squamous or non-squamous)

32. Treatment Strategy: Surgery
• NON SMALL CELL LUNG CANCER
• Surgical resection following bronchoscopic localization has
been shown to improve survival compared to no treatment
OCCULT AND STAGE 0 CARCINOMAS

33. Treatment Strategy: Surgery
• Surgical resection is the treatment of choice for patients with clinical stage
I and II NSCLC who are able to tolerate the procedure.
• In patients with stage IA NSCLC, lobectomy is superior to wedge resection
with respect to rates of local recurrence.
• Pneumonectomy
•
Stage I and II NSCLC CARCINOMAS

34. Treatment Strategy: Chemotherapy
• Adjuvant chemotherapy is best applied in patients with
resected stage II or III NSCLC.
• There is no apparent role for adjuvant chemotherapy in
patients with resected stage IA or IB NSCLC.
• NEOADJUVANT CHEMO : preoperative chemotherapy might
render an inoperable lesion resectable

35. Treatment Strategy: Radiotherapy
There is currently no role for postoperative radiation therapy in patients
following resection of stage I or II NSCLC with negative margins.
Those who are not candidates for surgery should be considered for radiation
therapy with curative intent

36. Metastatic NSCLC
• Cornerstone of treatment
• Early applicationof palliative care in conjunction with
chemotherapy is associated with improved survival and a
better quality of life

37. • Cytotoxic chemo for Metastatic or recurrent NSCLC
• Second line therapy
• Immunotherapy
• Supportive care

38. Prognosis
• The most important prognostic factor in patients
with lung cancer is the stage of disease at
presentation.

39. Long term follow up
• History and physical examination and chest computed tomography
(CT) scan with or without contrast every 6-12 months for 2-3 years,
then an H&P and noncontrast chest CT scan annually
• Assessment of smoking status at each visit
• Annual influenza vaccination; pneumococcal vaccination with
revaccination as appropriate; herpes zoster vaccination
• Counseling regarding health promotion and wellness (eg, regular
physical activity, healthy diet)
• Routine health monitoring

40. Concept map

41. MODIFIABLE RISK
FACTORS
Tobacco smoking
Frequent exposure to
tobacco smoke
Air pollution
Binds with cells DNA
and damge the cells
uncontrolled
abnormal cell growth
in one lung
Passing of damaged
cell to daughter DNA
cells
Malignant
transformation of
pulmonary epithelium
Local tumor growth
Obstruction of
proximal airway
Inability to clear
inhaled pathogens
Post obstructive
pneumonia
Cough, fever, dyspnea
Spread tumor to
pleural surface
Chest discomfort
Obstruction or
compression at local
site
Increase effort to
ventilate lungs
Dyspnea or shortness
of breath
Compression of the
laryngeal nerve
Impaired innervation
to the vocal cords
Voice hoarseness
Airway invasion
Hemoptysis
NON MODIFIABLE
RISK FACTORS
Genetic factors Age
Family history of
cancer

42. Take home messages
• Lung cancer is the most common cause of cancer mortality
worldwide for both men and women.
• Cigarette smoking is responsible for approximately 90 percent
of cases of lung cancer.
• Thus prevention of smoking and cessation of smoking offer
the most important route to decreasing the morbidity and
mortality associated with this disease.