2. Case profile
• 60 yr old male
• Farmer
• Satyabadi, Puri
• Came with chief c/o
• Cough for 4 months
• Decreased appetite for 2 months
• Weight loss for 2 months
• SOB for 1 month
3. HOPI
• Cough for 4 months, initially dry then productive, scanty sputum, 20-
30 ml/day, mucoid, no postural& diurnal variation, last 15 days it was
associated with B/L chest pain during cough & relieved after some
time without medication but he felt chest discomfort all over the day,
cough was not associated with blood expectoration, wheeze, loss of
conscious ness, now intensity of cough decreased
• Appetite decreased since 2 months
• Unquantified weight loss since 2 months
• SOB since 1 month, gradual in onset, progressive, II----III (mMRC), no
postural & diurnal variation, increased after coughing, not relieved by
medication
4. Past history
• k/c/o CAD
• k/c/o CA Buccal mucosa (10/11/21)
• No PTB, DM, HTN, CVA
5. Personal history
• Smoker, bidi smoking index 800
• Pawn chewer
• Farmer
• Married, 2 children
• Kuccha house, poor ventilation
• Last 5 years using gas for cooking
7. Treatment history
• PCI ( LCx+ RCA) on 08/03/2020 & Dual platelet therapy ( aspirin 75 mg& clopidogrel 75 mg OD)
• Squamous cell CA of buccal mucosa, ulceroproliferative growth (T2N0M0) 10/11/21
• SBRT 20 Gy/ 8#
• IGRT 60 Gy/ 30#
• Patient admitted in SCBMCH Respiratory medicine dept 1 month back, he underwent
bronchoscopy & EBBx– intra-luminal growth with 90% of occlusion
• Patient diagnosed as clinically diagnosed PTB 20 days back, ATT (4FDC) started & discharged
• He taken ATT for 10 days, Gastritis
• EBBx revealed Squamous cell lung cancer & then he stopped ATT
• He admitted in AHPGIC on16.06. 2023
• Treating with symptomatic T/t, planned to start chemotherapy on 22/06/2023 & IHC report
awaiting
8. GPE
• Pt c/c/c
• Height—170 cm & weight– 52 kgs, BMI—17.99 kg/m2
• Temp– afebrile
• PR– 86/min
• BP– 110/70 mm Hg
• RR– 16/min
• SpO2– 97%
• No Pallor, Icterus, Cyanosis, Clubbing, LE, PE, JVP
9. O/E
• Hyper pigmentation of jaw, B/L cheeks
• Mouth opening 2 finger width
• Left buccal mucosa atrophied, mucosal irregularity and dry
• Dentition normal, tobacco stained teeth
• Good oral hygiene
• Pharynx and tonsils normal
• Ear & nose– normal
10. Respiratory system
• Inspection
• Decreased movements on Lt side
• Lt shoulder drooping
• Lt SCF hollowness & ICA flattening
• Trachea deviated to Lt
• Apical impulse visible
• Lt IC recession more
• Low lying scapula on Lt
• Lt spinoscapular distance less
11. O/E
• Palpation
• VF decreased over Lt ICA,MA,AA,SSA,upper inter SA
• Apical impulse in Lt MCL in 4th ICS
• Percussion
• Lt clavicle and Kronigs isthmus dull
• Dull note on Lt ICA, MA, AA, SSA, upper inter SA
• Ascultation
• Decreased VBS over Lt ICA, MA, AA, SSA, upper inter SA
• VR decreased in above areas
• No added sounds
12.
13.
14. Diagnosis
• Squamous cell carcinoma of lung with lt upper lobe collapse ( ?
Primary/ metastasis) with ? Liver metastasis k/c/o CA Buccal mucosa
with post RT with CAD with Post PCI
15. Investigations
• Hb– 10.8
• WBC- 18120, N89L6M6
• PLT—303000
• Se Ur—43
• Se Cr– 1.0
• LFT Bil T—0.3, D—0.1
• SGOT/SGPT—45/43
• ALP—351
• Se Na—138, K– 3.7
16. 2D Echo
• RWMA I RCA territory
• Grade I D/D
• Normal LV function
• EF—56%
17. Management of Lung cancer depends on
• Age
• Performance status
• Comorbidities
• Patient preference
• Underlying lung function
• Histological type
• Tumour burden
• Stage (locally advanced & metastatic)
• Mutations
• PD-L1 status
18.
19.
20. CT protocol
• Inj. Dexamethasone 16mg plus inj. Ondansetron 16mg in 100 ml NS
over 15 mins
• Inj. Ranitidine 50 mg iv push
• Inj. Gemcitabine 1gm/m2 in 300ml NS over 30 mins (D1, D8)
• Inj. Carboplatin AUC 6 in 300ml 5% D over 1 hour (D2)
• 1 litre RL
• Cap. Aprepitant 1 hour before of CT & continued for next 2 days
• Inj. PEGfelgastrim 6mg IV 24 hours after CT for 3 days
21. Other drug combination
• Paclitaxel 45–50 mg/m2 weekly; carboplatin AUC 5
• Cisplatin 50 mg/m2 on days 1, 8, 29, and 36; etoposide 50 mg/m2
days 1–5 and 29–33;
• Paclitaxel 45–50 mg/m2 weekly; carboplatin AUC 5
• Cisplatin 50 mg/m2 on days 1, 8, 29, and 36; etoposide 50 mg/m2
days 1–5 and 29–33
• BSA (m2) = SQRT( [Height(cm) x Weight(kg) ]/ 3600 )
• Carboplatin Dose (mg) = (target AUC) x (GFR + 25)
22. Treatment of NSCLC
• Stage I, II, IIIA---- surgery/SBRT
• Adjuvant chemotherapy/ targeted therapy--- II,III, IB (size>4cm)
• Neoadjuvant chemo/immunotherapy– respectable locally advanced cancer
• Concurrent chemoradiotherapy– unresectable locally advanced cancer
• Metastatic cancer– chemo/immuno/chemo+immuno/targeted therapy±
Bevacizumab with palliative RT and palliative therapy
• Maintenance therapy for advanced cancer–
pemetrexed/gemcitabine/bevacizumab
• 2nd line therapy-- docetaxel ±ramucirumab/pemetrexed/immunotherapy
23. Response rate ( response evaluation criteria)
• The complete response (CR) classification means the original tumor
can no longer be detected on the RECIST scans
• The partial response (PR) category means the original tumor has
shrunk by 30% or more
• Progressive Disease (PD)the original tumor may have increased in size
by 20% or more. Or new tumors may be found in the scan
• stable disease (SD)It may have shrunk or grown, but not enough to be
classified into one of the other categories
24. Adverse events with chemotherapy
Grade 1
• Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only;
intervention not indicated.
Grade 2
• Moderate; minimal, local or noninvasive intervention indicated; limiting ageappropriate
instrumental ADL*.
Grade 3
• Severe or medically significant but not immediately life-threatening; hospitalization or
prolongation of hospitalization indicated; disabling; limiting self care ADL**.
Grade 4
• Life-threatening consequences; urgent intervention indicated.
Grade 5
• Death related to AE
