This case study describes a 49-year-old male smoker who presented with symptoms of lung cancer including weight loss, coughing, and chest pain. Imaging showed a large lung mass and fluid in his right lung. A biopsy revealed stage 3B lung adenocarcinoma with metastasis to the pleura. He underwent a procedure to drain fluid from his lung and insert drains. Treatment with chemotherapy and radiation was planned but could not be started due to the development of an empyema (infected fluid collection) in his lung. PET scanning was useful for detecting the pleural metastasis which signifies an advanced, difficult to treat stage of lung cancer.

1. Case Study
Prepared by Todd Charge
Section Manager
Nuclear Medicine & PET Centre
1

2. Background
 SN, 49yr old male
 Presented to GP with 4/52 history of
– SOBOE
– Rt sided chest pain on inspiration
– night sweats
– 10kg weight loss
– non-productive cough
– 10year history of smoking (22 yrs ago)
– 1 ½ packs/day
– previously well

3. Background
 GP diagnosis of pleurisy on clinical examination
 Treated with a single course of antibiotics
 Re-presented to GP rooms one week later with
no resolution of symptoms
 CXR requested by second GP

4. Imaging
 CXR showed
– Rt Pleural Effusion
– Rt side mid zone lung mass measuring
6.5cmx4cm
– CT chest suggested

5. Imaging
 Chest CT showed
– lobular soft tissue mass seen in the right mid
zone measuring about 78 x 62mm
– its lateral surface is in contact with the pleural
cavity
– consolidation could be seen in the right middle
lobe
– multiple oval soft tissue densities noted in
keeping with prominent mediastinal lymph
nodes. There is a large soft tissue mass lesion
seen in the right hilar region

6. Morbidity & Mortality
 Lung Adenocarcinoma
 Stage IIIb: T(any), N3, M0
 Stage 3b – 50% living at 12 months
 5year survival 10%

7. Plan
 PET
 VAT
 Combined chemotherapy and radiation therapy

8. Imaging
 PET

9. Imaging
 PET

10. Imaging
 Large irregular uptake mass in Rt lung
 Focus of abnormal uptake in Rt hilum
 Two foci of low grade upgrade in Rt neck
 Avid irregular uptake in almost entire Rt lung
pleura

11. Plan
 PET
 VAT
 Combined chemotherapy and radiation therapy

12. Treatment
 VAT (video-assisted thoracoscopy)
 Apical and basal drains inserted
 Tissue biopsies
 Adhesions
 Re-expanded Rt lung following collapse
 1Lt blood stained fluid
 Pleural cavity “studded with mets”
 Talc Pleurodesis

13. Anatomy
 Pleura
 Space between the inner and outer lining of the
lung

14. Pathology
 Pleural Effusion
– healthy individuals have less than 1 ml of fluid
in each pleural space
– fluid enters the pleural space from the
capillaries in the parietal pleura, from
interstitial spaces of the lung via the visceral
pleura, or from the peritoneal cavity through
small holes in the diaphragm
– fluid is normally removed by lymphatics in the
visceral pleura

15. Treatment
 Drainage
 5.41Lt over 14 days

16. Treatment
 Talc Plureodesis
– seal the space between pleura with sterile talc
– incites an intense granulomatous pleural
inflammatory reaction
– irritate the pleura making it stick together
– stop fluid build up and relieve symptoms
– 5grams sterile talc
– can be done multiple times
– usually occurring within 24 hours, and often
persisting many months

17. Plan
 PET
 VAT
 Combined chemotherapy and radiation therapy

18. Treatment
 Chemotherapy
 Radiation Therapy
 SATURN trial - a phase III trial of erlotinib
(Tarceva) following chemotherapy as 1st line
treatment for non-small cell lung cancer
 No effective therapy for pleural metastasis
 Generally not curative

19. Complications
 Empyema
– collection of inflammatory fluid and debris
within the pleural space
– resulting infection and inflammation can
proceed with adhesive bands form infected
fluid becomes loculated pus within the pleural
space
– high associated mortality rate related to
respiratory failure and systemic sepsis

20. Conclusion
 Treatment not commenced due to empyema
 PET can be invaluable in detecting pleural
involvement
 Pleural metastasis signify unresectable disease
and carry great therapeutic and prognostic
implications
 PET sensitivity 95%, specificity 67% for pleural
metastasis

21. Conclusion