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SGD 01: MALIGNANCY
Exam 3 | Med Onco Preceptors | August 23, 2012
OUTLINE
Case 1
Case 2
Case 3
Case 4
General Notes
CASE 1
R.S., 50, M
CC: Right lung nodule
o
o
HPI:
2 mo PTC
o CXR done for employment purposes revealed a
solitary pulmonary nodule measuring approx. 2 cm
o Px denied other symptoms except for an
occasional dry, non-productive cough
o diagnosed with PTB and was given anti-TB meds
regularly taken for 2 months
After 2 months
o repeat chest X-ray was done and revealed an
increase in the size of mass to 3cm
o chest CT scan revealed 3.5 x 2.8 cm enhancing
mass at SUPERIOR SEGMENT OF R UPPER LUNG.
o (-) enlarged peribronchial, hilar, mediastinal nodes
o still no other symptoms except for occasional dry
cough
PMHx: Unremarkable (U/R)
PSSx: (+) Smoking: 1 pack/day for 20 years (20 pack
years)
ROS: (-) anorexia, headache, weight loss, back pain,
hemoptysis
PE: (-) palpable lymph nodes, Clear lung fields, U/R
abdomen
Diagnosis
(Note from the transers: Case 1 contains all general data
applicable to lung malignancies. Italicized and underlined
phrases are applicable to Case 1.)
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Staging
(Note: See the Lecture
Malignancies for this part.)
trans
on
Overview
of
Lung
Management
Counseling
together with the patients family
3Cs: Coping, Communicating, Connecting
ADVISE TO QUIT SMOKING!!!
Good balanced diet, exercise
Avoid cancer risks: asbestos, radiation
explaining his condition: natural history of the disease
(stage of his disease), prognosis, treatment options
Intervention Options
Surgery - considered if cancer is only small and
localized to one tumor nodule
o Pneumonectomy
o Lobectomy - preferred operation for SCLC
o Segmentectomy
Radiation Therapy - given in patient with SCLC in the
ff situations:
Targeted Therapy
Complementary Methods and Palliative Care
Given after chemotherapy sessions and throughout
treatment as an adjunct to therapy, or to reduce the
side effects.
Help the patient feel better and add to patient's
comfort
o Ex. meditation to reduce stress, acupuncture to
relieve
pain,
peppermint
tea
to
relieve
nausea, aromatherapy, massage therapy, yoga.
Pain medication, palliative care, symptomatic therapy
(for difficulty breathing, etc.) can also be given as
necessary.
Group Counseling/Therapy
Follow-Up
Check-up every 2mo post-treatment
CA patients should be educated about signs and
symptoms of recurrence and potential adverse
effects related to therapy
Monitoring with: CXR, Chest CTSc
Liver UTS every 6 months
Bone scan every year
Cranial CTSc if with frequent headache or signs of inc.
ICP
CASE 2
65, M, Filipino
CC: Cough, mild difficulty of breathing, and progressive
hip pain
HPI:
CXR revealed pulmonary mass at the R upper lung with
2 nodules on the L upper and mid-lung fields.
PMHx: U/R
PSSx: (+) smoking: 40 pack years
ROS: (+) facial swelling upon awakening, weight
loss, anorexia
(-) headache, abdominal pain, or hemoptysis
PE: 2x2 cm hard, fixed right supraclavicular node,
decreased breath sounds at the right upper lung field
with dullness to percussion, and occasional inspiratory
wheezing on all lung fields.
Diagnosis
Table 2. Differentials (Case 2)
Disease
Reason for R/I
SCLC
(+) Pulmonary
mass
(+) Cough
(+) Dyspnea
(+) Facial swelling
(plethora)
(+) Weight loss
Smoking hx: 95%
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NSCLC
(Squamous
cell)
Adenocarcino
ma
of CA associated
with a chronic
smoking Hx is
SCLC
Presence of
nodules at R and
mid-upper lung
field
Hard, fixed R
supraclavicular
node
(+) Pulmonary
mass
(+) Cough
(+) Dyspnea
(+) Facial swelling
(+) Weight loss
Smoking hx
Presence of
nodules at R and
mid-upper lung
field
Age, Sex
(+) Pulmonary
mass
(+) Cough
(+) Dyspnea
(+) Facial swelling
(plethora)
does not
improve due to
constant
hormone
production of
the tumor)
No reason to rule
out
yet
(histopathologic
examination
needed
for
differentiation)
Ancillary
Tests:
paraneoplasms
o
o
o
o
o
Adenocarcinoma,
although more
common than
squamous cell
CA, is more
prevalent in
women,
nonsmokers
Mass is central (vs.
Adenocarcinoma
which is more
peripheral)
mainly
for
detection
4-6 months
Counseling
(see Case 1 > Management > Counseling)
Intervention Options
Symptomatic Management
o pain: give non-opioids first before moving on to
stronger drugs like morphine when the pain is
already unbearable
o cough (and hemoptysis): can be treated
pharmacologically
Palliative radiotherapy
o FOR: Bronchial obstruction with pneumonitis,
hemoptysis, upper airway or SVC obstruction brain
or spinal cord compression (important!), or
painful bony metastases.
o
It provides relief of intrathoracic symptoms:
o Hemoptysis (84%), SVC syndrome (80%), Dyspnea
(60%), Cough (60%), Atelectasis (23%), Vocal cord
paralysis (6%)
o Also for: cardiac tamponade, painful bony
metastasis, CNS compression, brachial plexus
involvement
Chemotherapy: Palliates symptoms, improves QOL, and
improves survival in newly-diagnosed patients
o First-line: Cisplatin or Carboplateine, Texane
(paclitaxel, docetaxel), Gemicitabine
o Second-line: Docetaxel or pemetrexed
Growth factor support is rarely needed
EGFR Targeted Therapy: Erlotinib (2nd or 3rd line)
o Prolong ssurvival, Second or Third line therapy
o Very expensive
Management for Bone Metastasis
o Radiotherapy
o Bisphosphonates: reduce secondary close, prevent
Complementary Methods and Palliative Care
(Note: In squamous cell lung CA, you will not give
Bevacizumab (which is an angiogenesis inhibitor) will
cause the patient to bleed out)
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Pulmonary 10 pack-year
embolism
smoking
(+) unproductive
cough for 1 mo
(+) occasional
pleuritic chest
pain
(+) Hemoptysis
Pneumonia (+) unproductive
cough for 1 mo
(+) occasional
pleuritic chest
pain
HPI:
1 mo PTC
o Non-productive progressing cough, assoc. pleural
chest pain
10 days PTC
o (+) Hemoptysis, Fatigue, Anorexia
PMHx: U/R
PSSx: (+) smoking: 10 pack year
ROS: (+) 30 % weight loss; (-) headache, abdominal
pain, back pain
PE: Slightly cachexic, no palpable nodes, occasional
wheezing at all lung fields
CXR: Large bulky mass with hilar adenopathy
CT Scan:
3x5 cm tumor invading the R main bronchus, 3 cm
distal to carina
Atelectasis at hilar region
Enlarged ipsilateral hilar and mediastinal lymph nodes
Diagnosis
Table 3. Differentials (Case 3)
Disease
Reason for R/I
Reason for R/O
Bronchoge 10 pack-year
nic CA
smoking
(SCLC)
(+) unproductive
cough for 1 mo
(+) occasional
pleuritic chest
pain
(+) Hemoptysis
(+) Anorexia,
weight loss
(+) wheezing in all
lung areas on PE
Large bulky mass
with hilar
adenopathy on
CXR
3x5 tumor invading
R main bronchus
Enlarged ipsilateral
hilar and
mediastinal
lymph nodes
Atelectasis at hilar
region on CT
Pulmonary 10 pack-year
(-) night sweats,
Tuberculosi
smoking
fever
s
(+) unproductive
no tests done for
cough for 1 mo
AFB
smear/culture
(+) occasional
pleuritic chest
pain
(+) Hemoptysis
(+) Anorexia,
weight loss
Large bulky mass
with hilar
adenopathy on
CXR
(-) evidence of
effusion
(transudative or
exudative)
no reported
dyspnea
(-) no PE findings
of consolidation,
abnormal breath
sounds
Staging
TNM Classification is not used in staging SCLC. Instead,
we describe the malignancy as Limited or Extensive
Limited
o Limited to one side of the chest
o Can be treated with sufficient radiation therapy
o Prognosis: 20 months, 2-year survival rate of 25%,
5-year survival rate of 20%
Extensive
o Spread to other side and/or other distant organs
(including pleural/pericardial effusion or
hematogenous metastases)
o Prognosis: 12 months, 2-year survival rate of 4.6%
Confinement to one Hemithorax Limited-Stage
Disease
Management
Counseling
(see Case 1 > Management > Counseling)
Intervention Options
Chemotherapy:
o Etopside +cisplatin / carboplatin
o CRx doses may be adjusted on the basis of nadir
granulocyte counts
o Blood work +CBC is needed prior to each cycle of
chemotherapy to ensure marrow recovery before
the next dose of chemotherapy is administered.
o Serum LDH is a good marker for response and
should be monitored.
o Renal function should be monitored because of
nephrotoxicity from cisplatin.
o CT scans should be obtained after 2 cycles of
therapy to assess response (if afforded)
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Cachexia and
weight loss
suggest systemic
spread
Subcarinal and
perihilar
lymphadenopathy
(bronchogenic
CA)
Small cell (+) chronic cough
Usually presents
lung
with central
(+) worsening or
carcinoma
endobronchial
new dyspnea
(SCLC) (+) weight loss
tumor
(-) headache upon
(+) hemoptysis
consult
(+) pleuritic pain
(+) decreased
breath sounds;
dull on percussion
Cachexia and
weight loss
suggest systemic
spread
Pulmonary Smoking hx
(-) night sweating
Tuberculosi (+) cough,
(-) orthopnea,
s
hemoptysis
PND
(+) chest pain
(+) weight loss,
anorexia
(+) perihilar and
subcarinal
lymphadenopathy
(remember
Rankes complex)
Primary Working Impression: Squamous Cell
Carcinoma
Presence of respiratory symptoms due to a possible
lung tumor (cough, dyspnea, hemoptysis - possible
rich blood supply of tumor)
decreased breath sounds at the right upper lung fields
with dullness to percussion
Signs suggesting the presence of a malignancy: weight
loss, anorexia, lymphadenopathy
Imaging studies reveal a mass at the right apex
History of smoking
To rule in: PTB (difficult to rule out unless patient is
asked to have sputum AFB and/or culture)
Diagnostic Procedures
CXR, CT Scan
PET Scan, Cranial and Abdominal CT or MRI,
Bone Scan, CT Scan for Adrenals
CBC with platelet count: check for hemodynamic
stability
o patient presented with pale conjunctive and
hemoptysis, which is not yet quantified.
o Px may present with a bleeding mass due to the
high vascularity of a carcinoma.
Biopsy
Sputum Cytology/Examination if its squamous
cell CA, it is likely that it will be detected using this
procedure
Ancillary tests
Staging
T2bN2M0 Stage IIA
o T2B: Tumor is >5 cm, does not directly involve
carina; invades visceral pleura
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Counseling
(see Case 1 > Management > Counseling)
Intervention Options
Surgical resection with lymph node dissection
o may have poor results because of node
involvement
o Some oncologist conclude that surgery should only
be conducted in patients who have clearing of the
mediastinal nodes after adjuvant therapy
Chemotherapy followed by Radiation Therapy (Tx
of choice)
o Cisplatin-based combination (with etoposide)
o Improved survival compared with sequential
therapy but more side effects such as fatigue,
esophagitis and neutropenia
Supportive Therapy: Pain relief, Emesis therapy,
Ondansetron, Prochloroperazine, Dexamethasone,
Nutritional intervention
Complementary Methods and Palliative Care
GENERAL NOTES
On History and PE:
Getting a good history and PE is important since
most CAs metastasize to the lungs. For women, usually
comes from breast cancer, and for men, rectal cancer.
Before doing treatment for Lung CA, always check for
CA in other locations.
On Doing a Biopsy
Do a biopsy to check for possible malignant cells
then classify what type of cancer; always opt for the
most accessible biopsy (e.g. lymph node)
FNAB
CT-guided biopsy (CT GAB): for peripheral masses
Bronchoscopy-guided biopsy: for central (hilar or
mediastinal) masses
VATS as a last resort if you're absolutely positive that
there's a malignancy but other the methods have
failed to give a positive result
On Staging and Treatment:
Stage dictates treatment
Stage 1: Surgery then chemo (Don't do radio)
Stage 2: Surgery
Stage 3A: Chemotherapy then surgery
Stage 4: Chemotherapy and Radiotherapy;
palliative
On Other diagnostics:
Do a brain CT scan for small cell carcinoma because it
is very malignant
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