Transcript Patient with prostate cancer and dyspnea

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• An 88 year old male
• increasing exertional
dyspnea, nonproductive
cough over several weeks.
• Remote smoking history
• Pipefitter – asbestos
• prostate cancer diagnosed 2
years ago – hormone
therapy
• Physical exam: VSS, no
distress, O2 sats 91% on
room air
• Decreased breath sounds
and decreased fremitus from
left base to left mid-lung
zone.
• Bloodwork unremarkable,
PSA normal (1.2 µg/L).
• CXR done
• Q1: Interpret the CXR
• Answer (Q1)
• Q2: At this point, what are the diagnostic possibilities
and your most likely diagnosis?
• Answer (Q2)
•
Q3: What is the next best investigation to determine
the cause of the effusion?
a)
b)
c)
d)
•
Thoracentesis
Surgical pleural biopsy
Bronchoscopy
CT chest
Answer (Q3)
• Pleural fluid:
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•
•
•
clear, yellow
total protein 46 g/L
LDH 259 units/L
glucose 5.5 mmol/L
WBC 400 x 106/L
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poly 27%
lymph 39%
mono 30%
eos 4%
• gram stain and AFB negative
• other tests pending
• Serum:
• total protein 74 g/L
• LDH 183 units/L
• Pleural fluid (other results)
– cytology shows
adenocarcinoma.
– Staining for PSA negative,
morphologic features
consistent with lung
adenocarcinoma.
– bacterial cultures negative.
• CT chest: 3 cm mass LUL,
mildly enlarged mediastinal
lymph nodes, tiny nodules on
pleura suggesting metastatic
deposits.
•
Q4: What is the most appropriate treatment?
a) Surgical resection of the tumor and surgical decortication to
prevent recurrence of effusion.
b) Chemotherapy to treat the tumor, which will also prevent
recurrence of the effusion.
c) Radiation therapy for the tumor, which will also prevent
recurrence of the effusion.
d) None of the above.
•
Answer (Q4)
• Q5: The patient and family ask whether the lung cancer
is due to his possible asbestos exposure. How would
you respond?
• Answer (Q5)