Transcript NYU Medical Grand Rounds Clinical Vignette Lisa Cioce MD, PGY-2 March 10, 2010

NYU Medical Grand Rounds
Clinical Vignette
Lisa Cioce MD, PGY-2
March 10, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
A 67-year-old man presents with
a persistent cough for 6 months.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient was in his usual state of health until 6 months
prior to admission, when he began to experience a cough
productive of white sputum.
• Over this time, he also experienced increasing fatigue
and a 10 pound weight loss.
• He had no fever, hemoptysis, and shortness of breath.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient initially presented to an outside hospital one
month ago, where a chest X-ray demonstrated a dense
opacity involving the left mid and lower lung fields
concerning for a mass.
• A subsequent CT scan of the chest revealed a mass in
the lingula causing obstruction of the lingular bronchus
with direct invasion of the left hilum and bronchovascular
spread of the tumor peripherally.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient underwent bronchoscopy with a
transbronchial biopsy of the mass.
• Pathology demonstrated malignant cells consistent
with poorly differentiated adenocarcinoma.
• He presents for further work-up.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
Past Medical History
• Hyperlipidemia
Past Surgical History
• Rotator cuff repair
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Family History
•Father: Lung cancer
•Brother: Diabetes mellitus
Social History
• Former Smoker
• Quit 4 years ago
• 40 pack-year history
• Denies alcohol use
• Denies illicit drug use
Outpatient Medications
Aspirin 81 mg daily
Simvastatin 80 mg at bedtime
Zolpidem 5 mg at bedtime
Allergies: No known drug allergies
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
General: Well-appearing man, in no acute distress
Vitals: T 97F, BP 156/71, HR 75, RR 14
O2 saturation: 98% on room air
The remainder of the physical exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Studies
• CBC: Within normal limits
• Basic Metabolic Panel: Within normal limits
• Hepatic Panel: Alkaline phosphatase 154 U/L
• The remainder was within normal limits
• Lactate dehydrogenase: 1733 U/L (110-225 U/L)
• CEA: 360.4 ng/mL (0-5.0 ng/mL)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Imaging
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Imaging
• Official CT Report:
Far advanced carcinoma of the lung with involvement
of the left hilum, mediastinum, direct bronchovascular
spread to the left lung and diffuse lymphangitic spread
of the tumor bilaterally.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
Non-small cell lung cancer:
adenocarcinoma
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Staging
• PET scan was performed, demonstrating hypermetabolic foci
in multiple areas including the left hilum, lingula, and posterior
basal segment of the left lower lobe.
• Multiple foci in the mediastinum were noted.
• A 1.1 cm foci was found in the left iliac bone.
• MRI of the brain did not show evidence of metastatic disease.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Staging
• CT guided left iliac bone biopsy was performed.
• Immunohistochemical studies showed reactivity for
CK7 and TTF1 and non-reactivity for CK20, consistent
with metastatic pulmonary adenocarcinoma.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Outpatient Treatment
• The patient was treated with an outpatient chemotherapy
regimen of cisplatinum, pemetrexed and zolendronic acid.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
Stage IV lung adenocarcinoma with
bony metastatic disease
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Correlations
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http://clinicalcorrelations.org
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS