1. Lesson for today… “Sticks and stones can break my bones…” Grand Rounds Presentation

2. To present a case of a rapidly progressing lung mass To discuss a diagnostic approach to lung carcinoma presenting with effusion Objectives

3. Identifying Data Insert picture Name: S.D. Age: 73 years old Sex: Female Chief Complaint: left shoulder pain “angsakitngkaliwangbalikatko” Sticks and stones can break my bones…

5. “nangangawit”

7. No other associatedSSxADMISSION Sticks and stones can break my bones…

9. Folk belief to relieve the pain

12. Increased in severity (8/10)

13. Inability to do household chores

14. Shortness of breath

15. No cough, chest pain, fever

16. Consult done, advised to see specialist LOM ADMISSION Sticks and stones can break my bones…

18. Shoulder xray APL: U/R L shoulder, infiltrates in the upper left lung Chest Xray suggested LOM ADMISSION Sticks and stones can break my bones…

20. For thoracentesisADMISSION Sticks and stones can break my bones…

21. History of Present Illness Chest X-ray PA view LOM Sticks and stones can break my bones…

24. S/P TAHBSO for myoma(1980s)

25. No allergies

26. G7P7 (7007)

27. Aside from myoma, unremarkable OB history Sticks and stones can break my bones…

31. Non-smoker

32. Non alcoholic drinker

33. Exposed to smokers in the family

34. No recent travels Insert picture Sticks and stones can break my bones…

35. Stakeholders analysis

37. weight loss of 3kg in 1 yr

38. Loss of appetite

39. easy fatigability

40. No hemoptysis, no cough

41. No changes in color of urine, no dysuria

42. (+) constipation

43. No anhydrosis

44. No leg cramps

45. No changes in personality

46. No easy bruisability

47. No heat/cold intoleranceSticks and stones can break my bones…

49. Alert, conscious, coherent,

50. not in cardiorespiratory distress

53. no suspicious nevi

54. multiple punctate crust-like burn marks at the left posterior shoulder Sticks and stones can break my bones…

56. No nasal congestion, no sinus tenderness

57. Supraclavicular lymph node enlargementSticks and stones can break my bones…

60. Left lung base findings:

61. Dullness to percussion

62. Crackles

63. Positive egophony

64. Decreased vocal fremitus

65. Decreased breath sounds, left hemithorax

66. No pleural rub, no wheezes Sticks and stones can break my bones…

68. No apparent masses or deformities

69. NABS, no abdominal bruits

70. Soft, non-tender with no note of masses or organomegaly

71. No CVA tenderness Sticks and stones can break my bones…

73. No cyanosis or edema was noted

74. Pulses are full and equal Sticks and stones can break my bones…

76. Cranial nerves intact

77. Left upper extremity 3/5, the rest 5/5

78. Inability to flex, extend, adduct, abduct fingers of left hand

79. Awake, GCS 15

80. No ataxia, normal gait

81. Bilateral, normoflexive, (-) Babinski

82. 80% Sensory deficit of C7-C8 dermatomal level, left

83. No meningeal signsSticks and stones can break my bones…

84. Physical Examination Sensory: 80% sensory deficit C7-C8 dermatomal of LUE 5/5 3/5 Motor: 3/5 on LUE, the rest 5/5; inability to flex, extend, abduct adduct fingers, left 5/5 5/5 Sticks and stones can break my bones…

86. left shoulder pain

87. Radiculopathy from left shoulder to elbow to hand

88. Inability to use left hand

89. shortness of breath

90. nonsmoker but with strong exposure to smoking

91. bloatedness, constipation, loss of appetite

92. easy fatigability, no fever, no cough, coldsLOM Sticks and stones can break my bones…

94. Dullness to percussion

95. Positive egophony

96. Decreased vocal fremitus

97. Crackles

98. Decreased breath sounds in the left hemithorax

100. Pleural effusion on Chest X-rayLOM Sticks and stones can break my bones…

101. Primary Impression: Pleural effusion, left (parapneumonicvs malignancy); brachial plexopathy Sticks and stones can break my bones…

102. Insert picture Differentials? LOM Sticks and stones can break my bones…

103. CARDIAC > Congestive Heart Failure PULMONARY > Tuberculosis INFECTIOUS > Parapneumonic process GI > Hepatic hydrothorax TRAUMA > hemothorax, chylothorax MALIGNANCY > Lung Ca

104. CARDIAC > Congestive Heart Failure most common cause of pleural effusion 80% bilateral effusion

105. CARDIAC > Congestive Heart Failure PULMONARY > Tuberculosis INFECTIOUS > Parapneumonic process GI > Hepatic hydrothorax TRAUMA > hemothorax, chylothorax MALIGNANCY > Lung Ca

106. 5% of patients w/ cirrhosis &ascites usually right-sided and large enough to cause severe dyspnea GI > Hepatic hydrothorax

107. CARDIAC > Congestive Heart Failure PULMONARY > Tuberculosis INFECTIOUS > Parapneumonic process GI > Hepatic hydrothorax TRAUMA > hemothorax, chylothorax MALIGNANCY > Lung Ca

108. Chylo – milky fluid and TG > 1.2mmol/L Hemo – bloody, hct >50% TRAUMA > hemothorax, chylothorax

109. CARDIAC > Congestive Heart Failure PULMONARY > Tuberculosis INFECTIOUS > Parapneumonic process GI > Hepatic hydrothorax TRAUMA > hemothorax, chylothorax MALIGNANCY > Lung Ca

110. CARDIAC > Congestive Heart Failure PULMONARY > Tuberculosis INFECTIOUS > Parapneumonic process GI > Hepatic hydrothorax TRAUMA > hemothorax, chylothorax MALIGNANCY > Lung Ca

111. Exudate Pneumonia Malignancy Tuberculosis Transudate CHF Cirrhosis Nephroticsyndrome

112. Tuberculosis Parapneumonic Process Malignancy

114. ✗ Tuberculosis Parapneumonic Process Malignancy

116. ✗ Tuberculosis ✗ Parapneumonic Process Malignancy

118. ✗ Tuberculosis ✗ Parapneumonic Process Malignancy ✔

119. Insert picture Work-up? Malignancy LOM Sticks and stones can break my bones…

120. Approach to Pleural Effusion

122. Approach to Pleural Effusion

123. Approach to Pleural Effusion PORCEL et al. AFP 2006; 73: 1212

124. Imaging

125. Biopsy

126. What happened to our patient? let us continue with the story…

128. Tramadol 50 mg IV

129. O2 support via nasal cannula

130. Ceftriaxone 2 g IV OD

131. Chest CT with IV requestedPleural fluid Day 1 Thoracentesis Tramadol Ceftriaxone Sticks and stones can break my bones…

133. Good activity, appetite

134. Still with inability to use left hand

135. No progression of lung findings on PEPassive left atelectasis Pleural effusion Day 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Sticks and stones can break my bones…

136. Axial Chest CT-Scan (Upper Lung) With Contrast Without Contrast

137. Axial Chest CT-Scan (Lower Lung) Without Contrast With Contrast

138. Chest CT-Scan w/ Contrast (Lung Window)

140. VS stable, same lung findings on PEMotor: 3/5 LUE; inability to flex and extend fingers, left Day 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 3 PF analysis, exudative; no growth on culture Sticks and stones can break my bones…

142. VS stable, same lung findings on PEInterpretation (Light’s Criteria): Exudative Day 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 3 PF analysis, exudative; no growth on culture Sticks and stones can break my bones…

144. Increased severity of shoulder pain

145. Progression of inability to move left upper extremity

146. PE: no significant progression or improvement of lung findingsDay 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 3 PF analysis, exudative; no growth on culture Sticks and stones can break my bones…

148. No note of DOB

149. Interval increase of pleural effusion on CXRDay 6 Day 1 S/P Thoracentesis Day 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 3 PF analysis, exudative; no growth on culture Day 6 CT scan –guided biopsy Chest xray Sticks and stones can break my bones…

151. Miosis

152. Oncology service called inDay 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 3 PF analysis, exudative; no growth on culture Day 6 CT scan –guided biopsy Chest xray Day 8 Biopsy result: Adenocarcinoma Sticks and stones can break my bones…

154. Miosis

155. Oncology service called inDay 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 3 PF analysis, exudative; no growth on culture Day 6 CT scan –guided biopsy Chest xray Day 8 Biopsy result: Adenocarcinoma Sticks and stones can break my bones…

157. No bowel movement for the past 4 days

158. Motor: 3/5 RLE and LLE

159. Sensory: 50% deficit, right and 75%, left3/5 3/5 - 50% - 75% Day 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 8 Biopsy result: Adenocarcinoma Day 3 PF analysis, exudative; no growth on culture Day 6 CT scan –guided biopsy Chest xray Day 9 Given Bisacodyl Sticks and stones can break my bones…

161. No bowel movement for the past 4 days

162. Motor: 3/5 RLE and LLE

163. Sensory: 50% deficit, right and 75%, leftDay 1 Thoracentesis Tramadol Ceftriaxone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 8 Biopsy result: Adenocarcinoma Day 3 PF analysis, exudative; no growth on culture Day 6 CT scan –guided biopsy Chest xray Day 9 Given Bisacodyl Sticks and stones can break my bones…

165. Foley catheter was inserted

166. DRE: lax sphincter tone3/5 0/5 Day 1 Thoracentesis Tramadol Ceftriaxone Day 9 Dexamethasone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 8 Biopsy result: Adenocarcinoma Day 3 PF analysis, exudative; no growth on culture Day 6 CT scan –guided biopsy Chest xray Day 9 Bisacodyl Sticks and stones can break my bones…

168. Foley catheter was inserted

169. DRE: lax sphincter toneDay 1 Thoracentesis Tramadol Ceftriaxone Day 9 Dexamethasone Day 2 PF AFB (-) CT scan: pleural based mass, likely malignant Day 8 Biopsy result: Adenocarcinoma Day 3 PF analysis, exudative; no growth on culture Day 6 CT scan –guided biopsy Chest xray Day 9 Bisacodyl Sticks and stones can break my bones…

171. (+) Babinski reflex

172. Same sensory deficit from T6 and belowDay 11 Thoracic MRI: metastatic findings at C7, T7, T8, T9 Ketorolac Sticks and stones can break my bones…

173. MRI: T2 Sagittal T2 Fat Suppressed

174. MRI T2 Axial & Sagittal (T7)

175. MRI T2 Axial & Sagittal (T8)

176. MRI T2 Axial Normal (T7) Compressed Spinal Cord (T8)

177. MRI T1 Axial: C7 T1 with Gadolinium T1

180. Official reading of histopathology: adenocarcinoma, pulmonary in originDay 11 Thoracic MRI: metastatic findings at C7, T7, T8, T9 Ketorolac Sticks and stones can break my bones…

182. CT stimulation dose and treatment planning done

183. First cycle of radiation therapyDay 11 Thoracic MRI: metastatic findings at C7, T7, T8, T9 Ketorolac Sticks and stones can break my bones… Day 14 1st cycle of RT Dulcolax suppository Lactulose Gabapentin

184. Final Diagnosis: Lung Cancer, Adenocarcinoma Stage 4 Pancoast tumor with spinal cord and left brachial plexus compression Sticks and stones can break my bones…

185. Case Discussion

187. Dyspnea

188. Blood-tinged sputum

191. Dyspnea

192. Blood-tinged sputum

193. Chest painLOM

197. Adenocarcinoma Lung Cancer Adenocarcinoma accounts for 40% of non-small-cell lung cancers It usually originates in peripheral lung tissue Most cases of adenocarcinoma are associated with smoking; however, among people who have never smoked ("never-smokers"), adenocarcinoma is the most common form of lung cancer A subtype of adenocarcinoma, the bronchioalveolar carcinoma, is more common in female never smokers, and may have different response to treatment

198. Types of NSCLC on smokers and non-smokers Women & adenocarcinoma Bryant, A; Cerfolio RJ (July 2007).Differences in epidemiology, histology and survival with patients between cigarette smokers and never smokers. Chest 132 (1): 198-

199. On cytology

200. Staging American Joint Committee on Cancer TNM System T4 N3 M1b Distant Metastasis Supraclavicular LN Separate tumor nodule

201. Staging American Joint Committee on Cancer TNM System T4 N3 M1b Distant Metastasis Supraclavicular LN Separate tumor nodule Stage IV

202. Pleural Effusion Horner’s syndrome Brachial Plexopathy Spinal Cord Compression

203. Pleural Effusion In a study by Diaz et. Al… 75% likely that it is pleural metastasis! Chest X-rays 7% Pleural Effusion

204. How about the shoulder pain? Later staging… ….Poorer prognosis

205. Pancoast tumor Severe pain in the shoulder region >>> toward the axilla & scapula & ulnar aspect of the muscles of the hand Atrophy of hand and arm muscles Horner syndrome Compression of the blood vessels with edema CLASSIC PANCOAST TUMOR

206. Horner’s Syndrome? + + Anhidrosis?

207. Brachial plexopathy

208. Spinal cord compression Early diagnosis is crucial Arrest the course of the disease 60% in the thoracic spine 30% the lumbosacral region Weakness is the most obvious and problematic manifestation of spinal cord compression Bowel and bladder disturbances tend to be a late occurrence

209. Insert picture Treatment? Lung Cancer Adenocarcinoma Stage IV PLUS Spinal Cord Compression LOM Sticks and stones can break my bones…

210. Risk Factors Protective Smoking passive smoking Diet: cured meat, deep fried cooking, chili Alcohol Occupational exposure: silica, asbestos, radioactive particle exposure Lung cancer susceptibility genes Diet: fruits, vegetables exercise Molina, J, et al (2008). Non–Small Cell Lung Cancer: Epidemiology, Risk Factors, Treatment, and Survivorship. Mayo Clinic Proceedings; 83 (5): 584-594

211. A study from Japan In 1981 Possible importance of passive or indirect smoking as one of the causal factors of lung cancer This explains why women develop lung cancer although they themselves are non-smokers Hirayama, T (1981). Non-smoking wives of heavy smokers have a higher risk of lung cancer: a study from Japan.. British Medical Journal. (183-185)

212. Passive smoking You’re not only killing yourself… you’re killing others too. 3,000 lung cancer deaths per year in U.S. nonsmokers age >35  environmental tobacco smoke 33% of all lung cancer deaths in female never-smokers is attributed to environmental tobacco smoke and 31% of this population are due to spousal environmental tobacco smoke Office of Health and Environmental Assessment, U.S. Environmental Protection Agency (1992). RESPIRATORY HEALTH EFFECTS OF PASSIVE SMOKING: LUNG CANCER AND OTHER DISORDERS

213. Tumor markers TPS (tissue polypeptide specific antigen) and CYFRA 21-2 were found to be useful for the diagnosis of NSCLC NSE (neuron specific enolase) seems to be a useful tumor marker for monitoring course of patients especially in SCLC Combined use of TPS and CYFRA 21-1 may provide additional information for prognosis Mumbarkar, P, et al (2006). Significance of Tumor markers in lung cancer. Indian Journal of Clinical Biochemistry,/ 21 (1) 173-176

214. CYFRA 21-1 Persistently elevated 21-2 level than that before therapy may remind clinicians of tumor recurrence or disease progression Sheng lain, R, et al (1996). Cyfrea 21-2 Enzyme-linked immunoabsorbent assay. Evaluation as a tumor marker in non-small cell lung cancer. American College of Chest Physicians. 109;995-1000

215. Treatment In a Stage IV Lung Cancer, what are our options? Surgery? Radiotherapy? Chemotherapy?

216. Treatment Surgery? For Stage I and II NSCLC (with no evidence of mediastinal disease or invasion of local organs) Stage IIIB or IV tumors are almost never surgical candidates.

217. Treatment In a Stage IV Lung Cancer, what are our options? Surgery? Radiotherapy? Chemotherapy?

218. Recommendations and Future Research Directions Treatment

219. Chemotherapy, cisplatin-based First-line therapy Good performance status and weight loss less than 10% of their body weight Side effects: Nephrotoxicity Nausea and vomiting Ototoxicity Electrolyre imbalance Treatment

220. Radiation therapy adjunct for operable patients with resectablediseases primary local treatment for patients with medically inoperable or unresectablediseases important palliative modality for patients with incurable diseases Treatment

221. Radiation therapy Side effects Minimal side effects Cytopenia Fatigue and nausea are uncommon Treatment

222. Treatment NCCN 2011 guidelines on NSCLC Commonly Used Doses for Conventionally Fractionated Radiation Therapy

223. 300 cGy/day x 10 days In the patient… reduced to 200 cGy/day x 5 day

224. Prognosis Overall median survival time: 10 months

225. Prognosis

226. Prognosis

227. Public health issues

228. Lung Cancer has been documented to be the most common type of cancer in the world for several decades. Globocan 2008 (Cancer Incidence and Mortality Worldwide in 2008, WHO-International Agency for Research on Cancer, http://globocan.iarc.fr/ )

229. Worldwide… the most common #1 #2

230. Among cases of lung cancers, prostate, breast, colorectal, LUNG CANCERhas the lowest 5-year survival rate. Cancer Trends Progress Report 2009/2010 update from the National Cancer Institute, http://progressreport.cancer.gov/doc_detail.asp?pid=1&did=2009&chid=95&coid=927&mid

231. Remember me?!?

232. YOSI KADIRI PICTURE CITY ORDINANCES RESOLUTION ON ANTI-SMOKING

233. YOSI KADIRI PICTURE CITY ORDINANCES Compelled to discontinue smoking Prohibited from smoking Mandated to educate patients Include smoking history

235. Lesson for today… “Sticks and stones can break my bones…” Grand Rounds Presentation

236. What if this is your baby?