ARCHER NOTES

1. Chest Conference
9/20/2011
Matthew Hammar, DO
Pulmonary Critical Care Medicine Fellow
Allegheny General Hospital

2. JZ
 82 y/o WM prior smoker (40
pack-years, quit age 65) with
PMH of COPD, HTN, HLD,
CAD, PVD, Carotid Stenosis, 4
cm AAA, Colon Cancer s/p
resection 1999 and TIA…
 Presented to outpatient
pulmonary office 9/7/2011 for
ongoing evaluation of COPD &
RLL 1 cm pulmonary nodule.

3. JZ
 Pertinent ROS:
 Admits chronic cough productive
of clear sputum. Increasing DOE
and vague right-sided CP.
 Denies SOB at rest. Denies
hemoptysis, fevers, chills,
night-sweats or weight loss.

4. JZ
 CT scan done same day showed a
new (compared to 9/21/2010)
right upper lobe nodule.
 2.3 CM, spiculated RUL nodule.
 Scheduled to undergo navigational
bronchoscopy 9/13/2011.
 PET/CT scheduled 9/16/2011.

5. Physical Exam
VS: Afeb, HR 59, BP 105/65, RR 20,
SpO2 98% RA.
GEN: A&A&Ox3. NAD, ASA class II.
HEAD: NC, AT.
EENT: PERRL. Ears/Nose wnl.
Edentulous. Mallampati 2.
NECK: Supple, full ROM.
CV: RRR with grade 2/6 SEM over
tricuspid area.
LUNGS: Scattered rhonchi,
otherwise CTAB with wheezing or
rales.
ABD: Soft, NT, ND. BS present.
NEURO: CN II-XII intact.
EXT: No CCE. Radial pulse 1+/4
equal bilaterally

6. LABS
14.1
5.6
41
INR 1.1
190

7. CT & Pathology

8. CT/PET 9/16/2011
 Enlarged (1.5 x 1.4 cm) 2A LN
with increased SUV 6.6.
 RUL nodule (2.4 cm) SUV 14.4.
 Right hilar LN SUV 10.5.
 Paratracheal LN SUV 6.9.

9. PFT’s 9/7/2011
 FVC: Pre 3.51(102%)
& Post 3.46(101%)
 FEV1: Pre 1.90 (79%) & Post 1.95(81%)
 FVC/FEV1:
Pre (54%)
&
Post (57%)
 TLC: 5.86, Ref 5.61 (104%)
 DLCO: 11, Ref 17.9 (61%)
 “Moderate obstructive disease w/o
bronchodilator response”. Decreased
diffusion capacity impairment.

10. NSCLC
 Any type of epithelial lung
cancer other than small cell
lung cancer (SCLC).
 3 most common types of
NSCLC are:
1) Squamous cell carcinoma
2)Adenocarcinoma
3)Large cell carcinoma, and
adenocarcinoma

11. NSCLC
 There are several other
types which occur less
frequently, and all types
can occur in unusual
histologic variants
 See figure on next slide

13. Sarcomatoid carcinomas are a group of
poorly differentiated non-small cell lung
carcinomas that contain a component of
sarcoma or sarcoma-like (spindle and/or
giant cell) differentiation.

14. Sarcomatoid carcinomas
 Rare accounting for ~0.31.3% of all lung
malignancies
 Average age onset 60 y/o
 Male:Female = nearly 4:1
 Etiology ~smoking,
carcinogens

15. Sarcomatoid carcinomas
 Sarcomatoid carcinomas can
arise in the central or
peripheral lung, though a
predilection for the upper
lobes has been reported

16. Sarcomatoid carcinomas
 Signs and symptoms are
related to tumor location
Eg: Central endobronchial
tumors tend to protrude
into the lumen of large
airways, causing cough,
hemoptysis, progressive
dyspnea and postobstructive pneumonia

17. Sarcomatoid carcinomas
 Signs and symptoms are
related to tumor location
Eg: Peripheral tumors,
(especially pleomorphic
carcinoma) grow to large
sizes and often present
with chest pain due to
pleural or chest wall
invasion

18. Giant Cell Carcinoma
 Characterized as “Very
aggressive” and
metastasize.
 Survival depends on staging.

19. Place Holder
• Did he have a PET scan…
• I presume serial CT scans…

20. JZ
 PMH: HTN, HLD, CAD, PVD,
Carotid Stenosis, COPD, 4 cm
AAA, Colon Cancer, TIA, HOH,
BPH
 PSH: CABG 2/19/2007, ureteral
implant 2/8/2007, Right CEA
10/24/2007, bilateral cataract
extraction 2006, LOA 2001,
Subtotal colectomy 1999, Right
LE arterial stent NOS.

21. JZ
 Fam: Mother had lung cancer.
Father & brother had colon
cancer.
 SOC: 40 pack-years smoking;
quit age 65. Married. Retired
glass worker. Builds birdhouses
as hobby therefore sawdust
exposure.

22. JZ
 Rx: Lopresor, Zocor, Zetia,
ASA, Spiriva, Singulair, Fish
Oil, Rapaflo.
 Allergies: NKDA.