Clinical Pathological Conference“TO BE OR NOT TO BE”

Kartikya Ahuja, M.D.Chief ResidentDepartment of MedicineNYU School of MedicineJuly 20th, 2007

Chief Complaint

• A 45 year old Chinese male presents with chest pain and dyspnea for 10 days

History of Present Illness

• The patient’s history begins at age 20 when he began to smoke 1 pack of cigarettes daily. He continues to smoke presently.

• At age 25 he was hospitalized in China for “fluid in the lungs” and a “chest infection.” He reports he received antibiotics that required hospitalization for six months, and made a full recovery.

• At age 38 he immigrated to the United States and worked in a restaurant. The same year he was diagnosed with peptic ulcer disease requiring a partial gastrectomy which was performed without complication.

History of Present Illness:

• He was in his usual state of good health until 10 days prior to admission when he began to feel pleuritic chest pain, dyspnea and fevers. He also reported a non-productive cough. No rigors. He sought treatment from a local health care practitioner who prescribed a Chinese herb. The patient took the herb for several days without alleviation of symptoms. His symptoms worsened, now associated with increasing fatigue.

• He reports no sick contacts, recent travel, headaches, dysuria, abdominal pain, nausea, vomiting nor diarrhea. The dyspnea was worsening, and the patient presented to Bellevue Hospital Center for further care.

• Past Medical History: as per HPI

• Past Surgical History: as per HPI

• Medications: An unknown Chinese herb for one week

• Allergies: none

• Family History: Father alive with history of CVA, Mother alive with no known medical history

• Social History: Born in China. No alcohol use. No elicit drug use. Lives with a friend. Not married. Sexually active with a female.

• Review of Systems: otherwise negative.

Physical Exam

• well developed, in acute respiratory distress, diaphoretic• BP 106/74, HR 103 and regular, RR 24, Temp 99.6, oxygen

saturation 94% on room air• Oropharynx clear• No lymphadenopathy• JVD to mandible• No rashes• Lungs clear• Tachyardic, regular, no murmurs• Normal bowel sounds, soft, non-tender• No clubbing, cyanosis nor edema

Laboratory Data

EKG

Defending Diagnoses

• Pulmonary Tuberculosis (9) - Elana Rosenberg • Pulmonary Embolism (6) - Bobby Tajudeen• Tuberculous Pericarditis (5) - Tian Gao • Small Cell Lung Cancer (1) - Carolyn Seib

• Other Diagnoses:- bacterial pneumonia

- pulmonary sarcoid

- pericarditis

Radiology

Jane Ko, M.D.

Associate Professor of Radiology

Department of Radiology

Faculty Discussion

David Chong, M.D.

Assistant Professor of Medicine

Division of Pulmonary and Critical Care

Pathology

Hua Chen, M.D.

Department of Pathology

BC07-2970 Pericardial fluid

5/14/07

BC07-3484Pericardial fluid

6/7/07

BC07-3484Pericardial fluid, Cell block

6/7/07

AE1/AE3 CEA

CK7 Mucin

BS07-4184Pericardium

6/06/07

BS07-4184 Pericardium

6/06/07

AE1/AE3

Final Diagnosis

pulmonary adenocarcinoma with metastasis

Carcinoma of the Lung

• Primary carcinoma of the lung is the leading cause of cancer death in the United States

• 90% of cases are in current or former smokers• The 5-year lung cancer survival rate is 14%• Histology:

– Adenocarcinoma (32%)– Squamous Cell Carcinoma (29%)– Small Cell Carcinoma (18%)– Large Cell Carcinoma (9%)– Others (12%)

Pulmonary Adenocarcinoma• The most common lung cancer; also the most

common lung cancer to develop in younger patients (age < 45 years) and non-smokers

• Usually located peripherally – frequently with pleural involvement

Pulmonary Adenocarcinoma

• Most patients are symptomatic at presentation– cough (45-75%), dyspnea (33-50%), chest pain (25-50%)

– hemoptysis is less common

– symptoms related to intra-thoracic spread• pleural effusions (pleural invasion or lymphatic obstruction)

• pericardial effusions (pericardial invasion)

• superior vena cava syndrome

• brachial plexus involvement

– symptoms related to distant metastasis

– symptoms related to paraneoplastic syndromes

Pulmonary Adenocarcinoma

• Aside from local invasion and regional spread, pulmonary adenocarcinoma can spread transbronchially, producing significant respiratory distress (dyspnea, hypoxemia and sputum production)

• Metastasis may occur to any organ

Treatment (non-small cell lung cancer)• Treatment decisions are based primarily upon the histology, categorized as

either small cell or non-small cell carcinoma, and the stage of the tumor.

• Non-small cell lung cancer (i.e. adenocarcinoma)– Stage I: Surgical resection is the preferred management.

– Stage Ib: Adjuvant chemotherapy is recommended.

– Stage II: Surgical resection plus adjuvant chemotherapy.

– Stage IIIa: Generally not treatable with primary resection alone. Frequently managed on an investigational protocol, which may include surgical

resection after initial chemotherapy, with or without radiotherapy.

– Stage IIIb: Managed according to a variety of options, ranging from symptom-based palliative therapy, chemotherapy, or to combined modality

therapy with radiotherapy and chemotherapy.

– Stage IV: Primarily managed with chemotherapy or a palliative, symptom-based approach. New chemotherapy regimens are currently

investigational. Resection of an apparent metastasis may be appropriate if it is solitary and/or if there is a suspicion that it could represent a second primary neoplasm.

Survival

Pathogenesis of Mr. L’s Disease

tobacco exposure(carcinogen)

sequential genetic mutations(tumor promoter)

malignant cell transformation

tissue invasion with metastasis

development of pericardial effusion

dyspnea, fatigue, pleuritic chest pain

cough and recurrentpleural effusions

jugular venous distention

respiratory arrest

Follow-up

• An echocardiogram showed tamponade physiology, and the patient was admitted to the CCU for a pericardiocentesis.

• After diagnosis he developed recurrent pericardial and pleural effusions requiring a pericardial window and repeat thoracentesis. A bronchoscopy confirmed the diagnosis.

• His course was complicated by the development of bilateral pulmonary emboli.

Follow-up

• Further workup revealed metastasis to the brain, for which he was treated with palliative radiation.

• His disease continued to progress, with recurrent large pleural effusions causing multiple episodes of respiratory distress.

• The patient died on July 2nd 2007

Thank You

Anthony Grieco, M.D.David Chong, M.D.

Jane Ko, M.D.Hua Chen, M.D.

Josh Olstein, M.D.