OS 213SGD 01: MALIGNANCY

OS 210LEC 0X: TITLE

OS 213: Human Disease Treatment 3 (Circulation and Respiration)SGD 01: MALIGNANCYExam 3 | Med Onco Preceptors | August 23, 2012

TransersUPCM 2016: XVI, Walang Kapantay!3 of 5

\\CES, MIKKI, JOLOUPCM 2016 B: XVI, Walang Kapantay!4 of 5

OUTLINE I. Case 1II. Case 2III. Case 3IV. Case 4V. General Notes

CASE 1R.S., 50, MCC: Right lung nodule

HPI: 2 mo PTC CXR done for employment purposes revealed a solitary pulmonary nodule measuring approx. 2 cm Px denied other symptoms except for an occasional dry, non-productive cough diagnosed with PTB and was given anti-TB meds regularly taken for 2 months After 2 months repeat chest X-ray was done and revealed an increase in the size of mass to 3cm chest CT scan revealed 3.5 x 2.8 cm enhancing mass at SUPERIOR SEGMENT OF R UPPER LUNG. (-) enlarged peribronchial, hilar, mediastinal nodes still no other symptoms except for occasional dry cough

PMHx: Unremarkable (U/R)PSSx: (+) Smoking: 1 pack/day for 20 years (20 pack years)ROS: (-) anorexia, headache, weight loss, back pain, hemoptysisPE: (-) palpable lymph nodes, Clear lung fields, U/R abdomen

Diagnosis(Note from the transers: Case 1 contains all general data applicable to lung malignancies. Italicized and underlined phrases are applicable to Case 1.)

As with diagnosing any disease condition (in this case, and in all other cases you will encounter), the most crucial initial step is a thorough history and physical examination.

By Hx:Sx of lung cancer can arise from 1. Local mass effects and systemic effects Symptoms related to tumor itself: hemoptysis and chest pain Constitutional non-specific symptoms such as: anorexia, weight loss, fevers/night sweats Tumor mass effects such as cough due to nerve irritation, hoarseness due to compression of recurrent laryngeal nerve, and facial/upper extremity syndrome2. Effects of metastatic disease bone, pleura, brain, liver, and adrenal glands3. Effects of products produced by the tumor (paraneoplastic syndromes). *Most lung cancers arise in patients with a long smoking history; the symptoms of cough and dyspnea are relatively non-specific. However, an acute change in previously stable symptoms can be a clue to an underlying malignancy.

By PE:Classic PE findings associated with lung CAs: Horners syndrome (sympathetic ganglion dysfunction with ptosis, miosis, enopthalmos and anhydrosis) A supraclavicular mass due to a Pancoast tumor (apical tumor involving C8 and T1-2 nerves causing shoulder pain radiating down to the arm) SVC syndrome (upper extremity swelling with or without facial swelling due to vascular obstruction) Clubbing of fingers and adenopathy - suggestive (but not pathognomonic) of an underlying malignancy.

Table 1. Diagnostic ProceduresChest X-Ray tumor in the lungs enlargement in the mediastinum due to enlarged lymph node opacity or white-out lung may indicate presence of malignancy or tuberculosis other thoracic causes

Chest and Abdominal CT Scan localizing tumors, especially central masses not visualized in chest X-ray metastasis (if present) commonly in the brain and adrenal glands determining the presence of fluid assist in biopsy procedures (CT GAB)

Positron Emission Tomography (PET) Scan visualize tumors 45 years old, with history of smoking, presenting with a solitary pulmonary nodule, should always be considered to have lung CA unless proven otherwise.)

Staging(Note: See the Lecture trans on Overview of Lung Malignancies for this part.)

Tumor tissue obtained:1. By bronchial/transbronchial biopsy during FOB2. By node biopsy during mediastinoscopy3. From operative specimen at the time of definitive surgical resection4. By percutaneous biopsy of enlarged lymph node, soft tissue mass, lytic bone lesion, bone marrow or pleural effusion5. By FNAB (CT Guided) Preferred for this Px because of the peripheral location of the lesion6. From adequate cell block from a malignant pleural effusion

TNM Classification: used in staging NSCLCs

Cancer Staging: Using the TNM guideline: T1 N0 M0 Stage IA

3.5x2.8 cm superior RUL, no note of enlarged peribronchial, hilar or mediastinal nodes; But needs other modalities to rule out possible metastasis

(Note: Patients usually come in late or advanced stages, seldomly early)

ManagementCounseling together with the patients family 3Cs: Coping, Communicating, Connecting ADVISE TO QUIT SMOKING!!! Good balanced diet, exercise Avoid cancer risks: asbestos, radiation explaining his condition: natural history of the disease (stage of his disease), prognosis, treatment options

Intervention Options Surgery - considered if cancer is only small and localized to one tumor nodule Pneumonectomy Lobectomy - preferred operation for SCLC Segmentectomy Radiation Therapy - given in patient with SCLC in the ff situations: In combination with chemotherapy: treat the tumor and lymph nodes in the chest; improve 3-year survival rates, especially in patients less than 65 years old After chemotherapy: kill any small deposits of cancer that may remain Chemotherapy - main treatment for SCLC. (Note: For more complete lists and details on the drugs used by Lung Cancer patients, see the Lecture trans on Overview of Lung Malignancies) Targeted Therapy

Complementary Methods and Palliative Care Given after chemotherapy sessions and throughout treatment as an adjunct to therapy, or to reduce the side effects. Help the patient feel better and add to patient's comfort Ex. meditation to reduce stress, acupuncture to relieve pain, peppermint tea to relieve nausea,aromatherapy, massage therapy, yoga. Pain medication, palliative care, symptomatic therapy (for difficulty breathing, etc.) can also be given as necessary. Group Counseling/Therapy

Follow-Up Check-up every 2mo post-treatment CA patients should be educated about signs and symptoms of recurrence and potential adverse effects related to therapy Monitoring with: CXR, Chest CTSc Liver UTS every 6 months Bone scan every year Cranial CTSc if with frequent headache or signs of inc. ICP

CASE 2

65, M, FilipinoCC: Cough, mild difficulty of breathing, and progressive hip pain

HPI: CXR revealed pulmonary mass at the R upper lung with 2 nodules on the L upper and mid-lung fields.

PMHx: U/RPSSx: (+) smoking: 40 pack yearsROS: (+) facial swelling upon awakening, weight loss, anorexia(-) headache, abdominal pain, or hemoptysis

PE: 2x2 cm hard, fixed right supraclavicular node, decreased breath sounds at the right upper lung field with dullness to percussion, and occasional inspiratory wheezing on all lung fields.

Diagnosis

Table 2. Differentials (Case 2)DiseaseReason for R/IReason for R/O

SCLC (+) Pulmonary mass (+) Cough (+) Dyspnea (+) Facial swelling (plethora) (+) Weight loss Smoking hx: 95% of CA associated with a chronic smoking Hx is SCLC Presence of nodules at R and mid-upper lung field Hard, fixed R supraclavicular node (-) ankle edema (-) muscle weakness (-) polyuria, polydipsia Facial swelling improves (in small cell CA, it does not improve due to constant hormone production of the tumor)

NSCLC(Squamous cell) (+) Pulmonary mass (+) Cough (+) Dyspnea (+) Facial swelling (+) Weight loss Smoking hx Presence of nodules at R and mid-upper lung field Age, SexNo reason to rule out yet (histopathologic examination needed for differentiation)

Adenocarcinoma (+) Pulmonary mass (+) Cough (+) Dyspnea (+) Facial swelling (plethora) Adenocarcinoma, although more common than squamous cell CA, is more prevalent in women, nonsmokers Mass is central (vs. Adenocarcinoma which is more peripheral)

Primary Working Impression: non small cell, squamous cell lung CA 65 yo, M, Smoker, with Pulmonary Mass probably malignancy! Cough, dyspnea Common manifestation of pulmonary disease; could be due to compression of airway by a mass in this case Facial swelling upon awakening Could be due to the compression of the Superior Vena Cava (SVC syndrome) by the mass on the right upper lung while on supine position (sleeping) Weight loss, anorexia Effect of cancer Two nodules on L upper & mid lung field Metastasis to the L lung Hard, fixed R supraclavicular node Nodal metastasis from R lung Progressive hip pain Metastasis to the hip boneDiagnostic Procedures CXR and Chest CT Scan Abdominal and Cranial CT Scan, Bone Scan: detect metastasis Biopsy: FNAB of the supraclavicular node, Bronchoscopy of mediastinal lymph nodes (for possible metastasis; the more specimens, the better!) PET scan: detects widespread metastases; but again, expensive! Sputum cytology: if (+), R/O head and neck primary lesions

Ancillary Tests: mainly for detection of paraneoplasms Serum ACTH Cushingoid syndrome; R/O ACTH-producing small cell CA Blood chemistry, ABG (to look for hypokalemic alkalosis) CBC BUN-Creatinine Clearance: to check whether or not the kidneys are competent to filter nephrotoxic CA drugs (platinum waste)

Staging T4N3M1 Stage IV Lung CA T4 2 x 2 cm hard supraclavicular node N3 involvement of mediastinal and contralateral lymph nodes M1 presence of metastasis to supraclavicular node and hip Very poor Prognosis Median survival for untreated patients with Stage IV bronchogenic CA: 4-6 months 5-year survival rate: 2% Survival time impkroves with chemotherapy and other targeted therapies

ManagementCounseling(see Case 1 > Management > Counseling)

Intervention Options Symptomatic Management pain: give non-opioids first before moving on to stronger drugs like morphine when the pain is already unbearable cough (and hemoptysis): can be treated pharmacologically Palliative radiotherapy FOR: Bronchial obstruction with pneumonitis, hemoptysis, upper airway or SVC obstruction brain or spinal cord compression (important!), or painful bony metastases. It provides relief of intrathoracic symptoms: Hemoptysis (84%), SVC syndrome (80%), Dyspnea (60%), Cough (60%), Atelectasis (23%), Vocal cord paralysis (6%) Also for: cardiac tamponade, painful bony metastasis, CNS compression, brachial plexus involvement Chemotherapy: Palliates symptoms, improves QOL, and improves survival in newly-diagnosed patients First-line: Cisplatin or Carboplateine, Texane (paclitaxel, docetaxel), Gemicitabine Second-line: Docetaxel or pemetrexed Growth factor support is rarely needed EGFR Targeted Therapy: Erlotinib (2nd or 3rd line) Prolong ssurvival, Second or Third line therapy Very expensive Management for Bone Metastasis Radiotherapy Bisphosphonates: reduce secondary close, prevent Complementary Methods and Palliative Care

(Note: In squamous cell lung CA, you will not give Bevacizumab (which is an angiogenesis inhibitor) will cause the patient to bleed out)

CASE 3

52, MCC: non-productive, associated with back pain.

HPI: 1 mo PTC Non-productive progressing cough, assoc. pleural chest pain 10 days PTC (+) Hemoptysis, Fatigue, Anorexia

PMHx: U/RPSSx: (+) smoking: 10 pack year

ROS: (+) 30 % weight loss; (-) headache, abdominal pain, back pain

PE: Slightly cachexic, no palpable nodes, occasional wheezing at all lung fields

CXR: Large bulky mass with hilar adenopathy

CT Scan: 3x5 cm tumor invading the R main bronchus, 3 cm distal to carina Atelectasis at hilar region Enlarged ipsilateral hilar and mediastinal lymph nodes

Diagnosis

Table 3. Differentials (Case 3)DiseaseReason for R/IReason for R/O

Bronchogenic CA (SCLC) 10 pack-year smoking (+) unproductive cough for 1 mo (+) occasional pleuritic chest pain (+) Hemoptysis (+) Anorexia, weight loss (+) wheezing in all lung areas on PE Large bulky mass with hilar adenopathy on CXR 3x5 tumor invading R main bronchus Enlarged ipsilateral hilar and mediastinal lymph nodes Atelectasis at hilar region on CT

Pulmonary Tuberculosis 10 pack-year smoking (+) unproductive cough for 1 mo (+) occasional pleuritic chest pain (+) Hemoptysis (+) Anorexia, weight loss Large bulky mass with hilar adenopathy on CXR (-) night sweats, fever no tests done for AFB smear/culture

Pulmonary embolism 10 pack-year smoking (+) unproductive cough for 1 mo (+) occasional pleuritic chest pain (+) Hemoptysis (-) evidence of effusion (transudative or exudative) no reported dyspnea

Pneumonia (+) unproductive cough for 1 mo (+) occasional pleuritic chest pain (-) no PE findings of consolidation, abnormal breath sounds

Primary Working Impression: Small cell lung CA Arises in peribronchial locations and infiltrate the bronchial submucosa Usually occurs in the big airways (hilar & central) Very rapid progression and highly malignant Smoking is a risk factor (as well as being male) Common spread is to the mediastinal lymph nodes, liver, bones, adrenal glands and brain

Diagnostic Procedures CXR, CT Scan Biopsy: Bronchoscopy with biopsy, CT scan-directed needle biopsy, Endoscopic esophageal ultrasound w/ biopsy, Mediastinoscopy w/ biopsy, Open lung biopsy, Pleural biopsy Ancillary Tests: CBC with platelet count, Serum electrolytes, glucose, calcium, Liver Function Tests (ALT, AST), Renal Function Test, ECG, Bone Scan, PET Scan

StagingTNM Classification is not used in staging SCLC. Instead, we describe the malignancy as Limited or Extensive Limited Limited to one side of the chest Can be treated with sufficient radiation therapy Prognosis: 20 months, 2-year survival rate of 25%, 5-year survival rate of 20% Extensive Spread to other side and/or other distant organs (including pleural/pericardial effusion or hematogenous metastases) Prognosis: 12 months, 2-year survival rate of 4.6%

Confinement to one Hemithorax Limited-Stage Disease

ManagementCounseling(see Case 1 > Management > Counseling)

Intervention Options Chemotherapy: Etopside +cisplatin / carboplatin CRx doses may be adjusted on the basis of nadir granulocyte counts Blood work +CBC is needed prior to each cycle of chemotherapy to ensure marrow recovery before the next dose of chemotherapy is administered. Serum LDH is a good marker for response and should be monitored. Renal function should be monitored because of nephrotoxicity from cisplatin. CT scans should be obtained after 2 cycles of therapy to assess response (if afforded) Radiotherapy In combination with Chemotherapy Main treatment for our case will consist of combination Chemotherapy and chest irradiation (etoposide plus cisplatin plus 45 Gy chest radiation therapy). PROPHYLACTIC BRAIN RADIATION THERAPY (PBRT) Lung CA can metastasize to the brain around 60% of controlled lung CA PBRT reduces the chance of metastasis to the brain Px should be advised of the possible cognitive deficits as a result of PBRT Supportive and Other Considerations: Antiemetics, Fluid support with Cisplatin, Monitoring for blood counts and blood chemistry, signs of bleeding and infection, Possible Blood Transfusions for the hemoptysis (if massive), Nutrition therapy for signs of cachexia, Analgesics (for the pleuritic chest pain), Cough suppressants, if cough becomes uncomfortable, If required, use of hemopoietins (treatment for anemia) Complementary Methods and Palliative care

CASE 4

55, MCC: Chronic cough and weight loss

HPI: 5 mo PTC: chronic cough and weight loss

PMHx:Ischemic Heart Disease diagnosed 2 years ago Tx: isosorbide mononitrate and aspirin No recent attacks of chest pain

PSSx: (+) smoking, alcohol (occasional)

ROS:(+) occasional hemoptysis, exertional dyspnea, 30% weight loss, anorexia, occasional right sided pleuritic chest pain(-) headache, back pain, facial swelling, abdominal pain, orthopnea, and PND.

PE: pale palpebral conjunctivae, no palpable cervical or supraclavicular nodes, decreased breath sounds at the right upper lung fields with dullness to percussion over said area, and an unremarkable abdomen.

CXR: (+) density at the right apex

Chest CT Scan: 5.5x6.8 cm mass with right perihilar and subcarinal lymph node enlargement. Diagnosis

Table 4. Differentials (Case 4)DiseaseReasons for R/IReasons for R/O

NSCLC (squamous cell CA) (+) chronic cough (+) worsening or new dyspnea (+) weight loss (+) hemoptysis (+) pleuritic pain (+) decreased breath sounds; dull on percussion Cachexia and weight loss suggest systemic spread Subcarinal and perihilar lymphadenopathy (bronchogenic CA) No reason to rule out yet (histopathological examination of biopsy sample needed)

Small cell lung carcinoma (SCLC) (+) chronic cough (+) worsening or new dyspnea (+) weight loss (+) hemoptysis (+) pleuritic pain (+) decreased breath sounds; dull on percussion Cachexia and weight loss suggest systemic spread Usually presents with central endobronchial tumor (-) headache upon consult

Pulmonary Tuberculosis Smoking hx (+) cough, hemoptysis (+) chest pain (+) weight loss, anorexia (+) perihilar and subcarinal lymphadenopathy (remember Rankes complex) (-) night sweating (-) orthopnea, PND

Primary Working Impression: Squamous Cell Carcinoma Presence of respiratory symptoms due to a possible lung tumor (cough, dyspnea, hemoptysis - possible rich blood supply of tumor) decreased breath sounds at the right upper lung fields with dullness to percussion Signs suggesting the presence of a malignancy: weight loss, anorexia, lymphadenopathy Imaging studies reveal a mass at the right apex History of smoking

To rule in: PTB (difficult to rule out unless patient is asked to have sputum AFB and/or culture)

Diagnostic Procedures CXR, CT Scan PET Scan, Cranial and Abdominal CT or MRI, Bone Scan, CT Scan for Adrenals CBC with platelet count: check for hemodynamic stability patient presented with pale conjunctive and hemoptysis, which is not yet quantified. Px may present with a bleeding mass due to the high vascularity of a carcinoma. Biopsy Sputum Cytology/Examination if its squamous cell CA, it is likely that it will be detected using this procedure Ancillary tests

Staging T2bN2M0 Stage IIA T2B: Tumor is >5 cm, does not directly involve carina; invades visceral pleura N2: metastasis to ipsilateral mediastinal and/or subcarinal lymph nodes M0: no distant metastasis (based on PE findings; ideal = radiographic image of lymph nodes)

ManagementCounseling(see Case 1 > Management > Counseling)

Intervention Options Surgical resection with lymph node dissection may have poor results because of node involvement Some oncologist conclude that surgery should only be conducted in patients who have clearing of the mediastinal nodes after adjuvant therapy Chemotherapy followed by Radiation Therapy (Tx of choice) Cisplatin-based combination (with etoposide) Improved survival compared with sequential therapy but more side effects such as fatigue, esophagitis and neutropenia Supportive Therapy: Pain relief, Emesis therapy, Ondansetron, Prochloroperazine, Dexamethasone, Nutritional intervention Complementary Methods and Palliative Care

GENERAL NOTES

On History and PE:Getting a good history and PE is important since most CAs metastasize to the lungs. For women, usually comes from breast cancer, and for men, rectal cancer. Before doing treatment for Lung CA, always check for CA in other locations.

On Doing a BiopsyDo a biopsy to check for possible malignant cells then classify what type of cancer; always opt for the most accessible biopsy (e.g. lymph node) FNAB CT-guided biopsy (CT GAB): for peripheral masses Bronchoscopy-guided biopsy: for central (hilar or mediastinal) masses VATS as a last resort if you're absolutely positive that there's a malignancy but other the methods have failed to give a positive resultOn Staging and Treatment:Stage dictates treatmentStage 1: Surgery then chemo (Don't do radio)Stage 2: SurgeryStage 3A: Chemotherapy then surgeryStage 4: Chemotherapy and Radiotherapy; palliative

On Other diagnostics: Do a brain CT scan for small cell carcinoma because it is very malignant Sputum cell cytology is seldom used as a diagnostic measure; do biopsy instead

On Patient Workups: Before doing biopsies, do PT, PTT test to see if there are any bleeding disorders Must have cardiopulmonary clearance (ECG, etc.) before having a bronchoscopy Platinum-containing anti-cancer drugs are nephrotoxic (also hepatotoxic) - check kidney function via BUN/Creatinine CBC is done to see if the patient has recovered from chemotherapy

On Other Treatment: Chemotherapy and Radiotherapy requires good performance status (i.e. children) otherwise the patient might die from the treatment Erythropoietin transfusion can increase the risk of stroke and ischemia if given at the wrong dose. Proper regimen is high dose erythropoietin once a week. Combine chemotherapy with other forms of therapy like anti-angiogenesis drugs and radiotherapy, etc. Leads to a better outcome

Others: Sarcoidosis is rarely a viable differential in the Philippines Always get a good history; the lung malignancy might only be secondary

END

Ces: Here it is, from 9 pages of pure redundancy, tenen! Haay. Antoxic tuloy magreorganize. Tinoxic ko rin yata ang sarili ko sa pag-aayos ng isang trans na hindi naman babasahin ng mga tao. T___T Sana ganito pa rin ung cases sa future, para purposeful naman ang pagpapaka-OC ko sa trans na to. Haha. Kung hindi, ohwell.

At dahil smileys na lang ang greetings nina Mikki at Jolo, uubusin ko na lang ang space na to. Not. Kalahati na lang siguro.

Hello Block B! Kumusta naman ang weekly transing natin?Hello 2016! 2nd place ang EPIMERS sa FATE! XVI: Walang Kapantay!Hello Medchoir 2016! Fun fun fun (and eat eat EAAAAT!) in San Juan! Sana next time makapunta na tayong lahat for more chikahan. Hahaha! Mag-ipon na lang muna tayo ng mga ala-The Buzz na mga tanong sa ngayon. ;)

Mikki, Jolo: TransersUPCM 2016: XVI, Walang Kapantay!3 of 5

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