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NYU Medical Grand Rounds Clinical Vignette
Lisa Cioce MD, PGY-2
March 10, 2010
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
A 67-year-old man presents with a persistent cough for 6 months.
Chief Complaint
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• 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.
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
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• 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.
Additional History
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Past Medical History• Hyperlipidemia
Past Surgical History• Rotator cuff repair
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
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Aspirin 81 mg daily
Simvastatin 80 mg at bedtime
Zolpidem 5 mg at bedtime
Allergies: No known drug allergies
Physical Examination
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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
Laboratory Studies
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• 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)
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
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
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.
Staging
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
• 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.
Outpatient Treatment
• The patient was treated with an outpatient chemotherapy regimen of cisplatinum, pemetrexed and zolendronic acid.
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Final Diagnosis
Stage IV lung adenocarcinoma with bony metastatic disease