Morning ReportMorning ReportOctober 27, 2009October 27, 2009

Physical Exam Vitals: T 98, BP 117/71, P 62, R20 O2 Sat 98% RA General: alert, oriented, appears tired, but NAD. Skin: no rashes. HEENT: AT/NC, Eyes: EOMI, PERRLA, no icterus. OP: clear, no lesions. Neck/Thyroid :supple, no LAD or masses. Cardiac: RRR no m/r/g. Chest/Lungs: Decreased BS LLL with coarse crackles LLL Abdominal: soft, NT/ND, BS+, No HSM Back: no deformities or spinal tenderness to palpation Extremities: WWP, trace edema, pulses strong and equal bilaterally. Neurological: Alert and oriented x3, Cranial Nerves II-XII intact. LE strength-

proximal and distal 3-4/5 on right. left 5/5. R & LUE 5/5. Mild right pronator drift. Sensation intact to light touch. Patella reflex on right 3+, left 2+. 3 beats of clonus on right. No babinski. Gait-ataxic, unsteady.

Laboratory

WBC 17.1 (71% N, 12% L, 7% B)

Hb 11.1 (MCV 80)

Plts 300

BMP entirely normal

CRP 131

ESR 58

Diagnosis:

Age-adjusted cancer death rates – US Lung CA – 160,000/yr1.2 million deaths/yr world wide

Men Women

Lung Cancer – Clinical Presentation

10 % asymptomatic at presentation

Metastases Bone – 20%

Pain, pathological fracturesHypercalcemia

Liver – 50%Pain, elevated transaminases

Brain – greatest with adenocarcinomaHA, vomiting, neurological symptoms, mental status

changes

Adrenal glands – 40% Spinal Cord

Compression symptoms – pain (96%), motor weakness, autonomic dysfxn, sensory loss

Risk Factors

Smoking90% lung cancer

Radiation Tx Environmental

Asbestos, radon

Pulmonary fibrosis Genetic

NSCLC

85-90% Lung Cancer 3 subtypes

Adenocarcinoma ○ Most common○ Peripheral lesion

Squamous cell carcinoma○ 25-30% lung cancers○ Central lesion

Large cell carcinoma○ 10% lung cancers

Adenocarcinoma

Squamous Cell

Diagnosis/Staging

Imaging – CXR, CT chest/abd minimum Symptoms – MRI, bone scan Tissue Diagnosis

Central ○ Sputum – up to 40% false negative○ Bronchoscopy

Peripheral - CT guided needle bxLymph node bx - Mediastinoscopy/Endobronchial US

Staging – Pleural Effusion - thoracentesisDistant metastases – PET scanMediastinal LAD - PET (sens 84%/sp 89%) > CT

Staging Stage I

No nodes or mets > 2 cm from carina

Stage II Locally advanced disease

○ Chest wall, diaphragm○ Nodes – ipsilateral hilar nodes

No mediastinal involvement

Stage III Mediastinal involvement A – mediastinal nodes - ipsilateral B – Invasion of medistinum

○ heart, great vessels, trachea, effusions○ nodes contralateral or supraclavicular

Stage IV - Distant Metastatic

5-year survival

A 60 yo woman is evaluated for a persistent , non-productive cough of several months. She has a 40 pack-year smoking history, but she quit 10 years ago.Her vital signs are BP 120/80, HR 60, RR 18. Physical exam is entirely normal.

CXR and CT scan confirm a 4-cm LUL nodule with irregular borders that was not present on CXR 2 years ago. PET scan shows uptake only in the pulm nodule and no obvious metastasis. Thoracotomy results in left upper lobectomy in which a 4-cm moderately differentiated adenocarcinoma is removed. The margins are clear.

Which of the following is the mostappropriate next step in management?

A. No further treatment

B. Radiation therapy

C. Chemotherapy

D. Erlotinib

E. Monthly bisphosphonate

A 68 yo man is evaluated for hemoptysis, increasing weakness, and a 13.5 kg weight loss over 4 months. He is WC-bound b/c of severe weakness and has been bedbound for 1 week. He has an 80-pack-year smoking history.

PE: BP 120/80, HR 72, RR 18. Abdomen, heart, lung exams are normal. A radiograph and CT scan of head, chest, abdomen, and pelvis show a 10-cm right perihilar lymph node mass with involvement of multiple mediastinal lymph nodes and more than ten 2-3 cm hepatic metastases, but no brain mets. Bone mets are too numerous to count. Squamous cell carcinoma is confirmed by bronchoscopic biopsy.

Which of the following is the most appropriatenext step in the management of this patient?

A. Hospice referralB. Radiation & bisphosphonate C. Chemo & bisphosphonateD. Chemo, radiation, and

bisphosphonateE. Lung tumor resection, chemo,

radiation, and bisphosphonate

Treatment Stage I and II – Resection + chemo

Stage IIIA – chemo +/- radiation resectable

Stage IIIB – unresectable (selected cases surgery)

Stage IV – chemo and/or supportive care, palliative radiation

Screening – no screening test has been shown to reduce mortality from lung cancer