nyu medical grand rounds clinical vignette rachel shur pgy-2 october 16, 2012 u nited s tates d...

NYU Medical Grand Rounds Clinical Vignette

Rachel ShurPGY-2

October 16, 2012

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DEPARTMENT OF VETERANS

AFFAIRS

• 56 woman who presented with 2 weeks of right foot numbness and weakness

Chief Complaint

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DEPARTMENT OF VETERANS

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•The patient was in her usual state of good health until approximately 1 month prior to presentation when she started experiencing intermittent headaches with associated nausea and vomiting. •Headaches became more frequent, occurring almost daily, worse in the morning•2 weeks prior to presentation, pt noted right foot numbness and weakness.•Presented to NYU after she had difficulty driving with her right foot.

History of Present Illness

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Additional History

•Past Medical History:•Gastroesophageal reflux disease

•Past Surgical History:•none

•Social History:•Lived with husband and 2 children, worked as real estate agent•No smoking or drug use, drank 2 glasses of wine per week

•Family History:•No family history of cancer or heart disease

•Allergies: •No Known Drug Allergies

•Medications:•Omeprazole 20mg daily

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DEPARTMENT OF VETERANS

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Physical Examination

•General: anxious, well appearing, no acute distress•Vital Signs: T: 97.8ºF BP:133/86 HR: 87 RR:14 and O2 sat: 99% on room air•Right foot: decreased sensation to light touch and pin prick on anterior and posterior aspect up to ankle, 4/5 strength on flexion and extension•Remainder of Physical Exam was normal

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DEPARTMENT OF VETERANS

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Laboratory Findings

•CBC: Hemoglobin 11.8 gm/dL / Hematocrit 34.2%

•Remainder of CBC was within normal limits

•Basic Metabolic panel: within normal limits

•Hepatic panel: within normal limits

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Other Studies

•CT and MRI brain revealed frontal lobe masses with edema and mass effect, but no herniation

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• The working diagnosis at this time was Gliobastoma Multiforme (GBM)

Working Diagnosis

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• Hospital Day 3:– Pt underwent resection of the right sided

lesion (pathology was consistent with glioblastoma multiforme)

• Hospital Day 10:– Pt developed deep vein thrombosis and was

started on Lovenox/Coumadin

Hospital Course

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Hospital Course

• Pre and post contrast MRI obtained 1 week post craniotomy revealed post-operative changes +/- residual tumor

• Pt was discharged on Hospital Day 15

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Hospital Course

• Within one month of surgery, she started focal external beam radiation therapy with concurrent temozolomide chemotherapy for a six week course (6480 cGy).

• Post radiation MRI revealed increased surrounding edema.

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DEPARTMENT OF VETERANS

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DEPARTMENT OF VETERANS

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DEPARTMENT OF VETERANS

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Disease Course

• The patient completed 6 cycles of adjuvant temozolomide prior to having progression of disease.

• She then had once cycle of BCNU chemotherapy complicated by anemia requiring transfusion.

• She was offered participation in a clinical trial with bevacizumab, after an IVC filter was placed and coumadin was discontinued.

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DEPARTMENT OF VETERANS

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Disease Course

• She had a dramatic response to bevacizumab therapy, maintained for 6 cycles.

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Disease Course

• A new lesion was detected, but additional treatment had to be interrupted in order to place a ventriculoperintoneal shunt for communicating hydrocephalus.

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DEPARTMENT OF VETERANS

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Disease Course

• The patient had further treatment delays for shunt related complications and intractable seizures. She was treated with enzyme-inducing antiepileptic drugs (EIAEDs).

• She developed clinical and radiographic progression of disease.

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DEPARTMENT OF VETERANS

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Disease Course

• Since her tumor over-expressed epidermal growth factor receptor (EGFR) and intact phosphate and tensin homolog gene (PTEN), she was treated with erlotinib despite being on EIAEDs.

• There was no response to erlotinib and she died several months later of progressive disease (~18 months from initial hospital admission).

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DEPARTMENT OF VETERANS

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Disease Course

• Gliobastoma multiforme

Final Diagnosis

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DEPARTMENT OF VETERANS

AFFAIRS