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Case Study Prepared by Todd Charge

Section Manager Nuclear Medicine & PET Centre

Background SN, 49yr old male

Presented to GP with 4/52 history of – SOBOE – Rt sided chest pain on inspiration – night sweats – 10kg weight loss – non-productive cough – 10year history of smoking (22 yrs ago) – 1 ½ packs/day – previously well

Background GP diagnosis of pleurisy on clinical examination

Treated with a single course of antibiotics

Re-presented to GP rooms one week later with no resolution of symptoms

CXR requested by second GP

Imaging CXR showed

– Rt Pleural Effusion

– Rt side mid zone lung mass measuring 6.5cmx4cm

– CT chest suggested

Imaging Chest CT showed

– lobular soft tissue mass seen in the right mid zone measuring about 78 x 62mm

– its lateral surface is in contact with the pleural cavity

– consolidation could be seen in the right middle lobe

– multiple oval soft tissue densities noted in keeping with prominent mediastinal lymph nodes. There is a large soft tissue mass lesion seen in the right hilar region

Morbidity & Mortality Lung Adenocarcinoma

Stage IIIb: T(any), N3, M0

Stage 3b – 50% living at 12 months

5year survival 10%

Plan PET

VAT

Combined chemotherapy and radiation therapy

Imaging PET

Imaging PET

Imaging Large irregular uptake mass in Rt lung

Focus of abnormal uptake in Rt hilum

Two foci of low grade upgrade in Rt neck

Avid irregular uptake in almost entire Rt lung pleura

Plan PET

VAT

Combined chemotherapy and radiation therapy

Treatment VAT (video-assisted thoracoscopy)

Apical and basal drains inserted

Tissue biopsies

Adhesions

Re-expanded Rt lung following collapse

1Lt blood stained fluid

Pleural cavity “studded with mets”

Talc Pleurodesis

Anatomy Pleura

Space between the inner and outer lining of the lung

Pathology Pleural Effusion

– healthy individuals have less than 1 ml of fluid in each pleural space

– fluid enters the pleural space from the capillaries in the parietal pleura, from interstitial spaces of the lung via the visceral pleura, or from the peritoneal cavity through small holes in the diaphragm

– fluid is normally removed by lymphatics in the visceral pleura

Treatment Drainage

5.41Lt over 14 days

Treatment Talc Plureodesis

– seal the space between pleura with sterile talc

– incites an intense granulomatous pleural inflammatory reaction

– irritate the pleura making it stick together

– stop fluid build up and relieve symptoms

– 5grams sterile talc

– can be done multiple times

– usually occurring within 24 hours, and often persisting many months

Plan PET

VAT

Combined chemotherapy and radiation therapy

Treatment Chemotherapy

Radiation Therapy

SATURN trial - a phase III trial of erlotinib (Tarceva) following chemotherapy as 1st line treatment for non-small cell lung cancer

No effective therapy for pleural metastasis

Generally not curative

Complications Empyema

– collection of inflammatory fluid and debris within the pleural space

– resulting infection and inflammation can proceed with adhesive bands form infected fluid becomes loculated pus within the pleural space

– high associated mortality rate related to respiratory failure and systemic sepsis

Conclusion Treatment not commenced due to empyema

PET can be invaluable in detecting pleural involvement

Pleural metastasis signify unresectable disease and carry great therapeutic and prognostic implications

PET sensitivity 95%, specificity 67% for pleural metastasis

Conclusion