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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

http://clinicalcorrelations.org

Clinical CorrelationsThe NYU Internal Medicine Blog

A Daily Dose of Medicine