1 case #2 sam shahpar, md instructor, feinberg school of medicine at northwestern university...

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CASE #2

Sam Shahpar, MD

Instructor, Feinberg School of Medicine at Northwestern University

Attending Physician, Cancer Rehabilitation Program at RIC

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DISCLOSURE

I have NO RELEVANT financial disclosures.

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L lung nodule identify incidentally in CT imaging

Initially needle biopsy was non-diagnostic but PET imaging revealed enlarged nodule and smaller R upper nodule

Underwent mediastinoscopy, B VATS with R upper lobe nodule/wedge resection and L upper lobe nodule resection/segmentectomy• Pathology revealed grade 2-3 L lung adenocarcinoma with neg

margins and R lung adenocarcinoma with positive margins (Requiring R upper lobectomy subsequently)

BACKGROUND

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Staging work-up notable for brain lesion c/w meningioma v. brain mets but no other systemic metastases

Thought to have 2 separate lung primary malignancies and initiated on adjuvant chemotherapy with cisplatin, pemetrexed with course notable for severe debilitating neuropathy requiring transition to carboplatin for last cycle

BACKGROUND

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Neuropathy started after 1st cycle of chemotherapy with numbness/tingling and burning of feet but soon progressed to hands/wrist

Associated weakness in hand grip and impaired balance, falling up to 4x/week

Lab work and EMG/NCS was WNL

BACKGROUND

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Seen by Physiatrist on Oct 2013 (started chemotherapy in April 2012 ) and reported decreased sensation of vaginal, perineal, and rectal areas

Had been present since initial neuropathy symptoms but had not told any other healthcare providers

Associated urinary incontinence managed with timed toileting and decreased bowel sensations

BACKGROUND

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Lives in home with husband with 1 daughter with cerebral palsy

Acts as primary caregiver to daughter

On disability due to lung cancer

Sister passed away from Lung cancer during the week she initiated chemotherapy (had same Oncologist)

BACKGROUND

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What would be your be the recommended treatment plan?

1. Refer to Neurologist and/or another specialist

2. Refer to physical and/or occupational therapy

3. Initiate medication

4. All of the above

DECISIONS, DECISIONS

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9/2/112 A Neural Interface for Artificial Limbs: Targeted Muscle Reinnervation

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Medications• Gabapentin 300mg QID• Nortriptyline 25mg HS• Hydrocodone/Acetaminophen 5-325mg q6hr PRN• Multivitamin daily

BACKGROUND

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What changes, if any, would you make to medication regimen?

1. No changes

2. Increase Gabapentin

3. Increase Nortriptyline

4. Increase Opioids

5. Trial New Medication


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Moderate recommendation for treatment with duloxetine

• Tricyclic antidepressants, Gabapentin, Compounded Topical gel (baclofen 10 mg, amitriptyline 40 mg, and ketamine 20 mg)

May be offered on the basis of data supporting their utility in other neuropathic pain conditions given the limited other treatment options

Further research on these agents is warranted

ASCO TREATMENT GUIDELINES

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Increase Gabapentin to 300/300/300/600mg • Patient hesitant to increase further due to possible

sedation/side effects

Further work-up with imaging for saddle anesthesia, bowel/bladder changes

Referred to intensive therapy program given significantly impaired function

INITIAL RECOMMENDATIONS

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Referral to Chronic Pain Program - enrolled in a Full day program

Includes M-F, 8 hours per day for 4 weeks

Team members include:• Physiatrist, Pain Psychologist, Occupational Therapists,

Physical Therapists, Relaxation Therapists, Nursing Education experts, Clinical Care Manager and Vocational Rehabilitation specialists

NEXT STEPS

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START OF PAIN PROGRAM

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What changes, if any, would you make to medication regimen?

1. No changes

2. Increase Gabapentin

3. Increase Nortriptyline

4. Increase Opioids

5. Trial New Medication


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Increased Gabapentin to 800mg QID

START OF PAIN PROGRAM

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No clear standard of care

Guidelines may help direct decision making

More research is needed

TAKE HOME POINTS

1 case #2 sam shahpar, md instructor, feinberg school of medicine at northwestern university...

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