case study- respiratory
TRANSCRIPT
Respiratory Case StudySL3, 12:36pm, 12/16/2009
Amber Strasburg
NSCLC: Bronchogenic mucinous adenocarcinoma 87 year old female Hospitalized for acute abdominal pain in
August 2009 Abdominal x-ray showed mass in left lung
PET/CT showed a 3cm mass in the lung SUV (standardized uptake value) of 21.6.
Needle core biopsy confirmed bronchogenic mucinous adenocarcinoma
Epidemiology Lung cancer is the leading cause of
cancer-related death in the U.S. Estimated new cases in 2014 is 224,210 Estimated deaths is 159,260 NSCLC accounts for about 85% of all lung
cancers. Adenocarcinoma is most common with
40% of all lung cancers Occurs most often in women
Etiology Most common cause is tobacco
exposure 87% of lung cancers are the result of
smoking Other risk factors include:
Occupational exposure Fumes from coal tar, nickel, chromium, and
arsenic as well as exposure to radioactive materials
RT to breast or chest
Histology 12 primary tumor types
Epidermoid carcinoma Small cell anaplastic carcinoma Adenocarcinoma Large cell carcinoma Combined epidermoid and adenocarcinoma Carcinoid tumors Bronchial gland tumors Papillary tumors of the surface epithelium Mixed tumors and carcinomas Sarcomas Unclassified Mesotheliomas
Presenting Symptoms Patient specific:
None Pt. denies any
change in respiratory status
Common: Hemoptysis Malaise Weight loss Dyspnea Hoarseness
Medical History History of bilateral breast cancer
Right breast DCIS and left breast invasive ductal carcinoma (T2 N0)
3 lumpectomies Whole breast irradiation to both breasts
60Gy to right side (1988), 50Gy to left side (2005) Bilateral mammogram in 2009 was negative for
malignancy History of endocarditis, TB, hyperlipidemia,
and hypertension
Family and Social History Family History:
2 sisters diagnosed with breast cancer at age 47 and 49 respectively
Social History: Pt. is retired No history of
tobacco, alcohol, or drug use
Very active ECOG (Eastern
Cooperative Oncology Group) score of 0
Lab/Imaging Studies PET/CT showed 3cm mass Needle core biopsy revealed invasive,
moderately differentiated mucinous adenocarcinoma
CBC showed abnormalities in MCHC (concentration of hemoglobin in RBC) and lymph. Immunophenotype of carcinoma confirms
pulmonary origin Not metastatic breast cancer
Stage TNM (Tumor, Node, Metastases) system is used Tumor size (T)
TX: Tumor cannot be assessed (not visible) T0: No evidence of tumor Tis: Carcinoma in situ T1a: Tumor ≤2cm, surrounded by lung of visceral pleura, without invasion of
main bronchus T2a: Tumor >3cm but ≤5cm or tumor involving main bronchus, ≥2cm distal
to carina; invading visceral pleura; associated with atelectasis or obstructive pneumonitis
T1b: Tumor >2cm but ≤3cm, surrounded by lung or visceral pleura, without invasion of main bronchus
T2b: Tumor >5cm but ≤7cm or tumor involving main bronchus, ≥2cm distal to carina; invading visceral pleura; associated with atelectasis or obstructive pneumonitis
T3: Tumor >7cm or tumor that invades parietal pleura, diaphragm, phrenic nerve, mediastinal pleura, or parietal pericardium or tumor in main bronchus or associated with atelectasis or obstructive pneumonitis of entire lung
T4: Tumor of any size that invades mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina, or separate tumor nodule(s) in a different ipsilateral lobe
Stage Node Involvement (N)
N0: No regional lymph node metastasis N1: Mets in ipsilateral peribronchial and/or
ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension
N2: Mets is ipsilateral mediastinal and/or subcarinal lymph node(s)
N3: Mets in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s).
Stage Metastasis (M)
M0: No distant mets M1: Distant mets M1a: Separate tumor nodule(s) in a
contralateral lobe tumor with pleural nodules or malignant pleural (or pericardial) effusion
M1b: Distant mets (in extrathoracic organs)
Stage Grouping Occult carcinoma: TX, N0, M0 Stage 0: Tis, N0, M0 Stage IA: T1a, N0, M0 or T1b, N0, M0 Stage IB: T2a, N0, M0 Stage IIA: T2b, N0, M0; T1a, N1, M0; T1b, N1, M0; T2a,
N1, M0 Stage IIB: T2b, N1, M0; T3, N0, M0 Stage IIIA: T1a, N2, M0; T1b, N2, M0; T2a, N2, M0;
T2b, N2, M0; T3, N1, M0; T3, N2, M0; T4, N0, M0; T4, N1, M0
Stage IIIB: T1a, N3, M0; T1b, N3, M0; T2a, N3, M0; T2b, N3, M0; T3, N3, M0; T4, N2, M0; T4, N3, M0
Stage IV: Any T, Any N, M1a, OR Any T, Any M, M1b
Grade GX: Grade not assessable G1: Well differentiated G2: Moderately differentiated G3: Poorly differentiated G4: Undifferentiated
Pt. Stage and Grade Clinical stage 1 (T1, N0, M0) Grade 2- Moderately differentiated
Tx. Summary stated mass was >3cm, so T2a, N0, M0
Typical Routes of Spread 3 spread patterns:
Direct When the mass itself grows into surrounding
structures (lung, ribs, heart, esophagus, vertebral column, chest wall, diaphragm, pleura, and pericardium.
Lymphatic Cells can be trapped in nodes when lymph fluid is
filtered and pass through the nodes Cells can grow through the node and gain access to
the circulatory system Hematogenous
Lymph drainage has access to the whole body through the circulatory system
Metastasis Common:
Cervical lymph nodes Liver Brain Bones Adrenal glands Kidneys Contralateral lung
Patient: No metastasis
Treatment Options Surgery
First step Only 20% of lung cancer patients considered candidates
for surgery Chemotherapy
Alone or with RT Most effective single agent drug is cisplatin
Radiation Therapy Standard therapy generally includes concurrent,
sequential, or alternating chemo and radiation May be done before surgery to shrink tumor or after
surgery Can be used with curative intent or for palliation
Radiotherapy Considerations Standard fractionated IMRT Hypofractionated SRS
Increased dose allowing for better local control
Pt. not a candidate for surgery because of poor pulmonary function tests and lung damage caused by TB
SRS recommended, but pt. declined Tx with standard fractionation
Pre-Sim Ask the pt 5 identifiers (name, date of birth, address, phone
number, and area being tx) Take face photo Let pt. know that you will be making an alpha cradle for
immobilization and that it will be warm Instruct pt. not to use any creams or lotions as they may
contain metals that could interact with radiation Discuss side effects with them:
Dermatitis, erythema, esophagitis, dysphagia, coughing, dry throat, excessive mucous secretions
Tell them that they will be seeing the physician and the nurse once a week
Discuss diet: Soft, moist, and non-spicy foods and liquids at room temp. or
slightly chilled
Simulation Procedure Setup:
Alpha cradle, knee fix, rubber band Pt. will be asked to lie down on table, supine, arms
up, and she will be aligned visually using the sagittal laser
Alpha cradle will be made for immobilization A 4D CT will be done for planning
Tracks motion of tumor with breathing After CT, levels will be given, chin measurement will
be recorded, and photos will be taken of setup and levels
Pt. will be told to come back for verify sim to place the isocenter once planning is complete
Verify Sim Therapists will look at skin rendering
and DRR’s to ballpark isocenter, then a CBCT is done to confirm isocenter placement.
Tattoo will be given to mark c/a and 3-point will be recorded
Photo of c/a tattoo and any additional photos needed for setup will be taken
SSD’s will be taken and recorded
Setup photos
Prescription Site: Lt. lower lung Technique: 7 field
IMRT Modality: 6x
Fractions: 40tx @ 200cGy daily
Total Dose: 8,000cGy
Dose Spec: Volume
Beam arrangement
GTV, CTV, PTV GTV is the 3cm tumor CTV is 0.5cm margin around tumor PTV is 0.5cm margin around CTV
Isodose
Ortho Pair
Skin Rendering
DRR
Critical Structures
Critical Structures/Tolerance Doses Lung
TD 5/5: 2000cGy Dose given:
Lt- 1857cGy Rt- 699cGy
Heart TD 5/5: 4300cGy Dose given: 1605cGy
Spinal Cord TD 5/5: 4500cGy Dose given: 846cGy
Esophagus TD 5/5: 5000cGy Dose given: 1291cGy
Complications No complications Pt. tolerated tx well and did not develop
any significant shortness of breath, chest pain, dysphagia, odynophagia, or skin erythema
PrognosisStage5-year Survival Rate IA49%IB45%IIA 30%IIB 31%IIIA 14%IIIB 5%IV1%
Lessons To Be Learned 87 year old woman had to come in
everyday for 8 weeks Takes time out of her day Many other places she’d rather be
Already went through RT for both breasts Probably feels like her life is being
controlled by cancer
References Washington CM, Leaver D. Principles and
Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsevier; 2010.
National Cancer Institute. Non-Small Cell Lung Cancer Treatment(PDQ). Available at: http://www.cancer.gov/cancertopics/pdq/treatment/non-small-cell-lung/healthprofessional/page1. Accessibility verified May 16, 2014.