Chest Conference9/20/2011

Matthew Hammar, DOPulmonary Critical Care Medicine FellowAllegheny General Hospital

82 y/o WM prior smoker (40 pack-years, quit age 65) with PMH of COPD, HTN, HLD, CAD, PVD, Carotid Stenosis, 4 cm AAA, Colon Cancer s/p resection 1999 and TIA…

Presented to outpatient pulmonary office 9/7/2011 for ongoing evaluation of COPD & RLL 1 cm pulmonary nodule.

JZ

JZ

Pertinent ROS:

Admits chronic cough productive of clear sputum. Increasing DOE and vague right-sided CP.

Denies SOB at rest. Denies hemoptysis, fevers, chills, night-sweats or weight loss.

CT scan done same day showed a new (compared to 9/21/2010) right upper lobe nodule.

2.3 CM, spiculated RUL nodule.

Scheduled to undergo navigational bronchoscopy 9/13/2011.

PET/CT scheduled 9/16/2011.

JZ

Physical ExamVS: Afeb, HR 59, BP 105/65, RR 20,

SpO2 98% RA.GEN: A&A&Ox3. NAD, ASA class II.HEAD: NC, AT.EENT: PERRL. Ears/Nose wnl.

Edentulous. Mallampati 2.NECK: Supple, full ROM. CV: RRR with grade 2/6 SEM over

tricuspid area.LUNGS: Scattered rhonchi, otherwise

CTAB with wheezing or rales.ABD: Soft, NT, ND. BS present.NEURO: CN II-XII intact.EXT: No CCE. Radial pulse 1+/4 equal

bilaterally

LABS

14.1

411905.6

INR 1.1

CT & Pathology

CT/PET 9/16/2011

Enlarged (1.5 x 1.4 cm) 2A LN with increased SUV 6.6.

RUL nodule (2.4 cm) SUV 14.4. Right hilar LN SUV 10.5. Paratracheal LN SUV 6.9.

PFT’s 9/7/2011 FVC: Pre 3.51(102%) & Post

3.46(101%)

FEV1: Pre 1.90 (79%) & Post 1.95(81%)

FVC/FEV1: Pre (54%) & Post (57%)

TLC: 5.86, Ref 5.61 (104%) DLCO: 11, Ref 17.9 (61%) “Moderate obstructive disease w/o

bronchodilator response”. Decreased diffusion capacity impairment.

Any type of epithelial lung cancer other than small cell lung cancer (SCLC).

3 most common types of NSCLC are: 1) Squamous cell carcinoma2)Adenocarcinoma3)Large cell carcinoma, and adenocarcinoma

NSCLC

NSCLC

There are several other types which occur less frequently, and all types can occur in unusual histologic variants

See figure on next slide

Sarcomatoid carcinomas are a group of poorly differentiated non-small cell lung carcinomas that contain a component of

sarcoma or sarcoma-like (spindle and/or giant cell) differentiation.

Sarcomatoid carcinomas

Rare accounting for ~0.3-1.3% of all lung malignancies

Average age onset 60 y/o

Male:Female = nearly 4:1

Etiology ~smoking, carcinogens

Sarcomatoid carcinomas can arise in the central or peripheral lung, though a predilection for the upper lobes has been reported

Sarcomatoid carcinomas

Sarcomatoid carcinomas Signs and symptoms are

related to tumor location

Eg: Central endobronchial tumors tend to protrude into the lumen of large airways, causing cough, hemoptysis, progressive dyspnea and post-obstructive pneumonia

Sarcomatoid carcinomas Signs and symptoms are

related to tumor location

Eg: Peripheral tumors, (especially pleomorphic carcinoma) grow to large sizes and often present with chest pain due to pleural or chest wall invasion

Characterized as “Very aggressive” and metastasize.

Survival depends on staging.

Giant Cell Carcinoma

Place Holder

• Did he have a PET scan…

• I presume serial CT scans…

JZ PMH: HTN, HLD, CAD, PVD,

Carotid Stenosis, COPD, 4 cm AAA, Colon Cancer, TIA, HOH, BPH

PSH: CABG 2/19/2007, ureteral implant 2/8/2007, Right CEA 10/24/2007, bilateral cataract extraction 2006, LOA 2001, Subtotal colectomy 1999, Right LE arterial stent NOS.

JZ Fam: Mother had lung

cancer. Father & brother had colon cancer.

SOC: 40 pack-years smoking; quit age 65. Married. Retired glass worker. Builds birdhouses as hobby therefore sawdust exposure.

JZ Rx: Lopresor, Zocor, Zetia,

ASA, Spiriva, Singulair, Fish Oil, Rapaflo.

Allergies: NKDA.