Download CPC Answer here - Clinical Correlations

Clinical Pathological Conference
“TO BE OR NOT TO BE”
Kartikya Ahuja, M.D.
Chief Resident
Department of Medicine
NYU School of Medicine
July 20th, 2007
Chief Complaint
• A 45 year old Chinese male presents with
chest pain and dyspnea for 10 days
History of Present Illness
• The patient’s history begins at age 20 when he began to smoke
1 pack of cigarettes daily. He continues to smoke presently.
• At age 25 he was hospitalized in China for “fluid in the lungs”
and a “chest infection.” He reports he received antibiotics that
required hospitalization for six months, and made a full
recovery.
• At age 38 he immigrated to the United States and worked in a
restaurant. The same year he was diagnosed with peptic ulcer
disease requiring a partial gastrectomy which was performed
without complication.
History of Present Illness:
• He was in his usual state of good health until 10 days prior to
admission when he began to feel pleuritic chest pain, dyspnea
and fevers. He also reported a non-productive cough. No
rigors. He sought treatment from a local health care
practitioner who prescribed a Chinese herb. The patient took
the herb for several days without alleviation of symptoms. His
symptoms worsened, now associated with increasing fatigue.
• He reports no sick contacts, recent travel, headaches, dysuria,
abdominal pain, nausea, vomiting nor diarrhea. The dyspnea
was worsening, and the patient presented to Bellevue Hospital
Center for further care.
• Past Medical History: as per HPI
• Past Surgical History: as per HPI
• Medications: An unknown Chinese herb for
one week
• Allergies: none
• Family History: Father alive with history of
CVA, Mother alive with no known medical
history
• Social History: Born in China. No alcohol use.
No elicit drug use. Lives with a friend. Not
married. Sexually active with a female.
• Review of Systems: otherwise negative.
Physical Exam
• well developed, in acute respiratory distress, diaphoretic
• BP 106/74, HR 103 and regular, RR 24, Temp 99.6, oxygen
saturation 94% on room air
• Oropharynx clear
• No lymphadenopathy
• JVD to mandible
• No rashes
• Lungs clear
• Tachyardic, regular, no murmurs
• Normal bowel sounds, soft, non-tender
• No clubbing, cyanosis nor edema
Laboratory Data
EKG
Defending Diagnoses
•
•
•
•
Pulmonary Tuberculosis (9) - Elana Rosenberg
Pulmonary Embolism (6) - Bobby Tajudeen
Tuberculous Pericarditis (5) - Tian Gao
Small Cell Lung Cancer (1) - Carolyn Seib
• Other Diagnoses:
- bacterial pneumonia
- pulmonary sarcoid
- pericarditis
Radiology
Jane Ko, M.D.
Associate Professor of Radiology
Department of Radiology
Faculty Discussion
David Chong, M.D.
Assistant Professor of Medicine
Division of Pulmonary and Critical Care
Pathology
Hua Chen, M.D.
Department of Pathology
BC07-2970
Pericardial fluid
5/14/07
BC07-3484
Pericardial fluid
6/7/07
BC07-3484
Pericardial fluid, Cell block
6/7/07
AE1/AE3
CEA
CK7
Mucin
BS07-4184
Pericardium
6/06/07
BS07-4184
Pericardium
6/06/07
AE1/AE3
Final Diagnosis
pulmonary adenocarcinoma with metastasis
Carcinoma of the Lung
• Primary carcinoma of the lung is the leading cause of
cancer death in the United States
• 90% of cases are in current or former smokers
• The 5-year lung cancer survival rate is 14%
• Histology:
–
–
–
–
–
Adenocarcinoma (32%)
Squamous Cell Carcinoma (29%)
Small Cell Carcinoma (18%)
Large Cell Carcinoma (9%)
Others (12%)
Pulmonary Adenocarcinoma
• The most common lung cancer; also the most
common lung cancer to develop in younger patients
(age < 45 years) and non-smokers
• Usually located peripherally – frequently with pleural
involvement
Pulmonary Adenocarcinoma
• Most patients are symptomatic at presentation
– cough (45-75%), dyspnea (33-50%), chest pain (25-50%)
– hemoptysis is less common
– symptoms related to intra-thoracic spread
•
•
•
•
pleural effusions (pleural invasion or lymphatic obstruction)
pericardial effusions (pericardial invasion)
superior vena cava syndrome
brachial plexus involvement
– symptoms related to distant metastasis
– symptoms related to paraneoplastic syndromes
Pulmonary Adenocarcinoma
• Aside from local invasion and regional spread,
pulmonary adenocarcinoma can spread
transbronchially, producing significant
respiratory distress (dyspnea, hypoxemia and
sputum production)
• Metastasis may occur to any organ
Treatment (non-small cell lung cancer)
• Treatment decisions are based primarily upon the histology, categorized as
either small cell or non-small cell carcinoma, and the stage of the tumor.
• Non-small cell lung cancer (i.e. adenocarcinoma)
– Stage I:
Surgical resection is the preferred management.
– Stage Ib:
Adjuvant chemotherapy is recommended.
– Stage II:
Surgical resection plus adjuvant chemotherapy.
– Stage IIIa:
Generally not treatable with primary resection alone. Frequently managed
on an investigational protocol, which may include surgical resection after
initial chemotherapy, with or without radiotherapy.
– Stage IIIb:
Managed according to a variety of options, ranging from symptombased palliative therapy, chemotherapy, or to combined modality
therapy with radiotherapy and chemotherapy.
– Stage IV:
Primarily managed with chemotherapy or a palliative, symptombased approach. New chemotherapy regimens are currently investigational.
Resection of an apparent metastasis may be appropriate if it is solitary
and/or if there is a suspicion that it could represent a second primary
neoplasm.
Survival
Pathogenesis of Mr. L’s Disease
sequential genetic mutations
(tumor promoter)
malignant cell transformation
tobacco exposure
(carcinogen)
cough and recurrent
pleural effusions
jugular venous distention
tissue invasion with metastasis
development of pericardial effusion
respiratory arrest
dyspnea, fatigue, pleuritic chest pain
Follow-up
• An echocardiogram showed tamponade physiology,
and the patient was admitted to the CCU for a
pericardiocentesis.
• After diagnosis he developed recurrent pericardial
and pleural effusions requiring a pericardial window
and repeat thoracentesis. A bronchoscopy confirmed
the diagnosis.
• His course was complicated by the development of
bilateral pulmonary emboli.
Follow-up
• Further workup revealed metastasis to the
brain, for which he was treated with palliative
radiation.
• His disease continued to progress, with
recurrent large pleural effusions causing
multiple episodes of respiratory distress.
• The patient died on July 2nd 2007
Thank You
Anthony Grieco, M.D.
David Chong, M.D.
Jane Ko, M.D.
Hua Chen, M.D.
Josh Olstein, M.D.