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01
Stefan Jungbauer, Universital hospital of Erlangen, Department of
internal medicine 1
CASE REPORT
SPRINGER LUNG CANCER INTERNATIONAL
PRECEPTORSHIP VIENNA
Anamnesis
• 45year old female patient presented to an externe clinic with
dyspnoe for 5 days
• thoracic pain on the right side for four weeks
• no haemoptysis
• risk factor: no smoking
• no weight loss, fever or night sweat
• medication: ibuprofen as needed, Candesartan 8mg 1/2-0-0
02
physical examination
• well-developed, well-nourished woman
• chest: decreased breath sound on the right
• heart: notable for a normal S1, S2 without frequent
extrasystole and no rubs, murmurs or gallops.
abdomen: soft, no pain, normoactive bowel sounds in all 4
quadrants.
• extremities: no edema.
• neurologic exam: Cranial nerves II through XII are grossly
intact. Strength is 5 out of 5 throughout with 2+ reflexes.
Sensation to fine touch is intact throughout. The
patient is alert and oriented x 3.
03
Differential diagnosis
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Respiratory infection with pleuritis
Pulmonary embolism
Cardiac insufficiency
Cardiac infarction
Trauma
Etc.
04
Lab
– Blood count was normal
– Electrolytes, kreatinine, liver function tests and CRP were
normal
– Troponine was normal
– Pathologic
• LDH 410+ (<214)
• D-dimere 1,39+ (<0,5µg/ml)
Further tests
– ECG: was normal
– Chest X-ray: huge pleural effusion on the right side
– Echocardiography: sinus rhythm, no abnormality of
repolarisation, indifferent type, PQ<0,2sec, QRS<0,1sec
– Cardiac ultrasound: normal right and left ventricular function,
ejection fraction 60%, valve function was normal, no pericardial
effusion
NEXT step?
CT scan
• Date:
• Subject:
• Content:
Thoracentesis
• pleural effusion on the right side thoracentesis was
performed
• LDH and protein were elevated exudate
• pathology: TTF1 positive adenocarcinoma
08
Bronchoscopy
• Endobronchial ultrasound with transbronchial aspiration of
lymph nodes postion 12R and 7
• No endobronchial tumor lesions
Pathology
• Strong positivity for CK7 and TTF1; negativitaty for CK5,
synaptophysin  primary adenocarcinoma of the lung
• EGFR-mutation analysis of the exons 18-21:
– Exon 19 deletion was found
• No EML-4ALK translocation
Further medical history
• Staging: cT3N2M1a (PLEUR)
• Afatinib-therapy was started with 40mg per day (19/02/2014)
• Pleurodesis with talc was performed 2/2014
• Staging was performed by CT scan
• 08/2015: progress with pleural effusion
occurred
P
• Higher dosage of Afatinib (50mg per day) was tried because of very
good therapy tolerance and no side effects under 40mg
• 09/2015: Systemic therapy with cisplatin 75mg/m2 and
pemetrexed 500mg/m2 was started (6 bouts of chemotherapy)
• Maintenance therapy with pemetrexed 500mg/m2 since 1/2016
• liquid biopsy for T790M mutation was negative