Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
ONCOLOGY GRANDROUNDS PRESENTER: MARIA KRISTINE S. MENDOZA, M.D. MODERATOR: EUGENIO REGALA, M.D. 11 JANUARY 2010 RM 205, MEDICINE BLDG. B.F. 63year old Female Married Housewife Aklan Date of admission: Dec. 19, 2009 History of Present Illness 4 months PTA • CC: Epigastricpain • Vomiting of partially digested food • (-) Anorexia, dysphagia, nausea, early satiety • Consult Impression: t/c Gastritis o Calcium carbonate tabs (Tums) prn o Further work-up recommended: Endoscopy 1 month PTA • Increased severity and frequency of epigastric pain •Weightloss (≈ 7 kg.) • (+) Early satiety, easy fatigability • Consult oUpper GI endoscopy: chronic gastric ulcer oCT scan: gastric mucosal thickening oFOBT: (+) oMx: Esomeprazole (Nexium) 40mg OD oRebamipide(Mucosta) 100mg TID CONSULT REVIEW OF SYSTEMS • • • • • • • • • No pigmentation, itchiness No visual dysfunction, naso-aural discharge No sore throat No neck stiffness, masses or lymphadenopathy No dyspnea, shortness of breath No chest pain, no syncope No diarrhea, constipation No dysuria, frequency, urgency or flank pain No heat-cold intolerance, no polyuria, polyphagia, polydipsia, paresthesia • No seizure, motor dysfunction, or hallucinations PAST MEDICAL HISTORY • HPN x 5 yrs. (HBP:160/100; UBP:130/90) Irbesartan 150mg + HCTZ 12.5mg 1 tab once a day • Internal hemmorhoidsx 20 yrs. with occasional hematochezia • No DM, asthma, allergies, PTB OB/GYNE HISTORY • G1P1 (1001) – M-15 y/o – I - 28-30 days – D- 3 days – A- 4ppd – S- (-) dysmenorrhea • Menopause: 53 y/o PERSONAL and SOCIAL HISTORY • Non-smoker, not exposed to second hand smoke and chemicals • Not an alcoholic beverage drinker • No illicit drug use • Preference for canned foods and grilled meat FAMILY HISTORY • • • • • (+)HPN – Both parents (-)DM (-) Asthma (-) Allergies (-) Cancer PHYSICAL EXAMINATION GEN. SURVEY • Conscious, coherent, ambulatory, not in cardiorespiratory distress • BP 140/90mmHg(supine/sitting) CR 94 bpm,reg. (supine/sitting) PR 94 bpm, reg. (supine/sitting) RR 19 cpm Temp 36.5 oC • Ht: 157cm Wt: 61kg BMI: 25kg/m2 • Warm moist skin, no active dermatoses (+)pallor PHYSICAL EXAMINATION • Pale palpebral conjunctivae, anictericsclerae HEENT • No nasoaural discharge, no tragal tenderness, moist buccal mucosa, no gingival bleeding, no oral petechiae, nonhyperemic posterior pharyngeal wall, tonsils not enlarged • Supple neck, thyroid not enlarged, no palpable cervical lymphadenopathy, no supraclavicularlymphadenopathy PHYSICAL EXAMINATION CHEST • • • • I - Symmetrical chest expansion, no retractions P - Equal tactile fremiti P - Resonant on percussion A - Clear and equal breath sounds; Equal vocal fremiti • Adynamicprecordium, no lifts, no heaves, no thrills, AB 5th LICS MCL,sustained S1>S2 apex, S2> S1 base, no murmurs PHYSICAL EXAMINATION ABDOMEN • Globular abdomen with whitish striae, (+) bulging flanks, normoactive bowel sounds, soft, (+) epigastric tenderness, (+) fluid wave and shifting dullness, (-) succusion splash, no costovertebral angle tenderness, AC:41 in. • DRE: (+) perirectal skin tags, no fissures, external sphincter tone intact, (+) 1x1 cm, soft, fleshymass, above thepectinateline, 12 o’ clock position, non-tender, No stool on examining finger PHYSICAL EXAMINATION EXTREMITIES • Pulses are full and equal. No limitation of motion of extremities, no swelling, no pain, no tenderness of joints, no edema, no cyanosis. PHYSICAL EXAMINATION NEURO EXAM • Awake, alert, oriented to 3 spheres • Cranial nerves intact • Can do alternating pronationsupination test and finger to nose test • (-) Romberg test, (-) pronator drift • No atrophy; Manual muscle testing (MMT): 5/5 on all extremities • No sensory deficit/impairment • Deep tendon reflex(DTRs): 2+ on all extremities • (-) nuchal rigidity, (-) Babinski sign, (-) Chaddock’s sign, (-) Kernig’s sign, (-) Brudzinski sign SALIENT FEATURES SUBJECTIVE • • • • • • 63 y/o, female Epigastric pain Vomiting Weight loss Early satiety Easy fatigability OBJECTIVE • CT scan: gastric mucosal thickening • (+)pallor • Pale palpebral conjunctiva • (+) bulging flanks • (+) epigastric tenderness • (+) shifting dullness • (+) fluid wave • (-) succusion splash • (+) soft 1x2 cm mass, above the dentate line, 12 o’ clock position, non-tender ASSESSMENT: Gastric Malignancy Anemia probably secondary to Upper GI bleeding secondary to 1)Gastric malignancy 2)PUD Hypertension Stage II Internal hemorrhoids 12/19/09 N.V. Hgb RBC Hct MCV 83 3.62 0.26 72.2 120-170g/L MCH MCHC RDW 23.00 31.80 16.70 34 + 2 g/dl WBC Neutro Lympho Monos 6.60 0.57 0.39 0.01 4.5-10 0.50-0.70 0.20-0.40 0-0.03 Eos 0.03 0-0.03 355 0-0.01 150-450 Baso Platelet 4-6 x 1012/L 0.37-0.54 87+5 U3 1ST HOSP. DAY • Transfused 1 ‘u’ pRBC 29 + 2 pg 11.6-14.6 • Other medications: – Amlodipine 10mg/tab 1 tab OD – Esomeprazole 40mg/ tab 1 tab OD COURSE IN THE WARD Normal Value FBS 92.7 70.9-110mg/dl Crea 0.68 0.5-1.2 mg/dl Na 142 137-147mmol/L K 3.6 3.8-5 mmol/L 1ST HOSP. DAY • Kaliumdur ule, 1 durule TID COURSE IN THE WARD 3rd HOSP. DAY • UGI Endoscopy with biopsy – The stomach was observed to be poorly distensible on air insufflation with poor contractility – There was a diffuse infiltrating lesion with friable nodular mucosa that appeared to have involved the cardia down the antrum of the lesser curve – Multiple bites for biopsy • IMPRESSION: GASTRIC MALIGNANCY, BORRMAN IV ENDOSCOPIC FINDINGS EGD with Biopsy DIAGNOSIS: SIGNET RING CELL CARCINOMA • The specimen consists of multiple light brown, soft tissue fragments altogether measuring 1 x 0.8 x 0.5 cm. • Microsections disclose fragments of gastric mucosa composed of nests of neoplastic cells with eccentric nucleis and large cytoplasmicmucin vacuole. EGD with Biopsy DIAGNOSIS: SIGNET RING CELL CARCINOMA • Other areas show cord and nests of neoplastic cells with large hyperchromatic nuclei, prominent nucleoli and scant to fair amount of cytoplasm Working diagnosis: GASTRIC SIGNET RING CELL CARCINOMA Gastric Cancer CA Cancer J Clin 2005; 55: 10-33 CA Cancer J Clin 2005; 55: 75 Stewart: World Cancer Reports IARC Press, Lyon 2003 • Worldwide:4th most common malignancy 2ndleading cause cancer mortality • 60% of cases from developing countries • 90% cases are adenocarcinoma Philippines • Gastric Cancer – 8th leading site in both sexes – 5th in males and 10th in females Epidemiology Gastric Cancer Incidence and Mortality Rates per 100,000 Cases (Age Adjusted) in the United States, 1997-2001 INCIDENCE Race/Ethnicity MORTALITY Male Female Male Female White 10.8 5.0 5.8 2.8 White Hispanic White nonHispanic African American 18.4 10.3 9.9 5.4 9.7 4.1 5.4 2.6 18.8 9.9 13.3 6.3 Asian/Pacific Islander 21.9 12.4 11.9 7.0 Native American/Native Alaskan Latino 15.7 8.9 7.3 4.1 17.8 10.0 9.7 5.3 Environmental Risk factors • • • • • H. pylori infection Dietary Factors Cigarette Smoking Alcohol Low Socioeconomic Status Premalignant Conditions • • • • • • Chronic Atrophic Gastritis Intestinal Metaplasia Gastric Dysplasia Gastric Polyps Previous Gastrectomy Gastric Ulcer APPROACH TO A PATIENT WITH GASTRIC CANCER WORK-UP NCCN Clinical Practice Guidelines in Oncology V.2.2009 • • • • • Abdominal CT with contrast PET/CT or PET scan(optional) Endoscopic ultrasound(optional) CBC and chemistry profile Chest imaging COURSE IN THE WARD 3rd HOSP. DAY • CT scan with contrast of the whole abdomen – Gastric wall thickening at the antrum, body and both curvatures of the stomach – There was also mesenteric fat stranding with nodularities which may represent mesenteric lymph nodes – Moderate ascites with associated mild bowel wall thickening – Small splenic cyst, superior aspect – Prominent medial limb of the left adrenal gland to consider metastatic process – Diverticulosis in the descending colon COURSE IN THE WARD 3rd HOSP. DAY • Referral to Medical Oncology • Labs and Ancillaries CBC 12/19/09 12/20/09 12/23/09 12/26/09 Hgb 83 106 118 115 Hct 0.26 0.35 0.38 0.36 WBC 6.60 5.7 4.10 Neutro 0.57 0.68 0.69 Lympho 0.39 0.29 0.31 Monos 0.01 0.01 Eos 0.03 0.02 355 295 Baso Platelet 281 LABORATORY EXAMINATION • • • • • • ALP SGOT SGPT TB DB0.23 IB0.48 74.1 (NV: 36-92 IU/L) 17.9 (NV:16-40 U/L) 11.1 (NV:8-53 U/L) 0.71 (NV: 0.5-1.5 mg/dl) (NV: 0.10-0.40 mg/dl) (NV:0.30-1.10 mg/dl) LABORATORY EXAMINATION • • • • • • Total protein5.3 (6-7.8 g/dl) Albumin3.2(4 – 5.5 g/dl) Globulin 2.2 (1.5-3.4 g/dl) A/G ratio1.5 (1-3 mg/dl) Mg 1.8 (1.6-2.5) iCa 1.33 Tumor markers • CA 125 • CA 19-9 • CEA 358 (NV: 0-35) 0.60 (NV: 0-39) 3.77 (NV:0-5) 2D Echo • Concentric LVH with good wall motion and contractility and normal resting systolic function • EF=69%