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NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds Clinical Vignette. Lisa Cioce MD, PGY-2 March 10, 2010. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. A 67-year-old man presents with a persistent cough for 6 months. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Lisa Cioce MD, PGY-2 March 10, 2010 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint A 67-year-old man presents with a persistent cough for 6 months. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  3. History of Present Illness • The patient was in his usual state of health until 6 months prior to admission, when he began to experience a cough productive of white sputum. • Over this time, he also experienced increasing fatigue and a 10 pound weight loss. • He had no fever, hemoptysis, and shortness of breath. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  4. History of Present Illness • The patient initially presented to an outside hospital one month ago, where a chest X-ray demonstrated a dense opacity involving the left mid and lower lung fields concerning for a mass. • A subsequent CT scan of the chest revealed a mass in the lingula causing obstruction of the lingular bronchus with direct invasion of the left hilum and bronchovascular spread of the tumor peripherally. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  5. History of Present Illness • The patient underwent bronchoscopy with a transbronchial biopsy of the mass. • Pathology demonstrated malignant cells consistent with poorly differentiated adenocarcinoma. • He presents for further work-up. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  6. Additional History • Past Medical History • Hyperlipidemia • Past Surgical History • Rotator cuff repair • Family History • Father: Lung cancer • Brother: Diabetes mellitus • Social History • Former Smoker • Quit 4 years ago • 40 pack-year history • Denies alcohol use • Denies illicit drug use UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  7. Outpatient Medications Aspirin 81 mg daily Simvastatin 80 mg at bedtime Zolpidem 5 mg at bedtime Allergies: No known drug allergies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  8. Physical Examination General: Well-appearing man, in no acute distress Vitals: T 97F, BP 156/71, HR 75, RR 14 O2 saturation: 98% on room air The remainder of the physical exam was normal UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  9. Laboratory Studies • CBC: Within normal limits • Basic Metabolic Panel: Within normal limits • Hepatic Panel: Alkaline phosphatase 154 U/L • The remainder was within normal limits • Lactate dehydrogenase: 1733 U/L (110-225 U/L) • CEA: 360.4 ng/mL (0-5.0 ng/mL) UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  10. Imaging UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  11. Imaging • Official CT Report: Far advanced carcinoma of the lung with involvement of the left hilum, mediastinum, direct bronchovascular spread to the left lung and diffuse lymphangitic spread of the tumor bilaterally. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  12. Working Diagnosis Non-small cell lung cancer: adenocarcinoma UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  13. Staging • PET scan was performed, demonstrating hypermetabolic foci in multiple areas including the left hilum, lingula, and posterior basal segment of the left lower lobe. • Multiple foci in the mediastinum were noted. • A 1.1 cm foci was found in the left iliac bone. • MRI of the brain did not show evidence of metastatic disease. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  14. Staging • CT guided left iliac bone biopsy was performed. • Immunohistochemical studies showed reactivity for CK7 and TTF1 and non-reactivity for CK20, consistent with metastatic pulmonary adenocarcinoma. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  15. Outpatient Treatment • The patient was treated with an outpatient chemotherapy regimen of cisplatinum, pemetrexed and zolendronic acid. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  16. Final Diagnosis Stage IV lung adenocarcinoma with bony metastatic disease UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  17. Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine http://clinicalcorrelations.org UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

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