Lung Cancer

Metastatic, Non Small Cell Lung Cancer
Short Summary

67-year-old with multiple co morbities: Heart, renal, vascular, hypertensive. His biopsy showed left lower lobe lung mass that was a TTF-1 Non small cell lung cancer- most likely an adenocarcinoma. Multiple small nodules < than 1cm were noted without certain etiology, together with “masses” in the upper abdomen and left arm. Recommended therapy includes single agent Vinorelbine.

Patient's Questions

The patient has the following questions:
1. Is this course of action the only option?

2. Is there any available treatment or doctor outside Israel who is able to help?

3. Are there alternative treatments available and suitable?
 

Medical Background

67 year’s old, male, from Israel
Diagnosis: Metastatic – non small cell - Lung Cancer

Below is the recent release letter from the hospital of the patient, who just diagnoses with advanced lung cancer:

To the Treating Physician,
Diagnoses
Diagnosis Description
1 SOL of LLL, multiple lung nodules, upper abdomen mass per CT 09/09
2 Transcutaneous lung SOL biopsy
3 Chronic renal failure
4 Hypertension
5 Dyslipidemia
6 Heavy smoker PH
7 S/P Gastric bypass – 1981
8 Osteoporosis
9 Bipolar disorder
10 IHD, significant two coronary artery disease – per angio, PCI to RCA, 05/2006
11 Normal LV & RV size and systolic function – per echo, 11/2006
12 No evidence for inducible myocardial ischemia – per stress echo, 05/2008

Chief Complaint
Weakness and pain in right chest

Current Illness
67 year old male, father of 3.
For two months, the patient has been feeling his general state of health worsening, suffering weakness, diminished appetite, and weight loss.

In addition, a mass has appeared in his left arm, growing over time. Due to complaints of pain in right chest, was sent for chest x-ray, and in light of results, for CT.

CT – mass was seen in LLL, centred in the lungs, possibly secondary spread: masses found in upper abdomen.

Background:
• Chronic renal insufficiency, nephritic syndrome, under nephrological observation
• Hypertension
• Dyslipidemia
• Previously a heavy smoker. For 3 years, has been smoking 5 cigarettes per day.
• Previously obese. At his heaviest, the patient weighed 135 kg. Underwent gastric bypass operation in 1981.
• Bipolar disorder, controlled with drugs.
• Osteoporosis. Under endocrinological observation. Treated with calcium and vitamin D.
• Has suffered fractures, including an open fracture in the left knee area, which is currently locally distorted.

Ischemic heart disease, coronary catheterization in May 2006, following periods of shortness of breath under stress, and positive scans, found two coronary arteries diseased. Underwent intervention with stent coated with medication on the far end of the right artery.

Family history: Brother died from lung cancer (smoker). Mother and daughter of the patient had breast cancer.

 

Long term Medications Taken
Name of Medication Method Dose Times per day
1 Micropirin Tab 100mg 1
2 Norvasc Tab 10mg 1
3 Disothiazide Tab* 25mg 1
4 Pravastatin Tab 40mg 1
5 Lamictal Tab 50mg 2
6 Cipralex Tab 10mg 2
7 Clonex Tab* 2mg 1+2mg
8 Vita cal + D Tab 1 1
9 Vitamidyne DRP 200IU DRP 10 1
10 Konsyl orange PWD 2 spoons 2

Physical Examination upon Admittance
Blood Pressure 121/56
Pulse 76 Regular
Temperature 36.5 P.O
Breaths 14
General condition Generally feeling poorly
Lymph nodes Small lymph glands felt in armpit
Chest No masses felt
Heart Sounds normal no additional or murmurs heard
Lungs Good breath sounds bilaterally, no rhoncus or whistling, tenderness of ribs on right.
Abdomen Soft belly, not tender.
Masses felt in upper abdomen


Peripheral pulses felt:
R F P DP TP
Right Yes Yes Yes
Left Yes Yes Yes

Limbs: No edema, and no signs of DVT

Chest CT
No contrast medium injected.
No enlarged lymph nodes demonstrated in the axilla and mediastinum.
Solid mass in left lower lobe, inseparable from the pleura, with defined edges. 4.8 x 7.3 cm.
Lung foci demonstrated on both lungs, diameter up to 8 mm.
Slight pleural discharge bilaterally.
Post operative state – metal pins in upper abdomen.
On the left, well defined mass demonstrated, undefined edges. 4.1 x 6.7 mm
Additional mass, inseparable from the diaphragm on the left, dimensions 4.1 x 4.9 cm.

1. Space occupying lesion in LLL, biopsy advised.
2. Lung foci on both lungs, possibly secondary lesions.
3. Two masses in left upper abdomen, of an unclear nature. Clarify with CT, with contrast medium.

Development and Discussion
67 year old male, previously a heavy smoker, suffering for 2 months from weakness, diminished appetite and weight loss. Tests showed a mass in right arm, possibly attached to muscle (?) Tenderness in right ribs.

Chest CT: Mass in LLL, lung foci, suspected secondary spread, masses in upper abdomen.
Seems to be metastatic spread originating in lungs.
On 09/09, biopsy taken using CT from right lung mass:
Consistent with no-small cell carcinoma with extensive necrosis
Immunostatins were positive for TTF-1, CK7, and CK8/18, and negative for CK20 and P63.
Post biopsy development/process normal.
Released.
1. Tab oxycontin mg X 2
2. Ambulatory bone scan

SPECT bone scan
A Whole body scan and SPECT was carried out from spinal column, back, waist and pelvis, including imaging of the upper limbs and comparison with the previous scan from 03/08.

In comparison with the previous scan, the current scan shows many focal findings in the vertebrae L,D2,7 and most of the ribs bilaterally (shown with SPECT), particularly ribs 8-9, anterior, on the right.

These findings increase our suspicion of pathology within the skeleton (possibly originating from the bone marrow), although pathology arising from a different source cannot be ruled out.

X-ray confirmation of these findings is recommended.

Status of the proximal left tibia and the right knee are without change.

On the other hand, very uneven absorption was seen in the limbs – tibias, femur, bilaterally, which also raises suspicions of secondary pathology.

Otherwise, nothing to mention.

The oncologist , Dr. G. recommended chemotherapy treatment as follows:
Carboplatin
(without diaplatin) with Navelbine, or taxol, or ALIMTA (one of the three), at a rate of one or two doses per three weeks.
Currently, she does NOT recommend biological treatment – NOT Erbitux, and NOT Avastin.

Weekly Cycles of Vinorelbine for 2 weeks and stop on third week. Additional therapy will be considered according to clinical status

Due to the patient deteriorated condition the treating oncologist has decided to start with Weekly Cycles of Vinorelbine for 2 weeks and stop on third week. Additional therapy will be considered according to clinical status.

 

Expert's Opinion

Impression:
I am not certain there is enough evidence of stage IV metastatic disease. Unless the abdominal and bone lesions are confirmed to be neoplastic (Biopsy or PET/CT), radiation therapy or even surgery would still be possible.

Treatment Alternatives:
If abdominal and bone lesions NOT malignant, surgery or irradiation.

If truly metastatic- Taxotere weekly 35mg/m2 would be a potentially more effective option.

If tissue available would check for EGFR mutation- if + and if disease truly metastatic- Erlotinib.

Comments:
The key is finding out if the disease is really metastatic to the lung, arm and abdomen. If so palliative chemo with Taxotere, Vinorelbine, Tarceva the best bet. If NOT metastatic- explore surgical and radiation options.
This can all be carried out in Israel.
 

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