lung adenocarcinoma and pet scanning a case study
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1
Case Study Prepared by Todd Charge
Section Manager Nuclear Medicine & PET Centre
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Background SN, 49yr old male
Presented to GP with 4/52 history of – SOBOE – Rt sided chest pain on inspiration – night sweats – 10kg weight loss – non-productive cough – 10year history of smoking (22 yrs ago) – 1 ½ packs/day – previously well
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Background GP diagnosis of pleurisy on clinical examination
Treated with a single course of antibiotics
Re-presented to GP rooms one week later with no resolution of symptoms
CXR requested by second GP
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Imaging CXR showed
– Rt Pleural Effusion
– Rt side mid zone lung mass measuring 6.5cmx4cm
– CT chest suggested
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Imaging Chest CT showed
– lobular soft tissue mass seen in the right mid zone measuring about 78 x 62mm
– its lateral surface is in contact with the pleural cavity
– consolidation could be seen in the right middle lobe
– multiple oval soft tissue densities noted in keeping with prominent mediastinal lymph nodes. There is a large soft tissue mass lesion seen in the right hilar region
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Morbidity & Mortality Lung Adenocarcinoma
Stage IIIb: T(any), N3, M0
Stage 3b – 50% living at 12 months
5year survival 10%
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Plan PET
VAT
Combined chemotherapy and radiation therapy
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Imaging PET
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Imaging PET
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Imaging Large irregular uptake mass in Rt lung
Focus of abnormal uptake in Rt hilum
Two foci of low grade upgrade in Rt neck
Avid irregular uptake in almost entire Rt lung pleura
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Plan PET
VAT
Combined chemotherapy and radiation therapy
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Treatment VAT (video-assisted thoracoscopy)
Apical and basal drains inserted
Tissue biopsies
Adhesions
Re-expanded Rt lung following collapse
1Lt blood stained fluid
Pleural cavity “studded with mets”
Talc Pleurodesis
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Anatomy Pleura
Space between the inner and outer lining of the lung
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Pathology Pleural Effusion
– healthy individuals have less than 1 ml of fluid in each pleural space
– fluid enters the pleural space from the capillaries in the parietal pleura, from interstitial spaces of the lung via the visceral pleura, or from the peritoneal cavity through small holes in the diaphragm
– fluid is normally removed by lymphatics in the visceral pleura
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Treatment Drainage
5.41Lt over 14 days
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Treatment Talc Plureodesis
– seal the space between pleura with sterile talc
– incites an intense granulomatous pleural inflammatory reaction
– irritate the pleura making it stick together
– stop fluid build up and relieve symptoms
– 5grams sterile talc
– can be done multiple times
– usually occurring within 24 hours, and often persisting many months
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Plan PET
VAT
Combined chemotherapy and radiation therapy
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Treatment Chemotherapy
Radiation Therapy
SATURN trial - a phase III trial of erlotinib (Tarceva) following chemotherapy as 1st line treatment for non-small cell lung cancer
No effective therapy for pleural metastasis
Generally not curative
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Complications Empyema
– collection of inflammatory fluid and debris within the pleural space
– resulting infection and inflammation can proceed with adhesive bands form infected fluid becomes loculated pus within the pleural space
– high associated mortality rate related to respiratory failure and systemic sepsis
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Conclusion Treatment not commenced due to empyema
PET can be invaluable in detecting pleural involvement
Pleural metastasis signify unresectable disease and carry great therapeutic and prognostic implications
PET sensitivity 95%, specificity 67% for pleural metastasis
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Conclusion