sacgr june 8, 2006

SACGRSACGR

June 8, 2006June 8, 2006

71 year old man with a pleural 71 year old man with a pleural effusioneffusion

CHIEF COMPLAINT: 71 y/o male transferred from OSH for further work up of bloody CHIEF COMPLAINT: 71 y/o male transferred from OSH for further work up of bloody exudative pleural effusion. exudative pleural effusion.

HPI:HPI:In April, week of worsening SOB, fatigue, cough with increased blood tinged sputum, and a In April, week of worsening SOB, fatigue, cough with increased blood tinged sputum, and a subjective report of fever and chillssubjective report of fever and chills

– CXR = LLL infiltrate and WBC was 15.9CXR = LLL infiltrate and WBC was 15.9– Cetriaxone and azithromycinCetriaxone and azithromycin– Subsequent CXR showed increasing LLL infiltrate and pleural effusionSubsequent CXR showed increasing LLL infiltrate and pleural effusion

Total protein 3.3, LDH 241, glucose 242, WBC 1700, 36% pmns, 62% lymphocytesTotal protein 3.3, LDH 241, glucose 242, WBC 1700, 36% pmns, 62% lymphocytesNegative cytology & AFBNegative cytology & AFBWent home requiring 3 L O2 along with a prednisone taper.Went home requiring 3 L O2 along with a prednisone taper.

On f/u, hct = 22.9 and he was transfused with 3 U PRBCOn f/u, hct = 22.9 and he was transfused with 3 U PRBCMid-May: worsening SOB& O2 sats were in the low 70sMid-May: worsening SOB& O2 sats were in the low 70s

– ABG = 7.15/75/150; BiPap startedABG = 7.15/75/150; BiPap started– Low BP, started on dopamine; pip/tazo and vanco added. Low BP, started on dopamine; pip/tazo and vanco added. – Respiratory distress continued on BiPAPRespiratory distress continued on BiPAP– CXR = large left pleural effusionCXR = large left pleural effusion– 1.5 L of bloody fluid was removed. RBC count 65000, WBC 4300, 60% pmns, 29% lymphs, 1.5 L of bloody fluid was removed. RBC count 65000, WBC 4300, 60% pmns, 29% lymphs,

glucose 97, LDH 1012, ph 7.12. Cytology & AFB negativeglucose 97, LDH 1012, ph 7.12. Cytology & AFB negative– CT after the tap showed large effusion and possibility of organized clot. CT after the tap showed large effusion and possibility of organized clot. – Chest tube was placed, 3.2 L drained. Chest tube was placed, 3.2 L drained. – O2 requirements decreased and he was able to go back to a nonrebreather at 8L O2. O2 requirements decreased and he was able to go back to a nonrebreather at 8L O2.


PAST MEDICAL HISTORY:PAST MEDICAL HISTORY:COPD on home O2COPD on home O2Pulmonary fibrosisPulmonary fibrosishx of alcoholism hx of alcoholism hx of homelessnesshx of homelessnesshtnhtnhyperlipidemiahyperlipidemiaanemia of chronic disease (low fe, low tibc, high ferritin) – colonoscopy pendinganemia of chronic disease (low fe, low tibc, high ferritin) – colonoscopy pendingChronic LBP (Sciatica)Chronic LBP (Sciatica)Prostate cancer treated with seedsProstate cancer treated with seedshx of head injury in 1982 2/2 MVAhx of head injury in 1982 2/2 MVA

ALLERGIES: BANANAS, no known drug allergiesALLERGIES: BANANAS, no known drug allergies


Medications at homeMedications at homeFurosemide 40 mg po qdFurosemide 40 mg po qdalbuterol albuterol ipratropriumipratropriumvalsartan 80 mg po bidvalsartan 80 mg po bidmetoprolol 100 mg po qdmetoprolol 100 mg po qdspironolactone 12.5 mg po qdspironolactone 12.5 mg po qdASA 81 mg po qdASA 81 mg po qdterazosin 4 mg po bidterazosin 4 mg po bidgabapentin 200 mg po qidgabapentin 200 mg po qidtramadol 50 mg po bidtramadol 50 mg po bidFerrous sulfate TIDFerrous sulfate TID

Medications on transferMedications on transferProtonix 40 mg po qdProtonix 40 mg po qdzosyn 3.375 gm IV q8hzosyn 3.375 gm IV q8hvancomycin 1 gm IVvancomycin 1 gm IVmethylprednisolone 20 mg IV BID methylprednisolone 20 mg IV BID Acetylcysteine 600 mg po bid Acetylcysteine 600 mg po bid through 5/17/06through 5/17/06combivent q4combivent q4lantus insulin 10 units qamlantus insulin 10 units qammorphine 1-3 mg q30 min prn morphine 1-3 mg q30 min prn


HABITSHABITSTobacco: 1.5 ppd x 50yrsTobacco: 1.5 ppd x 50yrsAlcohol: history of abuse, no alcohol for >1 yrAlcohol: history of abuse, no alcohol for >1 yr

SOCIAL HISTORY Lives with ex-wife in Walla Walla. Has had many periods SOCIAL HISTORY Lives with ex-wife in Walla Walla. Has had many periods of homelessness, during which he stayed on the streets or in shelters. of homelessness, during which he stayed on the streets or in shelters.

FAMILY HISTORY:FAMILY HISTORY:parents were heavy drinkers. Father had emphysema. parents were heavy drinkers. Father had emphysema. Brother with CAD, died at age 68.Brother with CAD, died at age 68.Brother died of lung disease, of unknown type.Brother died of lung disease, of unknown type.


PHYSICAL EXAM:PHYSICAL EXAM:T96.8F BP122/54 P100 R17 SpO2 94% RA WT80.3 kg HT67in T96.8F BP122/54 P100 R17 SpO2 94% RA WT80.3 kg HT67in GENERAL: NAD, wearing non-rebreatherGENERAL: NAD, wearing non-rebreatherHEAD/EYES/EARS/NOSE/THROAT: no scleral icterus, MMM, no O/P erythema or exudateHEAD/EYES/EARS/NOSE/THROAT: no scleral icterus, MMM, no O/P erythema or exudateNECK: carotid bruit on left, soft rubbery smooth thyroid mass palpated during swallowingNECK: carotid bruit on left, soft rubbery smooth thyroid mass palpated during swallowingLYMPH NODES: no cervical, supraclavicular, axillary or inguinal nodes palpatedLYMPH NODES: no cervical, supraclavicular, axillary or inguinal nodes palpatedCHEST: diffusely wheezy, decreased b.s., no dullness to percussion; L chest tubeCHEST: diffusely wheezy, decreased b.s., no dullness to percussion; L chest tubeCARDIOVASCULAR: S1, S2, no M/R heardCARDIOVASCULAR: S1, S2, no M/R heardABDOMEN: could hear heart beat throughout abdomen, mild RUQ tenderness, no Murphy's ABDOMEN: could hear heart beat throughout abdomen, mild RUQ tenderness, no Murphy's

sign, no masses, sign, no masses, GENTIOURINARY: foley in placeGENTIOURINARY: foley in placeSKIN: warm, drySKIN: warm, dryEXTREMITIES: trace edemaEXTREMITIES: trace edemaNEUROLOGIC: AO x 4, CN ii-xii intact, reflexes 2/4 diffusely, toes downward going, strength NEUROLOGIC: AO x 4, CN ii-xii intact, reflexes 2/4 diffusely, toes downward going, strength

5/5 diffusely, except LUE 4/5 (not new to pt)5/5 diffusely, except LUE 4/5 (not new to pt)


LABS:LABS:WBC 60.0 (PMN’s 87 % BANDS 6% LYMPH 3% MONO 4%; toxic granulation)WBC 60.0 (PMN’s 87 % BANDS 6% LYMPH 3% MONO 4%; toxic granulation)

Peak WBC of 106Peak WBC of 106Hct 32 MCV 89 Plts 357Hct 32 MCV 89 Plts 357NA 143 K 4.6 CL 101 CO2 34.0 BUN 71 CREA 1.6 Glc 106 iCa 2.48NA 143 K 4.6 CL 101 CO2 34.0 BUN 71 CREA 1.6 Glc 106 iCa 2.48AST 10 ALT 11 ALK PHOS 132 T BILI 0.3 ALB 2.5AST 10 ALT 11 ALK PHOS 132 T BILI 0.3 ALB 2.5

UA: trace glucose and 1+ occult blood without rbcs. No casts.UA: trace glucose and 1+ occult blood without rbcs. No casts.


BronchoscopyBronchoscopyRIGHT SIDE: All segments examined and normal in appearance.RIGHT SIDE: All segments examined and normal in appearance.LEFT SIDE: Large amount of thick, dark, secretions. Narrowing of the distal LEFT SIDE: Large amount of thick, dark, secretions. Narrowing of the distal left mainstem bronchus, unable to pass scope beyond carina at left upper lobe left mainstem bronchus, unable to pass scope beyond carina at left upper lobe take-off. Airway appears edematous and inflamed.take-off. Airway appears edematous and inflamed.

Micro: negativeMicro: negativePathology: insufficient for diagnosisPathology: insufficient for diagnosis

VATSVATSBiopsy:Malignant epithelioid neoplasm, mesothelioma vs lung epithelial though IHC Biopsy:Malignant epithelioid neoplasm, mesothelioma vs lung epithelial though IHC

inconclusive. inconclusive. Cam 5.2: Neoplastic cells 2-3 (+) VIM: Neoplastic cells 3 (+)Cam 5.2: Neoplastic cells 2-3 (+) VIM: Neoplastic cells 3 (+)S-100: Neoplastic cells (-) HMB-45: Neoplastic cells (-)S-100: Neoplastic cells (-) HMB-45: Neoplastic cells (-)Surfactant: Neoplastic cells (-) Calretinin: Neoplastic cells (-)Surfactant: Neoplastic cells (-) Calretinin: Neoplastic cells (-)WT-1: Neoplastic cells have faint, infrequent and non-revealingWT-1: Neoplastic cells have faint, infrequent and non-revealingpositivity.positivity.Mesothelin: Neoplastic cells (-) TTF: Neoplastic cells (-)Mesothelin: Neoplastic cells (-) TTF: Neoplastic cells (-)CK5/6: Neoplastic cells rarely positive (1+)CK5/6: Neoplastic cells rarely positive (1+)

IHC in Mesothelioma vs Lung IHC in Mesothelioma vs Lung CancerCancer

Leukemoid ReactionsLeukemoid Reactions SPURIOUS LEUKOCYTOSIS SPURIOUS LEUKOCYTOSIS Platelet clumping Platelet clumping Cryoglobulinemia Cryoglobulinemia PRIMARY NEUTROPHILIA PRIMARY NEUTROPHILIA Hereditary neutrophilia Hereditary neutrophilia Chronic idiopathic neutrophilia Chronic idiopathic neutrophilia Pelger-Huet anomaly Pelger-Huet anomaly Chronic myelogenous leukemia Chronic myelogenous leukemia Other myeloproliferative disorders Other myeloproliferative disorders Familial myeloproliferative disease Familial myeloproliferative disease Congenital anomalies and leukemoid Congenital anomalies and leukemoid

reaction reaction Down syndrome Down syndrome Leukocyte adhesion deficiency Leukocyte adhesion deficiency Familial cold autoinflammatory Familial cold autoinflammatory

syndrome and Muckle-Wells syndrome and Muckle-Wells syndrome syndrome

SECONDARY NEUTROPHILIA SECONDARY NEUTROPHILIA Cigarette smoking Cigarette smoking Acute infection Acute infection Chronic inflammation Chronic inflammation

- Effect of proinflammatory cytokines - Effect of proinflammatory cytokines Stress neutrophilia Stress neutrophilia

- Exercise - Exercise - Myocardial infarction - Myocardial infarction - Other - Other

Glucocorticoids and other drugs Glucocorticoids and other drugs Retinoic acid syndrome Retinoic acid syndrome Marrow stimulation Marrow stimulation Marrow invasion and leukoerythroblastic Marrow invasion and leukoerythroblastic

reaction reaction Nonhematologic malignancy Nonhematologic malignancy Sweet's syndrome Sweet's syndrome Heatstroke Heatstroke AspleniaAsplenia

Leukocytosis & nonhematological Leukocytosis & nonhematological malignanciesmalignancies

77 out of 252 patients (30%) 77 out of 252 patients (30%) 10 different types of nonhematological malignancy 10 different types of nonhematological malignancy Carcinomas of the lung and colorectum were the most prevalent Carcinomas of the lung and colorectum were the most prevalent Absolute monocytosis was found in 25% Absolute monocytosis was found in 25% Absolute eosinophilia in only 4.8%Absolute eosinophilia in only 4.8%Neither the age nor the sex of the patients affected the incidence or Neither the age nor the sex of the patients affected the incidence or magnitude of leukocytosismagnitude of leukocytosisMetastases was associated with a significantly higher incidence of Metastases was associated with a significantly higher incidence of leukocytosis (p less than 0.05leukocytosis (p less than 0.05Leukocytosis associated with a significantly (p less than 0.007) Leukocytosis associated with a significantly (p less than 0.007) shorter survival timeshorter survival time

Shoenfeld Y; Tal A; Berliner S; Pinkhas J. Leukocytosis in non hematological malignancies--a possible tumor-associated marker. J Cancer Res Clin Oncol 1986;111(1):54-8.

MesotheliomaMesotheliomaIncidence: 2200 cases per yr & increasingIncidence: 2200 cases per yr & increasingAt least 70% of cases associated with asbestosAt least 70% of cases associated with asbestosRegulated by OSHA in 1970Regulated by OSHA in 1970Asbestos workers have 50% chance of dying of malignancyAsbestos workers have 50% chance of dying of malignancyLifetime mesothelioma risk is 10%Lifetime mesothelioma risk is 10%Latency 30-40 years after exposureLatency 30-40 years after exposureHistology: epithelial, sarcomatoid, and biphasicHistology: epithelial, sarcomatoid, and biphasic

MesotheliomaMesothelioma

Herndon JE, Green MR, Chahinian AP, Corson JM, Suzuki Y, Vogelzang NJ. Factors predictive of survival among 337 patients with mesothelioma treated between 1984 and 1994 by the Cancer and Leukemia Group B. Chest. 1998 Mar;113(3):723-31.

But then…..But then…..

Pulmonary giant cell cancerPulmonary giant cell cancerRetrospective study of 78 patients w/ pleomorphic lung cancerRetrospective study of 78 patients w/ pleomorphic lung cancer

Seventy-eight cases of pleomorphic (spindle and/or giant cell) carcinoma of the Seventy-eight cases of pleomorphic (spindle and/or giant cell) carcinoma of the lunglung57 men and 21 women 57 men and 21 women 58 patients (80%) presented with symptoms: thoracic pain, cough, & hemoptysis, 58 patients (80%) presented with symptoms: thoracic pain, cough, & hemoptysis, StageStage– Stage 1 = 41%Stage 1 = 41%– Stage II = 6%Stage II = 6%– Stage III = 39%Stage III = 39%– Stage IV = 12%Stage IV = 12%

SubtypeSubtype– squamous cell carcinoma = 8%squamous cell carcinoma = 8%– large cell carcinoma = 25%large cell carcinoma = 25%– Adenocarcinoma = 45%Adenocarcinoma = 45%– Complete spindle/giant cell: 22%Complete spindle/giant cell: 22%

Survival (69 had f/u info)Survival (69 had f/u info)– 53 (77%) died within 7 days to 6 years after diagnosis53 (77%) died within 7 days to 6 years after diagnosis– 23-month mean survival23-month mean survival– median 10 months median 10 months

Fishback NF, Travis WD, Moran CA, Guinee DG Jr, McCarthy WF, Koss MN. Pleomorphic (spindle/giant cell) carcinoma of the lung. A clinicopathologic correlation of 78 cases. Cancer. 1994 Jun 15;73(12):2936-45.

Leukocytosis and large cell lung Leukocytosis and large cell lung cancercancer

Retrospective study of 105 patients w/ NSCLC over 5 yrs Retrospective study of 105 patients w/ NSCLC over 5 yrs 43 had leukocytosis43 had leukocytosis19 of the 43 attributed to tumor 19 of the 43 attributed to tumor 13 of 19 w/ absolute neutrophilia 13 of 19 w/ absolute neutrophilia 3 of 19 w/ eosinophilia 3 of 19 w/ eosinophilia Tumor-associated leukocytosis occurred predominantly, Tumor-associated leukocytosis occurred predominantly, and eosinophilia exclusively, in patients with large cell and eosinophilia exclusively, in patients with large cell pulmonary neoplasmspulmonary neoplasms

Ascensao JL; Oken MM; Ewing SL; Goldberg RJ; Kaplan ME. Leukocytosis and large cell lung cancer. A frequent association. Cancer 1987 Aug 15;60(4):903-5.

ReferencesReferencesOhbayashi H, Nosaka H, Hirose K, Yamase H, Yamaki K, Ito M. Granulocyte colony

stimulating factor-producing diffuse malignant mesothelioma of pleura.Intern Med. 1999 Aug;38(8):668-70.

Ascensao JL; Oken MM; Ewing SL; Goldberg RJ; Kaplan ME. Leukocytosis and large cell lung cancer. A frequent association. Cancer 1987 Aug 15;60(4):903-5.

Shoenfeld Y; Tal A; Berliner S; Pinkhas J. Leukocytosis in non hematological malignancies--a possible tumor-associated marker. J Cancer Res Clin Oncol 1986;111(1):54-8.

Herndon JE, Green MR, Chahinian AP, Corson JM, Suzuki Y, Vogelzang NJ. Factors predictive of survival among 337 patients with mesothelioma treated between 1984 and 1994 by the Cancer and Leukemia Group B. Chest. 1998 Mar;113(3):723-31.

sacgr june 8, 2006

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