DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: Jane Doe, MD
REASON FOR CONSULTATION: Metastatic adenocarcinoma, unknown primary.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who was admitted with progressive back pain and was found to have L2 compression fracture. She underwent kyphoplasty with pathology material revealing mucinous adenocarcinoma. Her MRI scans also showed edema at T1, T2, and T3, but no obvious metastatic disease. In the course of her evaluation, a CT of the abdomen and pelvis showed some mild common bile duct dilation, but no obvious primary malignancy. The patient apparently has had little in the way of other symptoms. No nausea or vomiting. No altered bowel pattern. No breast pain. No significant cough or shortness of breath. However, she does have an extensive smoking history of at least 30-35 years of 1 to 2 packs of rolled cigarettes, smoked on a daily basis. The patient has not noted any significant weight loss. There is no known family history of malignancies.
PAST MEDICAL HISTORY: Hypertension, asthma, and apparently had a cerebrovascular accident in the past; although, exact site of her deficit is uncertain to us. The patient has a known 5 cm thoracic aortic aneurysm found instantly on the CT scan in the past.
MEDICATIONS ON ADMISSION:
1. Advair.
2. Albuterol.
3. Lisinopril 5 mg daily.
4. Lovastatin 40 mg daily.
5. Diovan 160/12.5 mg daily.
6. Senna.
ALLERGIES: No known allergies.
FAMILY HISTORY: No malignancies.
SOCIAL HISTORY: The patient has a significant smoking history as noted previously. Does not consume alcohol. The patient is married and lives with her husband. Apparently, she has no unusual occupational exposures.
REVIEW OF SYSTEMS: Basically as noted in the history of present illness without GI or GU symptomatology. No menorrhagia. In general, no altered activities with the exception of this recent back pain.
PHYSICAL EXAMINATION:
VITAL SIGNS: This woman is lying in bed with blood pressure of 124/76 with pulse of 68. She is afebrile.
GENERAL: The patient is lying in bed and having some pain with attempts to roll to the side or sit up.
HEENT: Normocephalic and atraumatic head. Oropharynx showed no mucosal lesions.
NECK: Supple.
LYMPH NODES: No obvious cervical, supraclavicular or axillary nodes.
LUNGS: Fairly clear anteriorly and laterally, and no particular rales or dullness were identified.
HEART: Regular rate and rhythm. There is grade 2/6 pansystolic murmur heard best at the left apex, radiating slightly to the axilla. No diastolic component. No gallop or click.
BREASTS: No palpable nodules or masses.
ABDOMEN: Mildly tender diffusely, particularly in the epigastric region. No obvious mass. No palpable liver or spleen.
EXTREMITIES: No significant edema. No clubbing.
RECTAL: We did not do a rectal examination. Per the medical records, an ER physician did do a rectal exam demonstrating good rectal tone.
NEUROLOGIC: No obvious focal deficits.
SKIN: No unusual rashes.
DIAGNOSTIC AND LABORATORY DATA: The workup thus far included a CT of the pelvis. We could not find imaging of the chest. A mammogram was performed in the past and reportedly showed no particular abnormalities. Pathology report is still pending. However, our discussion with the pathologist indicates mucinous adenocarcinoma, which is CK7 positive and CK20 negative.
IMPRESSION:
1. Metastatic mucinous adenocarcinoma of unknown primary. Considerations as noted below.
2. Pathologic compression fracture, L2.
3. Probable metastatic disease, T1-T3, asymptomatic.
4. Extensive smoking history.
This patient has mucinous adenocarcinoma. Considerations would be lung primary site, gastric primary site, and ovarian would also be of consideration. The differential for CK7 positivity and CK20 negativity would include an upper GI source versus lung versus pancreatic or biliary or even GYN. The prognosis is grim regardless of the primary site; however, fortunately, she does not appear to have extremely high tumor burden. Thus, we can focus mostly on symptom management at present and at some point consider systemic therapy if her performance status worsens.
RECOMMENDATIONS:
1. We will obtain a chest x-ray looking for any obvious disease.
2. If the chest x-ray is unrevealing, it maybe reasonable to consider a CT scan in the future.
3. We will await plans for the MRCP.
4. We will check CA 19-9, CA-125, and CEA.
5. We would also like to check a bone scan to see if she has other sites of disease that may need palliation soon.
6. Corpectomy as per Dr. John Doe. This may be the most effective way to rapidly alleviate her symptoms and improve her performance status. Following this, she should also consider radiation treatment.
Thank you very much for allowing us to participate in this patient’s care. We will continue to follow along with you.
