DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Metastatic non-small cell lung cancer.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic woman with multiple medical problems, who presented with increasing shortness of breath, orthopnea and paroxysmal nocturnal dyspnea. She was suspected of having an effusion and was referred for emergency assessment. She was found to have a large left-sided pleural effusion and was admitted for further evaluation and therapy.
Her hospital course has been notable for CT scan of the chest revealing multiple pulmonary nodules, left and right lung, with the largest being on the left side in the upper lung fields. She had an associated large left-sided pleural effusion with associated atelectasis and compressive changes. Thoracentesis had been performed twice. The second time, it was performed today for relief of symptoms. She has had some improvement in her sense of dyspnea, but she requires oxygen therapy. A pleural fluid analysis was performed for sampling of pleural fluid four days ago. This revealed abnormal cells consistent with adenocarcinoma. This was CK7 positive, TTF-1 positive. Mammaglobin was negative. GCDFP-15 and cytokeratin 20 were also negative.
The patient does have a remote history of breast cancer but apparently of an early stage, treated with lumpectomy and radiation, and did not require adjuvant treatments. She has also had a history of thyroid malignancy, treated probably 25 years ago with a total thyroidectomy and radioactive iodine. She does not have any evidence of recurrent thyroid cancer since that time.
PAST MEDICAL HISTORY: Notable for chronic lung disease with asthmatic bronchitis. She has had a history of right-sided breast cancer, treated with lumpectomy and radiation therapy 10 years ago, apparently early stage, although we could not find the primary information. She has a history of thoracic aortic aneurysm that was repaired eight years ago. Again, we do not have the primary information available. Last year, she had an intracerebellar hemorrhage, midline, treated conservatively. During this time, she was also on anticoagulation. She also has underlying atrial fibrillation, of a chronic nature, was previously on Coumadin anticoagulation, presently on aspirin. She did not have Coumadin reinitiated after her intracerebellar hemorrhage. She also has a history of hypothyroidism, following the treatment for thyroid cancer, and hypertension.
PAST SURGICAL HISTORY: In addition to the right breast surgery, total thyroidectomy, bilateral hip arthroplasties, and bunion excision from both feet.
ALLERGIES: NKDA.
MEDICATIONS ON ADMISSION: Levothyroxine 0.5 mg daily, allopurinol 100 mg daily, potassium chloride 20 mEq daily, Toprol-XL 100 mg daily, lisinopril 10 mg daily, hydrochlorothiazide 12.5 mg daily, Celexa 20 mg daily and aspirin 81 mg daily.
FAMILY HISTORY: Notable for lung cancer in her brother, who recently passed away. Her brother was apparently a nonsmoker. However, no other family history of breast, lung, thyroid or other malignancies. Both of her parents have passed away. She has five children, apparently alive and in good health.
SOCIAL HISTORY: The patient is widowed and lives independently in an assisted care facility. She is a nonsmoker and has not smoked at all during her adult life. She was exposed to secondary smoke as a child. She does not drink alcohol. She is independent in activities of daily living.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Notable for stable weight. No recent change in activity, except with the recent physical activity with shortness of breath. She has noted some fatigue over the past week or two.
HEENT: No vision or hearing loss.
RESPIRATORY: Notable for shortness of breath as noted.
CARDIOVASCULAR: No chest pain or palpitations.
GASTROINTESTINAL: No altered bowel pattern, melena or hematochezia.
GENITOURINARY: No dysuria, hematuria or frequency.
MUSCULOSKELETAL: No arthritis or arthralgias. Her hip arthroplasties are functioning well.
SKIN: Without unusual rashes.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 112/76 with a pulse of 82, temperature 98.8. She is on nasal cannula oxygen with O2 saturation 98% on 2 liters.
HEENT: Normocephalic, atraumatic head. Pupils are reactive. She has oxygen delivered by nasal cannula. The oropharynx shows no mucosal lesions.
NECK: Supple.
LYMPH NODES: No obvious cervical, supraclavicular or axillary nodes.
LUNGS: Notable for decreased breath sounds bilaterally, could not definitely hear any rubs. She is dull throughout the left and right lung fields.
HEART: An irregularly irregular rhythm, soft early systolic flow murmur. No diastolic component. There is no significant jugular venous distention.
ABDOMEN: Soft and nontender. There is no clearly palpable liver or spleen.
EXTREMITIES: No clubbing, cyanosis or edema. She does have bilateral hip scars consistent with her arthroplasties.
SKIN: Notable for no significant rashes or cutaneous lesions.
LABORATORY DATA: CBC showed white count yesterday of 7500, hemoglobin 12.2 and platelet count 178,000. This is not appreciably different from her admission studies. Her BUN was 25 and creatinine was 1.1. She did not have any liver profile recently.
DIAGNOSTIC DATA: CT scan of the chest was reviewed and is notable for multiple spiculated nodules present in the right upper lobe, smaller nodules in the left upper lobe along with the largest nodule measuring about 2 cm in the left upper lobe. The liver, any area visualized, looks unremarkable. She has a large pleural effusion on the left as noted. Post thoracentesis today, chest x-ray still reveals a fairly sizable effusion.
IMPRESSION:
1. Poor prognosis, stage IV (T4NxM1) non-small cell lung carcinoma, adenocarcinoma (non-squamous).
2. History of cerebellar hemorrhage.
3. History of thoracic aortic aneurysm, repaired in the past.
4. History of right-sided breast cancer, apparently early stage, status post lumpectomy in the past, followed by radiation therapy.
5. Remote history of thyroid cancer, 25 years or more ago, treated with thyroidectomy and radioactive iodine.
This patient is currently with symptomatic pleural effusion and had a declining performance status. She has mild anorexia and multiple other medical problems, which do not appear to be acutely impairing her. Her overall prognosis with respect to the lung cancer is obviously quite poor, as this is an incurable process. We may be able to control the disease for a reasonable period of time through use of chemotherapy or through use of the EGFR inhibitor, erlotinib. As a nonsmoking Hispanic woman with adenocarcinoma, she actually may have a reasonably high chance of response to erlotinib. Further investigation for EGFR mutation would also be predictive of the likelihood of response. In fact, if we could document EGFR mutation, she may be more likely to benefit from the targeted therapy than chemotherapy. At this point, however, we will need to deal with a number of issues. Presently, insurance coverage of erlotinib depends on previous treatment with chemotherapy, i. e. erlotinib as a second-hand agent. We may be able to negotiate with the insurance companies if we could prove EGFR mutation. Secondly, however, is the uncertainty of the drug coverage that she may have, which may make the erlotinib unaffordable if she does not have appropriate insurance coverage. At this point, however, the patient is also uncertain as to whether she wishes to pursue therapy. She would like to discuss this with her daughter. Things to consider would include transportation for chemotherapy and/or insurance coverage for agents such as erlotinib. In addition, given the remote history of thyroid cancer, we should also check for this possibility, and this could be screened with a thyroglobulin assessment. Finally, it may be worthwhile also looking at a baseline bone scan to see whether she has any potential long bone involvement that could result in compromise in the near future.
RECOMMENDATIONS:
1. Although thoracentesis has been successful, long term she may be better treated with a pleural drainage catheter with subsequent pleurodesis.
2. As an outpatient, she can consider chemotherapy versus erlotinib.
3. We will make arrangements for a baseline bone scan.
4. We will also check the thyroglobulin level and CEA.
5. We will investigate whether the pathology department can run EGFR mutational analysis on the samples of tissue that they have available.
Thank you very much for the opportunity to participate in her care. We will continue to follow up along with you.
