1. NYU Medical Grand Rounds Clinical Vignette Lisa Cioce MD, PGY-2 March 10, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. A 67-year-old man presents with a persistent cough for 6 months. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS The patient was in his usual state of health until 6 months prior to admission, when he began to experience a cough productive of white sputum. Over this time, he also experienced increasing fatigue and a 10 pound weight loss. He had no fever, hemoptysis, and shortness of breath.

4. History of Present Illness The patient initially presented to an outside hospital one month ago, where a chest X-ray demonstrated a dense opacity involving the left mid and lower lung fields concerning for a mass. A subsequent CT scan of the chest revealed a mass in the lingula causing obstruction of the lingular bronchus with direct invasion of the left hilum and bronchovascular spread of the tumor peripherally. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS The patient underwent bronchoscopy with a transbronchial biopsy of the mass. Pathology demonstrated malignant cells consistent with poorly differentiated adenocarcinoma. He presents for further work-up.

6. Additional History U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Past Medical History Hyperlipidemia Past Surgical History Rotator cuff repair Family History Father: Lung cancer Brother: Diabetes mellitus Social History Former Smoker Quit 4 years ago 40 pack-year history Denies alcohol use Denies illicit drug use

7. Outpatient Medications U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Aspirin 81 mg daily Simvastatin 80 mg at bedtime Zolpidem 5 mg at bedtime Allergies: No known drug allergies

8. Physical Examination U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS General: Well-appearing man, in no acute distress Vitals: T 97F, BP 156/71, HR 75, RR 14 O 2 saturation: 98% on room air The remainder of the physical exam was normal

9. Laboratory Studies U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS CBC: Within normal limits Basic Metabolic Panel: Within normal limits Hepatic Panel: Alkaline phosphatase 154 U/L The remainder was within normal limits Lactate dehydrogenase: 1733 U/L (110-225 U/L) CEA: 360.4 ng/mL (0-5.0 ng/mL)

10. Imaging U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Imaging Official CT Report: Far advanced carcinoma of the lung with involvement of the left hilum, mediastinum, direct bronchovascular spread to the left lung and diffuse lymphangitic spread of the tumor bilaterally. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Non-small cell lung cancer: adenocarcinoma

13. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Staging PET scan was performed, demonstrating hypermetabolic foci in multiple areas including the left hilum, lingula, and posterior basal segment of the left lower lobe. Multiple foci in the mediastinum were noted. A 1.1 cm foci was found in the left iliac bone. MRI of the brain did not show evidence of metastatic disease.

14. Staging U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS CT guided left iliac bone biopsy was performed. Immunohistochemical studies showed reactivity for CK7 and TTF1 and non-reactivity for CK20, consistent with metastatic pulmonary adenocarcinoma.

15. Outpatient Treatment The patient was treated with an outpatient chemotherapy regimen of cisplatinum, pemetrexed and zolendronic acid. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

16. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Final Diagnosis Stage IV lung adenocarcinoma with bony metastatic disease

17. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS http://clinicalcorrelations.org Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine