SURGERY CASE
PRESENTATION
HISTORY
GENERAL DATA
J.A
68 y/o.
Male
Filipino
Roman Catholic
Langkaan, Dasmarinas Cavite
February 2, 1950
CHIEF
COMPLAINT Difficulty of breathing
HISTORY OF PRESENT ILLNESS
01 2 weeks history of on and off DOB
02 Occasional cough with blood tinged sputum
03 No febrile episode
04 History of consult at General Trias Hospital
CBC noted leukocytosis of 20. Sent home
05 given Levofloxacin 500 mg tab BID
HISTORY OF PRESENT ILLNESS
3 days PTA
After taking oral chemo noted DOB and
01
chest tightness
Consult at General Trias Hospital given
02
hydrocortisone IV, sent home.
On the interim, patient had loss of appetite,
03
complain of mouth sores
04 History of consult at General Trias Hospital
HISTORY OF PRESENT ILLNESS
Few hours
Sudden onset of DOB,
hence brought to ER.
PAST MEDICAL HISTORY
01 (+) HPN 2005
Amlodipine 5mg CD
03 S/P 9 cycle oral chemotx
Nabelvine
02 (+) Lung CA Stage IV
(April 2018)
PERSONAL HISTORY
01 50 pack years; smoking history
02 Alcoholic beverage drinker: occasional
PHYSICAL EXAMINATION
GENERAL SURVEY
Conscious, coherent, in
cardiorespiratory distress, weak looking
VITAL SIGNS:
BP: 100/60
CR: 120
RR: 32
Temp: 36.5 Celsius
O2: 90-91%
PHYSICAL EXAMINATION
SKIN
01
Warm to touch CHEST AND LUNGS
SCE
HEAD AND NECK Decreased breath sounds
03 R mid-base
Dry lips and oral mucosa
AS (-) wheezing
02 Pink palpebral conjunctiva decrease vocal and tactile fremitus
Noted white plaque on tongue on right
(-) NAD
(-) CLAD
(-) TPC
PHYSICAL EXAMINATION
CARDIOVASCULAR
04 AP
Tachycardic EXTREMITIES
Regular rhythm
No murmur
06 (+) Swelling Left leg
Full pulses
ABDOMINAL
Flabby
05
NABS
Soft
Non tender
NEUROLOGICAL EXAM
• Mental Status: Conscious, coherent
• Cranial Nerves:
• CN I: N/A
• CN II: 2-3 mm pupils equally reactive to light
• CN III, IV, VI: Extraocular muscles intact
• CN: V: Can clench teeth
• CN VII: No facial asymmetry
• CN VIII: Intact gross hearing
• CN IX, X: (+) gag reflex
COURSE IN THE WARD
1st day Patient is conscious but with cardiorespiratory
distress and weak looking.
BP is 100/60 HR is 120
Decreased breath sound at right mid to base
lung field
Swelling on the left leg
Urinalysis
• Color: Dark Yellow • Specific Gravity: 1.020
• Transparency: Slightly hazy • PUS cells: 0-2/HPF
• Reaction: Acidic 5.0 • RBC: 5-10/HPF
• Protein: Trace • Epithelial Cells: Rare
• Glucose: Negative • Hyaline Cast: >10/LPF
Chest AP
Previous flm not available for comparison
There is homogenenous density in the right lower lobe with suspicious
semicircmscribed density.
Right hemidiaphragm amd right costophrenic sulcus are obscured.
Heart size cannot be properly evaluated.
Aortic knob is calcified.
Other visualized structures are unremarkable.
Impression:
Consider Pleural effusion or thickening with
suspicious concomittant pulmonary mass.
Correlation with contrast enhanced chest C
T scan is suggested.
Atherosclerotic Aorta.
Sputum
Gram Stain:
Specimen Source: Pleural Fluid
Gram Stain Result: PMS (Polymorphonuclear segmenters)/PUS Cells: MOre
than 50/ HPF
No microorganism seen
No fungal elements seen
AFB STain:
Specimen Source: Pleural Fluid
Result: No AFB seen in 300 visual fields
COURSE IN THE WARD
01 Venoclysis was started with PNSS x 1L x 60cc/hr
02 Piperacillin-Tazobactam (Piptaz) 4.5 g IV
2.25 g IV every 8 hours, Fenoterol hydrobromide +
03 Ipratropium
Bromide (Berodual) nebulization every 6 hours
04
Hydrocortisone 100 mg IV every 8 hours
CBC noted leukocytosis of 20.
05
Sent home given Levofloxacin 500 mg tab BID
COURSE IN THE WARD
Few hours Difficulty of breathing. Calcium gluconate 1
01 amp slow through IV push and 1 vial
02 D5050 + HR 5u every 8 hours for 3 doses were given
and Norepinephrine 8 mg + 100 cc
03 PNSS run at 24 ugtts (0.5 mg/kg.hr) titrated by 2-3 ugtts
to maintain systolic bloodpressure ≥ 110mmHg
(Max: 49 ugtts/mg/kg/hr)
04 Fluconazole 100 mg/cap, 1 cap once a day
Mycostatin oral suspension, 10cc dilute in 10 cc water,
05 gargle then swallow 3x a day were started
COURSE IN THE WARD
Few hours Hydrocortisone was increased to 150 mg IV
06 every 8 hours
07 Berodal nebulization was increased to every 4 hours
08 N-acetylcysteine (Exflem) 600 mg/tab 1 tab in 75 mL
water once a day
09 Fluconazole 100 mg/cap, 1 cap once a day
Piperacillin-Tazobactam (Piptaz) 2.25 g IV was
10
shifted to Meropenem (Meromax) 1g IV every
8 hours
2nd day
CT Scan
CT scan of the chest with lung and mediastinal windows show the following findings:
• The previously noted soft tissue density is seen in the right lower lobe measuring ab
out 11.3 x 9.7 x 9.0 cm
• There is atelectasis of the adjacent lung.
• Basal pleural thickening is noted bilaterally.
Impression:
Right Lower lobe mass
Fibrotic changes, both lower lobes
Bibasal pleural thickening
Emphysematous changes both upper lobes
2nd day
Histologic Findings
Gross and Microscopic Examination:
Submitted for cytology labeled as “Pleural fluid” with approximate volume of 120 ml, reddish
brown and turbid. Four (4) smears and cell block are prepared.
The smears and cell block contain many singly scattered neoplastic cells that have large dark
pleomorphic nuclei and have minimum cytoplasm. These also form sheets and small loosely
cohesive clusters. Multinucleated giant are seen. These are set in granular background.
3rd day
COURSE IN THE WARD
01 4th – 6th day
• Edema L Leg
• Still decreased
breath sounds
COURSE IN THE WARD
8th day
7th day
• Dysuria
• Edema progressed
from grade 2 to
grade 3
COURSE IN THE WARD
12th day
10th day
• Hospital day
• No fever
• No DOB
• No chest pain
• Grade 2 edema on right leg,
with grade 3 edema on left
leg
COURSE IN THE WARD
01 17th day
• Cough
• Decreased breath • Fondaparinux was decreased to 5 mg SC once a day
sounds on right • Levopront syrup 10 ml twice a day was started
base lung field • Repeat x-ray
• Erythema • Management was continued.
• Swelling on the • Patient improved.
left leg
• Repeat PTT
COURSE IN THE WARD
01 26th day
• No difficulty of breathing
• No chest pain
• No desaturation, still with decreased breath sounds at right base
• Soft and non-tender abdomen
• Scrotum swelling
• Hyperpigmentation of left leg
• Medical management was continued
• Transfer to other hospital was considered.
INITIAL IMPRESSION
Acute Respiratory Failure Type 1 Secondary to
Pneumonia High Risk, Pleural Effusion Right; Lu
ng Cancer Stage IV (NSSCA); S/P Oral Chemot
herapy 9 Cycles (Navelbine); Hypertension; Sep
tic Shock Secondary to Community Acquired Hig
h Risk; Oral Candidiasis
DIFFERENTIAL DIAGNOSIS
• Pulmonary Tuberculosis
Rule in Rule out
DOB (-) Fever
Cough (+) swelling
Blood-tinged sputum (-) Anorexia
• Pulmonary Tuberculosis
Rule in Rule out
DOB (-) Fever
Cough (+) swelling
Blood-tinged sputum (-) Anorexia
FINAL DIAGNOSIS
Peripheral Arterial Occlusive Disease Left
Leg; ARF Type 1 Secondary to Pneumonia
High Risk; Pleural Effusion, Right
Secondary to Paramalignancy Lung Cancer
Stage IV (NSSCA); S/P Oral Chemotherapy
9 cycles (Navelbine); Hypertension
DISCUSSION
Anatomy
• Organ for respiration
• Paired cone shaped organ lying in the
thoracic cavity
LUNGS
• Base - resting on the diaphragm Hilum – site of entrance and exit of structures
• Apex - extending superiorly to associated with the lungs (bronchus, blood ve
a point superior to the clavicle ssels, lymphatic vessels and nerves)
Pleura
Visceral pleura (inner)
covers the lungs and adjoining
structures, including blood ves
sels, bronchi and nerves.
Parietal pleura (outer)
the pulmonary cavities and
adhere to the thoracic wall,
mediastinum and diaphragm
The pleural cavity is
Pleural 01 the potential space
between the visceral
Cavity and parietal layers of
the pleura
Surface tension create
d by the pleural cavity
provides the cohesion It contains a capillary
that keeps the lung 02 layer of serous pleural
fluid which lubricates
surface in contact with the pleural surfaces
the thoracic wall and allows the layers to
slide smoothly over
each other during
respiration
Right lung
Upper Lobe 1. Anterior
2.Posterior
3.Apical
Medial Lobe 4.Lateral
Broncho Lower Lobe
5.Medial
6.Superior
7.Medial basal
Pulmonary 8.Anterior basal
9.Lateral basal
Segment 10.Posterior basal
Left lung
Upper Lobe 1-2. Apical-Posteri
or
3.Anterior
4.Superior lingual
5.Inferior lingual
Broncho Lower Lobe 6.Superior
Pulmonary 7-8.Anterior basal
9.Lateral basal
Segment 10.Posterior basal
Blood Supply
Nerve Supply
• Innervated by the branches of sympathetic
Bronchial arteries
trunk and vagus
provide blood supply to the non-respiratory
nerve airways, pleura, and connective tissue
Sympathetic nervous stimulation:
Pulmonary arteries
bronchodilation and vasoconstriction
supply the respiratory units (acini) and
participate in gas exchange.
Parasympathetic nervous stimulation:
Venous drainage
bronchoconstriction and vasodilation
pulmonary veins (right and left
superior and inferior pulmonary veins)
Nodal
Station 10: Hilar
11: Interlobar
12: Lobar
Pulmonary Lymph
13: Segmental
nodes N1
14: Subsegmental
•More peripheral
•All are paired
1: Higher mediastinal
Nodal 2: Upper paratracheal
3: Retro paratracheal
Station
4: Lower paratracheal
5: Subaortic
Mediastinal nodes N2
6: Para aortic (Ascending Aorta)
7: Subcarinal
8: Paraesophageal
9: Pulmonary ligament
Epidemiology
Most common cause of cancer
death (1.59 million)
New lung cases:
117,920 cases
106,470 cases
Lung
Cancer • top cause of cancer-related deaths amo
ng men
• third cause of cancer deaths among wo
men
> 39 yrs. Very Low
old
50-70
yrs. old
70 yrs.
old and
Predominate
Peak age
>
above
Etiology
LUNG CANCER
Pathophysiology
History of Lung
Cancer
Cancer Cells
Metastasize
Enters lymphatic system Enters blood stream
Travels along pulmonary
Settles at parietal lymphatic vessel
vessels to ipsilateral
of the pleura
visceral pleura
Cells accumulate and
Cells accumulate and proliferate
proliferate
Occlusion of stoma on the
Occlusion of stoma on the parietal
parietal pleura; Increase in
pleura; Increase in oncotic pressure
oncotic pressure
Increase capillary
Increase capillary permeability or
permeability or vascular
vascular disruption
disruption
Malignant Pulmonary
Malignant Pulmonary Effusion
Effusion
DIAGNOSTICS
HISTORY AND PHYSICAL EXAM
CHEST RADIOGRAPH
CT SCAN: Standard for staging
MRI: Spinal cord compression
• Diagnostic and therapeutic
NEEDLE THORACENTESIS • Sensitivity (80%)
• Specificity (>90%)
SPUTUM CYTOLOGY
THORACOSCOPY
COMPLETE BLOOD COUNT
LIVER FUNCTION TEST
• AST, ALT, GGT, PT, Alkaline phosphatase level
ARTERIAL BLOOD GAS
• respi
Diagnostic Tests
Surgical Treatment
Operative Procedure: CTT, Right (JP drain insertion)
Post Op Diagnosis: Pleural Effusion Secondary to Malignancy
Lung Cancer Stage IV
OR FIndings: Initially drained 200 cc of serous non-clotting pleural fluid
Surgical Pathology Report:
Operation performed: CTT, Right (JP Drain Insertion)
Specimen: Pleural FLuid right
CLinical DIagnosis: Pleural Effusion secondary to malignancy
Diagnosis: Right Pleural fluid, cytology and cell block
Positive for malignant cells
Remarks: Favor Non-small cell carcinoma
Pharmacological Treatment
a) Antineoplastic agent-carboplatin, vinorelbine, paclitaxel
b) PD-1/PD-L1 inhibitors(expressed on T-cells)-Nivolumab, Pembrolizumab, Atezolizumab
c) Anti-emetic-Ondansetron, Granisetron, Dolasetron
d) Antineoplastic, MEK inhibitors- Trametinib
e) Antineoplastic , Anaplastic lymphoma kinase inhibitor-Crizotinib, Ceritinib
Prognosis
Conclusion
The patient was given medicines and CTT procedure that were directed at h
is symptomatology and thus, was palliative. Surgery is occasionally appropri
ate for highly selected patients with tumors invading the SVC, carinal or vert
ebral body involvement, or satellite nodules in the same lobe. However, surg
ery generally does not have a role in the care of patients with any tumor with
N3 disease or T4 tumors with N2 disease. Thus, the only appropriate mana
gement for the patients’ lung cancer is chemotherapy.
Patient was discharged after his expressed desire to transfer to another insti
tution.
Recommendation
A comprehensive physical examination, specifically of the extremities, would have giv
en the impression of peripheral arterial occlusive disease from the start. It is expecte
d that the patient has unequal pulses and supposedly unequal blood pressure, if take
n on both upper and lower extremities.
Also, a copy of the biopsy would have given the physicians a clearer view as to what
type of non-small cell lung carcinoma is the patient dealing with.
The patient could also benefit from the endovascular or surgical interventions of perip
heral arterial occlusive disease such as stent placement, thrombectomy, thromboaspi
ration, embolectomy, or bypass graft thrombectomy and other similar modalities.
Review of Related Literature
According to Molina et. al (2008), lung cancer is the leading cause of cancer-related mortali
ty not only in the United States but also around the world. Over half of patients diagnosed with l
ung cancer die within one year of diagnosis and the 5-year survival is around 17.8% (Zappa & M
ousa, 2016).
A study conducted by Zappa & Mousa (2016) identified smoking as the major risk factor.
A study conducted by Zarogoulidis et. al. (2013) revealed that, radical surgery is the standar
d of care for fit stage I non-small cell lung cancer (NSCLC) patients.
Schad et. al. (2018) study revealed that one-year and three-year overall survival rates were
greater with CTx plus VA compared to CTX alone which suggest that concomitant VA is positive
ly associated with survival in stage IV NSCLC patients treated with standard CTx.
References
Molina, J. R., Yang, P., Cassivi, S. D., Schild, S. E., & Adjei, A. A. (2008). Non–Small Cell Lung Cancer: E
pidemiology, Risk Factors, Treatment, and Survivorship. Mayo Clinic Proceedings. Mayo Clinic, 83(5), 58
4–594.
Schad, F., Thronicke, A., Steele, M.L., Merkle, A., Matthes, B., Grah, C., Matthes, H. (2018). Overall s
urvival of stage IV non-small cell lung cancer patients treated with Viscum album L. in addition to
chemotherapy, a real-world observational multicenter analysis. Plos. https://doi.org/10.1371/journ
al.pone.0203058
Tan, W. W., & Karim, N. A. (2018). Non-Small Cell Lung Cancer. https://emedicine.medscape.com/article/
279960-overview
Zappa, C., & Mousa, S. A. (2016). Non-small cell lung cancer: current treatment and future advances. Tra
nslational Lung Cancer Research, 5(3), 288–300. http://doi.org/10.21037/tlcr.2016.06.07
Zarogoulidis, K., Zarogoulidis, P., Darwiche, K., Boutsikou, E., Machairiotis, N., Tsakiridis, K., … Spyratos,
D. (2013). Treatment of non-small cell lung cancer (NSCLC). Journal of Thoracic Disease, 5(Suppl 4), S3
89–S396. http://doi.org/10.3978/j.issn.2072-1439.2013.07.10
