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SACGR June 8, 2006

SACGR June 8, 2006. 71 year old man with a pleural effusion. CHIEF COMPLAINT: 71 y/o male transferred from OSH for further work up of bloody exudative pleural effusion. HPI:

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SACGR June 8, 2006

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  1. SACGRJune 8, 2006

  2. 71 year old man with a pleural effusion CHIEF COMPLAINT: 71 y/o male transferred from OSH for further work up of bloody exudative pleural effusion. HPI: • In April, week of worsening SOB, fatigue, cough with increased blood tinged sputum, and a subjective report of fever and chills • CXR = LLL infiltrate and WBC was 15.9 • Cetriaxone and azithromycin • Subsequent CXR showed increasing LLL infiltrate and pleural effusion • Total protein 3.3, LDH 241, glucose 242, WBC 1700, 36% pmns, 62% lymphocytes • Negative cytology & AFB • Went home requiring 3 L O2 along with a prednisone taper. • On f/u, hct = 22.9 and he was transfused with 3 U PRBC • Mid-May: worsening SOB& O2 sats were in the low 70s • ABG = 7.15/75/150; BiPap started • Low BP, started on dopamine; pip/tazo and vanco added. • Respiratory distress continued on BiPAP • CXR = large left pleural effusion • 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 negative • CT after the tap showed large effusion and possibility of organized clot. • Chest tube was placed, 3.2 L drained. • O2 requirements decreased and he was able to go back to a nonrebreather at 8L O2.

  3. 71 year old man with a pleural effusion PAST MEDICAL HISTORY: • COPD on home O2 • Pulmonary fibrosis • hx of alcoholism • hx of homelessness • htn • hyperlipidemia • anemia of chronic disease (low fe, low tibc, high ferritin) – colonoscopy pending • Chronic LBP (Sciatica) • Prostate cancer treated with seeds • hx of head injury in 1982 2/2 MVA ALLERGIES: BANANAS, no known drug allergies

  4. Medications at home Furosemide 40 mg po qd albuterol ipratroprium valsartan 80 mg po bid metoprolol 100 mg po qd spironolactone 12.5 mg po qd ASA 81 mg po qd terazosin 4 mg po bid gabapentin 200 mg po qid tramadol 50 mg po bid Ferrous sulfate TID Medications on transfer Protonix 40 mg po qd zosyn 3.375 gm IV q8h vancomycin 1 gm IV methylprednisolone 20 mg IV BID Acetylcysteine 600 mg po bid through 5/17/06 combivent q4 lantus insulin 10 units qam morphine 1-3 mg q30 min prn 71 year old man with a pleural effusion

  5. 71 year old man with a pleural effusion HABITS • Tobacco: 1.5 ppd x 50yrs • Alcohol: history of abuse, no alcohol for >1 yr 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. FAMILY HISTORY: parents were heavy drinkers. Father had emphysema. Brother with CAD, died at age 68. Brother died of lung disease, of unknown type.

  6. 71 year old man with a pleural effusion PHYSICAL EXAM: T96.8F BP122/54 P100 R17 SpO2 94% RA WT80.3 kg HT67in GENERAL: NAD, wearing non-rebreather HEAD/EYES/EARS/NOSE/THROAT: no scleral icterus, MMM, no O/P erythema or exudate NECK: carotid bruit on left, soft rubbery smooth thyroid mass palpated during swallowing LYMPH NODES: no cervical, supraclavicular, axillary or inguinal nodes palpated CHEST: diffusely wheezy, decreased b.s., no dullness to percussion; L chest tube CARDIOVASCULAR: S1, S2, no M/R heard ABDOMEN: could hear heart beat throughout abdomen, mild RUQ tenderness, no Murphy's sign, no masses, GENTIOURINARY: foley in place SKIN: warm, dry EXTREMITIES: trace edema 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)

  7. 71 year old man with a pleural effusion LABS: WBC 60.0 (PMN’s 87 % BANDS 6% LYMPH 3% MONO 4%; toxic granulation) Peak WBC of 106 Hct 32 MCV 89 Plts 357 NA 143 K 4.6 CL 101 CO2 34.0 BUN 71 CREA 1.6 Glc 106 iCa 2.48 AST 10 ALT 11 ALK PHOS 132 T BILI 0.3 ALB 2.5 UA: trace glucose and 1+ occult blood without rbcs. No casts.

  8. 71 year old man with a pleural effusion Bronchoscopy RIGHT SIDE: All segments examined and normal in appearance. 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 take-off. Airway appears edematous and inflamed. Micro: negative Pathology: insufficient for diagnosis VATS Biopsy:Malignant epithelioid neoplasm, mesothelioma vs lung epithelial though IHC inconclusive. Cam 5.2: Neoplastic cells 2-3 (+) VIM: Neoplastic cells 3 (+) S-100: Neoplastic cells (-) HMB-45: Neoplastic cells (-) Surfactant: Neoplastic cells (-) Calretinin: Neoplastic cells (-) WT-1: Neoplastic cells have faint, infrequent and non-revealing positivity. Mesothelin: Neoplastic cells (-) TTF: Neoplastic cells (-) CK5/6: Neoplastic cells rarely positive (1+)

  9. IHC in Mesothelioma vs Lung Cancer

  10. SPURIOUS LEUKOCYTOSIS Platelet clumping Cryoglobulinemia PRIMARY NEUTROPHILIA Hereditary neutrophilia Chronic idiopathic neutrophilia Pelger-Huet anomaly Chronic myelogenous leukemia Other myeloproliferative disorders Familial myeloproliferative disease Congenital anomalies and leukemoid reaction Down syndrome Leukocyte adhesion deficiency Familial cold autoinflammatory syndrome and Muckle-Wells syndrome SECONDARY NEUTROPHILIA Cigarette smoking Acute infection Chronic inflammation - Effect of proinflammatory cytokines Stress neutrophilia - Exercise - Myocardial infarction - Other Glucocorticoids and other drugs Retinoic acid syndrome Marrow stimulation Marrow invasion and leukoerythroblastic reaction Nonhematologic malignancy Sweet's syndrome Heatstroke Asplenia Leukemoid Reactions

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

  12. Mesothelioma • Incidence: 2200 cases per yr & increasing • At least 70% of cases associated with asbestos • Regulated by OSHA in 1970 • Asbestos workers have 50% chance of dying of malignancy • Lifetime mesothelioma risk is 10% • Latency 30-40 years after exposure • Histology: epithelial, sarcomatoid, and biphasic

  13. Mesothelioma 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.

  14. Mesothelioma 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.

  15. But then…..

  16. Pulmonary giant cell cancer Retrospective study of 78 patients w/ pleomorphic lung cancer • Seventy-eight cases of pleomorphic (spindle and/or giant cell) carcinoma of the lung • 57 men and 21 women • 58 patients (80%) presented with symptoms: thoracic pain, cough, & hemoptysis, • Stage • Stage 1 = 41% • Stage II = 6% • Stage III = 39% • Stage IV = 12% • Subtype • squamous cell carcinoma = 8% • large cell carcinoma = 25% • Adenocarcinoma = 45% • Complete spindle/giant cell: 22% • Survival (69 had f/u info) • 53 (77%) died within 7 days to 6 years after diagnosis • 23-month mean survival • 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.

  17. Leukocytosis and large cell lung cancer Retrospective study of 105 patients w/ NSCLC over 5 yrs • 43 had leukocytosis • 19 of the 43 attributed to tumor • 13 of 19 w/ absolute neutrophilia • 3 of 19 w/ eosinophilia • Tumor-associated leukocytosis occurred predominantly, and eosinophilia exclusively, in patients with large cell pulmonary 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.

  18. References Ohbayashi 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.

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