27 Nov 2020

11/12/20: Metastatic Lung Adenocarcinoma

PGY2 Dominic Engracia presented a case of a 28 year old female with no known past medical history presents for chronic cough x 6months.  Patient was in her usual state of health until 6months ago when she started to notice a dry cough.  She went to an outside clinic 1 month ago where she reports she received an injection and a short course of oral antibiotics without improvement.  Over the same time, she has noticed a 20 pound non-intentional weight loss, headaches, nausea, chills and back pain.  She denies fevers, night sweats or hemoptysis.  Denies recent travel or sick contacts.  Family history significant for “pulmonary fibrosis” in maternal aunt, paternal grandfather with liver CA, deceased at age 72 and grandmother’s sister deceased at age 60 with unknown cancer.  The patient was born in Mexico and moved to Los Angeles since age 6.  Denies any history of homelessness, incarceration, tobacco/alcohol/drug use.  Previously worked at a warehouse but denies any chemical exposures.

Vitals: T 36.8, HR 104, RR 22, BP 126/82, O2 sat 99% on RA, BMI 39.1

Physical Exam significant for obese female, appearing comfortable, normal cardiac exam, lungs were difficult to appreciate due to body habitus, decreased breath sounds at bilateral bases, no wheezes or increased work of breathing.  No edema in extremities.  No clubbing or cyanosis.

CBC: WBC 9.4> Hb 16.4/Hct 48.1 <Plt 361 (MCV 88.6, RDW 13.3%)

CMP:

Na 141/K 3.7/Cl 104/HCO3 23/BUN 11/Cr 0.68 <Glucose 100

ALP 188>T.protein 7.0/Albumin 4.2/AST 31/ALT 38/Tbili 0.6/Dbili 0.2

Ca 9.6, Mg 2.1, Phos 4.2

Coags: PT 12, INR 1, PTT 27

Stat CXR done which showed diffuse pulmonary nodular opacities, concerning for infectious vs malignant process.

Infectious workup initiated, with the following findings:

  • Pulmonary TB rule out completed with 2 neg MTB PCRs and 3 negative AFB sputum smears
  • HIV negative
  • Respiratory culture nonspecific with multiple contaminated species
  • PCP DFA negative
  • Fungal studies negative including cocci, histo and aspergillus

CT Chest done showed extensive upper lung predominant bilateral pulmonary nodules and confluent consolidation.

Bronchoscopy with biopsy performed which resulted in lung adenocarcinoma.

Treatment: Once bronchoscopy was performed and confirmed lung malignancy, the patient underwent further scans that revealed multiple small enhancing spinal lesions and enhancing lesions in the R occipital lobe and L middle cranial fossa, all concerning for metastasis.  Guardant testing sent and the cancer was positive for EGFR.  At oncology clinic, the patient was started on Osimertinib 80mg qday and gamma knife radiosurgery single day treatment by radiology oncology. 

Teaching points:

  1. Non-small cell lung cancer (NSCLC) has a median age at diagnosis of 70 years old. In young patients (<40 years old) who are diagnosed with NSCLC, there is a higher proportion of women, adenocarcinoma, metastatic disease at diagnosis but survival rates are better than older patients. There is a higher genetic susceptibility among younger patients.
  2. Nonsquamous NSCLC should be tested for presence of a driver mutation – EGFR, ALK, etc.
  3. In the absence of significant toxicity, treatment with an EGFR TKI (Osimertinib) is continued until there is evidence of progression.

Teaching points:

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