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:
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
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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.
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
71 year old man with a pleural effusion
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
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.
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)
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.
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+)
IHC in Mesothelioma vs Lung Cancer
Leukemoid Reactions
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
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.
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
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.
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.
But then…..
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
–
–
–
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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.
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.
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):66870.
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.