Treatment and Care of NSCLC

Treatment and Care of NSCLC
MGR Treatment and Care of NSCLC R2 이은정 / prof 김시영

History 10818899 이○희 (M/54) Adm> 2003.9.2
Chief Complaint 호흡 곤란 o/s> 내원 한달 전 Present illness 54세 남자환자로 내원 한달 전부터 운동시 발생하는 호흡 곤란 있었으며 이후 증상 점차 악화되고 우측 옆구리 통증 동반되어 내과 외래 방문, 흉부 방사선 검사 시행 결과 우측 흉수 발견되어 자세한 평가 위해 입원함.

History Past Medical History Personal History none Family History
DM / Tb / hepatitis ( - / - / - ) HTN (+) : 7년 전부터 약 복용 clinidipine 10mg qd Operation Hx (+) : 20년전 맹장수술 Personal History none Family History Unremarkable

Review of System General Febrile sensation (-) Chill (-) weight loss (+) : 4개월간 3kg Skin Rash (-) Pigmentation (-) H&N Headache (-) Visual field defect (-) Respiratory Cough (+) Sputum (-) Dyspnea on exertion(+) Cardiac Chest pain (-) Palpitation (-) G-I Anorexia (-) Nausea (-) Vomiting (-) Diarrhea (-) Constipation (-) Renal Dysuria (-) Urgency (-) Frequency (-) Hematuria (-) Back & Ext Back pain (-) Arthralgia (-)

Physical Examination General Appearance
V/S 150/90mmHg – 90/min – 20/min – 36.8 ℃ General Appearance Alert mentality Acutely ill looking appearance Head & Neck No cervical LN enlargement No neck vein engorgement Eye & ENT Isocoric pupil with PLR (++/++) Pinkish conjunctiva Clear sclera Chest Decreased breathing sound on RLL Regular heart beat without murmur Body weight :74.6 Kg Height : 162 cm BMI : 28.4

Physical Examination Abdomen
Soft and flat abdomen Normoactive bowel sound Tenderness (-) Rebound tenderness (-) Hepatosplenomegaly (-) Back & Ext. CVA tenderness (-/-) Pretibial pitting edema (-/-)

Initial Laboratory Findings
CBC/DC 12,650/mm g/dL – 47.6% - 280,000 /mm3 (Seg 72.4%) PT INR 1.00 Chemistry Prot / Alb / 4.4 g/dL LD / CK / 136 U/L ALP U/L Ca / P / 2.5 mg/dL AST / ALT / 30 U/L BUN / Cr / 1.0 mg/dL Na / K / Cl / 3.8 / 107 mmol/L U/A RBC 0-1 /HPF WBC 0-1 /HPF

Initial Chest X-ray ( )

Initial EKG ( )

Initial Assessment & Plan
#1. Pleural effusion, Rt r/o Neoplastic disease r/o Infectious disease r/o Congestive heart disease #2. HTN

Initial Assessment & Plan
#1. Pleural effusion, Rt Thoracentesis – pleural fluid analysis, cytology Pleural biopsy, if needed Chest CT #2. HTN Serial BP check

#1. Pleural effusion, Rt Pleural fluid analysis
pH : 7.4 WBC : 700 / mm3 (seg 1%, lymph 71%) RBC : 1500 / mm3 Prot : 4.9 g/dL ADA 24 LD : 434 unit glc : 95 Pleural fluid analysis Chest CT, Abdominal sono Pathology Bone scan No active bony lesion cytology : highly suggestive of malignancy pleural biopsy : adenocarcinoma < abd sono > Rt pleural effusion Mild fatty liver

Staging Clinical information: R/O esophageal ca.
Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. 13

Clinical information: R/O esophageal ca.

Clinical course (2003.9.16 ~ 2009.6.24) Date Chemotherapy
~ PTx #7 ~ GemVnr #3 Brain meta ~ RTx #6 ~ Iressa po (OPD) ~ Alimta #9 Liver, lung meta Bone meta ~ CbdTx #8 ~ IrP #6 ~ CbTx #3 / GKRS #2 Genexole + Cisplatin Clinical information: R/O esophageal ca. Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. 17

Clinical course Date Chemotherapy 03.9.16 ~ 04.1.26 PTx #7
~ GemVnr #3 Brain meta ~ RTx #6 ~ Iressa po (OPD) ~ Alimta #9 Liver, lung meta Bone meta ~ CbdTx #8 ~ IrP #6 ~ CbTx #3 / GKRS #2 Clinical information: R/O esophageal ca. Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. : equivocal slight enlarged right lower lobe mass(48x30mm) 18

~ GemVnr #3 Brain meta ~ RTx #6 ~ Iressa po (OPD) ~ Alimta #9 Liver, lung meta Bone meta ~ CbdTx #8 ~ IrP #6 ~ CbTx #3 / GKRS #2 Gemzar + Vinorelbine Clinical information: R/O esophageal ca. Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. 19

~ GemVnr #3 Brain meta ~ RTx #6 ~ Iressa po (OPD) ~ Alimta #9 Liver, lung meta Bone meta ~ CbdTx #8 ~ IrP #6 ~ CbTx #3 / GKRS #2 Clinical information: R/O esophageal ca. Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. : metastatic tumor at Rt frontal lobe with surrounding edema (30x38mm) 20

~ GemVnr #3 Brain meta ~ RTx #6 ~ Iressa po (OPD) ~ Alimta #9 Liver, lung meta Bone meta ~ CbdTx #8 ~ IrP #6 ~ CbTx #3 / GKRS #2 300cGry/fx/day x 12fx = 3600 cGy Clinical information: R/O esophageal ca. Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. 21

~ GemVnr #3 Brain meta ~ RTx #6 ~ Iressa po (OPD) ~ Alimta #9 Liver, lung meta Bone meta ~ CbdTx #8 ~ IrP #6 ~ CbTx #3 / GKRS #2 Gefitinib 250mg Clinical information: R/O esophageal ca. Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. 22

~ GemVnr #3 Brain meta ~ RTx #6 ~ Iressa po (OPD) ~ Alimta #9 Liver, lung meta Bone meta ~ CbdTx #8 ~ IrP #6 ~ CbTx #3 / GKRS #2 Clinical information: R/O esophageal ca. Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. : aggravated lung cancer on RML, RLL with distal collapse (33.89mm) 23

~ GemVnr #3 Brain meta ~ RTx #6 ~ Iressa po (OPD) ~ Alimta #9 Liver, lung meta Bone meta ~ CbdTx #8 ~ IrP #6 ~ CbTx #3 / GKRS #2 Pemetrexed 820mg Clinical information: R/O esophageal ca. Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. 24

~ GemVnr #3 Brain meta ~ RTx #6 ~ Iressa po (OPD) ~ Alimta #9 Liver, lung meta Bone meta ~ CbdTx #8 ~ IrP #6 ~ CbTx #3 / GKRS #2 Clinical information: R/O esophageal ca. Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. : suggestive of hepatic metastasis 25

~ GemVnr #3 Brain meta ~ RTx #6 ~ Iressa po (OPD) ~ Alimta #9 Liver, lung meta Bone meta ~ CbdTx #8 ~ IrP #6 ~ CbTx #3 / GKRS #2 Clinical information: R/O esophageal ca. Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. : multiple bony meta to T9, T11, Both iliac bones and Rt acetabulum 26

~ GemVnr #3 Brain meta ~ RTx #6 ~ Iressa po (OPD) ~ Alimta #9 Liver, lung meta Bone meta ~ CbdTx #8 ~ IrP #6 ~ CbTx #3 / GKRS #2 Clinical information: R/O esophageal ca. Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. Carboplatin + Docetaxel 27

~ GemVnr #3 Brain meta ~ RTx #6 ~ Iressa po (OPD) ~ Alimta #9 Liver, lung meta Bone meta ~ CbdTx #8 ~ IrP #6 ~ CbTx #3 / GKRS #2 Clinical information: R/O esophageal ca. Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. : aggravation of lung cancer on RML, RLL aggravation of lung metastasis 28

~ GemVnr #3 Brain meta ~ RTx #6 ~ Iressa po (OPD) ~ Alimta #9 Liver, lung meta Bone meta ~ CbdTx #8 ~ IrP #6 ~ CbTx #3 / GKRS #2 Clinical information: R/O esophageal ca. Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. Irinotecan + Cisplatin 29

~ GemVnr #3 Brain meta ~ RTx #6 ~ Iressa po (OPD) ~ Alimta #9 Liver, lung meta Bone meta ~ CbdTx #8 ~ IrP #6 ~ CbTx #3 / GKRS #2 Clinical information: R/O esophageal ca. Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. : increased size of lung cancer (64.42x41.25mm) aggravation of lung metastasis 30

~ GemVnr #3 Brain meta ~ RTx #6 ~ Iressa po (OPD) ~ Alimta #9 Liver, lung meta Bone meta ~ CbdTx #8 ~ IrP #6 ~ CbTx #3 / GKRS #2 Clinical information: R/O esophageal ca. Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. Carboplatin + Taxol 31

~ GemVnr #3 Brain meta ~ RTx #6 ~ Iressa po (OPD) ~ Alimta #9 Liver, lung meta Bone meta ~ CbdTx #8 ~ IrP #6 ~ CbTx #3 / GKRS #2 Clinical information: R/O esophageal ca. Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. : suggestive of newly developed meta at Lt frontal and temporal lobe 32

~ GemVnr #3 Brain meta ~ RTx #6 ~ Iressa po (OPD) ~ Alimta #9 Liver, lung meta Bone meta ~ CbdTx #8 ~ IrP #6 ~ CbTx #3 / GKRS #2 Clinical information: R/O esophageal ca. Definite esophageal wall thickening이나 mass, proximal dilatation은 보이지 않음. Both lung field에 abnormal consolidation이나 nodule은 보이지 않으며 right hilar lymph node의 slight enlargement가 있음. Aorta에 atherosclerotic change가 있으며 great vessels는 normal diameter를 유지하고 있음. Bony destructive lesion은 없음. 33

Recent admission : 09. 8. 26 cc) anorexia o/s> 내원 4일전
Brain CT ( ) : Increased size of metastatic lesion at both frontal lobe Increased peritumoral edema NS consultation (prof. 임영진) : IMPD 166mg q 8hr D1 IMPD 125mg q 8hr D2 BMPD 8mg bid D3~9 BMPD 4mg bid D10~16  이후 OPD f/u

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