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
• Transparency: Slightly hazy
• Reaction: Acidic 5.0
• Protein: Trace
• Glucose: Negative
• Specific Gravity: 1.020
• PUS cells: 0-2/HPF
• RBC: 5-10/HPF
• Epithelial Cells: Rare
• 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

Pleural 01
Cavity
Surface tension create
d by the pleural cavity
provides the cohesion
that keeps the lung 02
surface in contact with
the thoracic wall
The pleural cavity is
the potential space
between the visceral
and parietal layers of
the pleura
It contains a capillary
layer of serous pleural
fluid which lubricates
the pleural surfaces
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