Medical Case Details:
A patient (age 56 years and weight 70 kg) has been diagnosed with Non-Small Cell Lung Cancer, Stage 4 with primary tumor in his Left Upper Lobe and metastasis in Liver and Bone. The biopsy report has confirmed it to be adenocarcinoma.He complained of wheezing and breathing difficulty. For ascertaining the cause, an X-ray was taken on 23 Feb 17, which showed massive pleural effusion in his left lung. A series of tests followed with the ultimate result as NSCLC Stage 3B. It was categorized as Stage 3B, as the pleural effusion was para-malignant and no metastases were noted in any other body part.
He was started with CCRT treatment which concluded on 05 May 17. During the treatment, he was given a daily dose of radiation therapy to his primary tumor site in his left upper lobe using IGRT (60 Gy/ 30 #/6 weeks) and weekly chemotherapy with paclitaxel (150 mg) & Carboplatin (300 mg) for 6 weeks. Despite the treatment, the cancer is advancing and has now spread to Liver and Bones as brought out in his latest PET CT report.
Lung tissue which was obtained during a CT-guided biopsy conducted in the month of Mar 17, before the CCRT treatment was started, has tested positive for EGFR mutation – “E746_A750del is detected in EXON 19 of EGFR gene”. His doctor has started him on Erlotinib 150 mg OD since 26th Jun 17.
He has developed Post Obstructive Pneumonia in his left lung, and there is consolidation in his entire left lung. This is evident from a recent X-ray. He is having difficulty in breathing, takes short and fast breath, sweats a lot, feels cold, has irritation in his throat and gets tired very fast. He also has an issue eating solid food and has greatly cut down his diet.
He was started on an oral antibiotic for a week but did not respond to it. He is admitted to the hospital and is being injected with antibiotics through IVs and injections. His condition remains to be same with no much improvement. His SPO2 level is also low at 90-92%.
Can you suggest anything towards his treatment? What is the sequence of treatment that we should follow to ensure recovery, in case he does not respond to the antibiotic injections?
Discussions
Dr. Sujata Mittal
Obstetrician And Gynaecologist
Dear Doctor! I would have liked to suggest something in form of life style modification and dietary changes but Patient is too critical to undergo that radical changes. Pranayam with simple walking and meditation could have initially increased his lung capacity. All adenocarcinoma have the mostly same reason I.e inappropriate life style, diet, obesity, stress .
You can read the boik: cancer new way of life by Dr David Servan
Obstetrician And Gynaecologist
Dear Doctor! I would have liked to suggest something in form of life style modification and dietary changes but Patient is too critical to undergo that radical changes. Pranayam with simple walking and meditation could have initially increased his lung capacity. All adenocarcinoma have the mostly same reason I.e inappropriate life style, diet, obesity, stress .
You can read the boik: cancer new way of life by Dr David Servan
29.Jul, 05:40am
Dr. Patil Pratik Pramod
Medical Oncologist
As the patient is already on chemo and radiotherapy and has multiple seconadaries with infective complications , I would suggest an approach of immunotherapy...
Cancer cells are not recognized as invaders because they are the body’s own cells that have mutated, so that once-healthy cells no longer behave like normal cells. The immune system doesn’t recognize this distinction, allowing these dangerous cells to grow, divide and spread throughout the body. One way cancerous cells stay hidden is by sending signals to the PD-1 CTLA-4 receptors at certain checkpoints on immune cells. Those signals trick the body’s police force into thinking the cancer cells are normal. Immunotherapy drugs known as checkpoint inhibitors are designed to disrupt those signals, allowing the cancer cells to be exposed as invaders and triggering an immune system response. Cytokines and cancer vaccines are other types of immunotherapies used to generate an immune response by helping the body recognize cancer cells.
Medical Oncologist
As the patient is already on chemo and radiotherapy and has multiple seconadaries with infective complications , I would suggest an approach of immunotherapy...
Cancer cells are not recognized as invaders because they are the body’s own cells that have mutated, so that once-healthy cells no longer behave like normal cells. The immune system doesn’t recognize this distinction, allowing these dangerous cells to grow, divide and spread throughout the body. One way cancerous cells stay hidden is by sending signals to the PD-1 CTLA-4 receptors at certain checkpoints on immune cells. Those signals trick the body’s police force into thinking the cancer cells are normal. Immunotherapy drugs known as checkpoint inhibitors are designed to disrupt those signals, allowing the cancer cells to be exposed as invaders and triggering an immune system response. Cytokines and cancer vaccines are other types of immunotherapies used to generate an immune response by helping the body recognize cancer cells.
30.Jul, 03:59pm
Dr. Mazmudar Jagan Styendraprasad
Child Health Specialist
What is causing entire lung to consolidate?
Is there any lymph node obstructing the airway?CT may be helpful.
Is the infection community acquired or hospital acquired?
Bronchoscopy also will be helpful.
Can you do culture and sensitivity of the material retrieved from Bronchoscopy?
That way ,we know the micro organism causing the pneumonia.
Child Health Specialist
What is causing entire lung to consolidate?
Is there any lymph node obstructing the airway?CT may be helpful.
Is the infection community acquired or hospital acquired?
Bronchoscopy also will be helpful.
Can you do culture and sensitivity of the material retrieved from Bronchoscopy?
That way ,we know the micro organism causing the pneumonia.
12.Aug, 12:28pm
Dr. Kakade Amol Sham
Radiation Oncologist
Palliative care only for this patient.Unlikely to respond to any cancer directed treatment.May continue Erlotinib until further worsening of genral condition.Hope the patient is alive now.
Radiation Oncologist
Palliative care only for this patient.Unlikely to respond to any cancer directed treatment.May continue Erlotinib until further worsening of genral condition.Hope the patient is alive now.
17.Jan, 02:57pm
Dr. Kushal Sen
General Practitioner
Patient was on Erlotinib 1st generation EGFR TKI, one of the important cause of resistance to EGFR TKI is T790m mutation and OSIMERTINIB can be given..
But there will be cost burden to patient for this... Pembrolizumab 200mg q21 days is another option..
For bone mets bisphosphonate therapy can be given if not contraindicated otherwise
General Practitioner
Patient was on Erlotinib 1st generation EGFR TKI, one of the important cause of resistance to EGFR TKI is T790m mutation and OSIMERTINIB can be given..
But there will be cost burden to patient for this... Pembrolizumab 200mg q21 days is another option..
For bone mets bisphosphonate therapy can be given if not contraindicated otherwise
24.Jun, 12:20pm
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