Metastatic Bone Adenocarcinoma with Positive TTF-1 Tumor Stain with a Lung Mass: the Role and Treatment Consideration of RT

Transcription

1 Metastatic Bone Adenocarcinoma with Positive TTF-1 Tumor Stain with a Lung Mass: the Role and Treatment Consideration of RT Case Number: RT (M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: to present a case of metastatic bone adenocarcinoma with positive TTF-1 tumor stain with lung mass; to discuss the role and treatment consideration of RT Scenario: You are radiotherapy (RT) Intent Doctor/Special Nurse/Resident Doctor, and you are assigned to evaluate the following patient before visiting of your RT attending physician. Please review the following description carefully; your RT attending physician will visit this patient later and discuss with you after your review. Case Presentation: This 68 year-old female patient, 林 O, was referred for post-bone-biopsy RT assessment. S: Right hip pain for one months and biopsy revealed adenocarcinoma favored metastasis from the lung; low back pain also noted O: <<PE: ECOG, 4; lying on bed; speech, OK; bone knocking pain over the right hip/pelvic region and low back; limbs, free movement but with painful sensation>> 1. Pathology in 2007/10, bone, acetabulum, biopsy: metastatic adenocarcinoma, poorly differentiated, TTF-1 50% (+) 2. CXR in 2007/10: a 5.7-cm mass over the left low lung region 3. Chest CT in 2007/10: a mass lesion with size of 5 cm over the left lower lung with abutting the pleura; no medistinum LNs 4. MRI of spine in 2007/10: Right acetabular mass. 5. Bone scan in 2007/10: multiple bone mets over the right parietal skull, left shoulder, upper T-, L1-, L4-spine, and bilateral pelvics, especially the right acetabulum region

2 Key Image(s): Fig. 1. Fig. 2. Fig. 3.

3 Questions & Discussions: (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? Q4: What are your Oncology Diagnosis / Assessments for this case? Q5: What is your Oncology Plan for this case? Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.)

4 Questions & Discussions: (with potential answers) (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? A1: As described in the last attached page. Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? A2: ct3 cn0 pm1(bone), stage IV (2007/10, AJCC 2006) Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? A3: no pathology stage can be defined. The pathology M classification is pm1 (bone). Q4: What are your Oncology Diagnosis / Assessments for this case? A4: Adenocarcioma, Gr. 3, of the lung (5cm tumor with abutting the pleura), LLL, with multiple bone mets, ct3 cn0 pm1(bone), stage IV (2007/10, AJCC 2006) Q5: What is your Oncology Plan for this case? A5: 1. Keep chemotherapy and add palliative RT 2. RTC 1 week later Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) A6: RT Plan may be designed as the following one: (1). Indication: lung cancer with bone mets with pain (2). Goal: palliative; symptoms alleviation (3). Target & Volume: bone mets region (mainly the right pelvic bone) with adequate margin (4). Technique: 2D then 3DCRT (5). Dose & Fractionation: cgy in fractions, depending on the degree of symptoms relieving Further Readings & References: NCCN 2009 & Perez 2008 & AJCC 2006 Radiation Oncologist Hon-Yi Lin 2009/03/23

5 Key Image(s): (with marked) Fig. 1. Fig. 1. Multiple bone metastases were noted, including the right pelvic bone (as the white arrows). Fig. 2. Fig. 2. The contrast-enhanced mass with size more than 3 cm over the right pelvic bone, acetabulum region (as the white arrow). Fig. 3. Fig. 3. The primary lung mass with size more than 3 cm over the left lung (as the white arrow).