SEER Training Modules
Case #4
History
76-year-old white female with a history of chronic nasal drip and sinus infection leading to a routine chest x-ray which revealed a mass in the left lung. No chest pain or discomfort. One month ago patient experienced pink-tinged sputum from an early morning expectorant.
Physical Exam
Physical exam was essentially negative. Lungs are clear to auscultation.
Imaging
8/1/04
Chest x-ray: a mass in the left lung.
8/5/04
CT Scan, Chest: 6 x 5 cm mass in the left lower lobe of the lung abutting the pleura and extending to the mediastinum. No mediastinal adenopathy.
8/10/04
PET Scan: large hypermetabolic mass in the left posterior mid lung.
Laboratory
8/1/04
SMA 20: within normal limits
Pre-operative Therapy
9/1/04
Chemotherapy: Carboplatin and Taxol, 3 cycles
Surgical Observations
8/16/04
Bronchoscopy and brushings: Left lower lobe nodule
12/6/04
Thoracotomy and left lower lobectomy and lymph node dissection: Revealed primary tumor in the left lower lobe extending into the vertebral body. Tumor could not be excised completely at the margin.
Pathological Report
8/16/04
Bronchoscopy specimen: Poorly differentiated non-small cell carcinoma
12/6/04
Lung, left lower lobe, lobectomy: Adenocarcinoma of the left lower lobe of the lung, measuring 5 cm. Tumor extends to the parietal pleura. Spinal vertebral margin is positive for adenocarcinoma, all other margins are negative. Seven (7) regional lymph nodes, ipsilateral, negative for tumor.
Post-op Therapy
Patient referred for post operative radiation therapy.
