| 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. |
