2025-12-10 (三) 15:00 ~ 17:00

2025年南區胸腔病例討論會

 2025 Chest case discussion

摘要課程表

地  點：阮綜合醫院  B棟十樓大教室

地  址：高雄市苓雅區成功一路162號      連絡人：

                                                   內科部曾玲雯07-3351121#3075

                                                   林莞茹專科護理師07-3351121#2258

 

場次	會議日期	時間	主持人
1	2025年11月12日	15:00〜17:00	蕭惠元、楊明泉等
2	2025年12月10日	15:00〜17:00	蕭惠元、楊明泉等

 場次2

15：00-15：30討論病例

Name: 龍XX

Age : 54 year-old 

Gender: female

Chart  NO:  596502

C/C : target drug resistance of lung cancer

Past history :

1. Right lower lobe lung adenocarcinoma with lung to lung metastases, ipsilateral mediastinal lymph node metastases and malignant pleural effusion (T4N2M1a, stage  IVA) was diagnosis on 2023/05/18  s/p target Afatinib 30mg/tab(Giotrif) treatment on 2023/06/01~2024/12/04.(r/o has drug resistance)

@.2023/08/18-> GROSS EXAMINATION:

right lung ct guide biopsy :  adenocarcinoma ,

The specimen submitted consists of 7 pieces of tissue, measuring up to 0.3 x 0.1 x 0.1 cm in size.  All are embedded for section.

MICROSCOPIC EXAMINATION:

The sections of the specimen show a picture of adenocarcinoma, consisting of clusters of moderately differentiated neoplastic cells in focal glandular pattern and desmoplastic stromal reaction.The number of tumor cells is more than 100 cells.

2.Type 2 diabetes mellitus was regular follow up at LMD (Galvus Met 1# BID, Mefenamic 1# BID)

3.Arrhythmia wiht hypertension was regular follow up at 宇平診所(Propranolol Hcl 1# BID and Diltiazem (Hcl) 1# BID)

4.Hyperlipidemia was regular follow up at LMD (Bezafibrate 1# BID)

5.Invasive ductal carcinoma of left breast post left partial mastectomy and axillary lymph nodes dissection, pT2N0M0, stage IIA (2023/07)

6.Fibroadenoma of right breast, R/10/3 post excision with EnCor  (2023/07)

7.Fibrocystic disease of right breast, R/12/2 post excision with EnCor  (2023/07)HBV/HCV: denied

Allergy history: nil

家族史：

Denied family history of Hypertension, Type 2 diabetes mellitus, CAD, CKD, Cancer

旅遊史：

 T.O.C.C:

Travel history:Denied

Occupation:Housewife

Contact history:

Pet/Animal:Denied

Disease/Environment:Denied

Cluster:共同居住的家人(或朋友、同學)是否有其他2人(含)有類似症狀:Denied

History of venereal disease (隱私'性'的疾病): Denied

家族史：

Family history:

- Month : nil

- Heart disease: nil

- Renal disease: nil

- HBV/HCV: nil

- Pulmonary disease: nil

- Cancer : nil

- Hypertension: nil

- Diabetes Mellitus: nil

個人病史：

[Personal History]-->

Education:junior-high 

Marital status: Marital

Exercise:no

Alcohol:no 

Tobacco:no 

Coffee: no

Tea: no  

Betel nut: no 

T: travel history: denied. in recent three months

O: occupational hitory: Housewife

C: contact history: denied

C: cluster history: denied

理學發現：

[Vital Sign]

--> BH:163cm  BW:58.7kg

Temp:35.9C  BP:147/101mmHg

   PR:73/min  RR:18 /min

 [General appearance]

--> Consciousness:alert  GCS:(E4V5M6 ) 

Development:normal 

Nourishment:well 

[Ear]

--> EEC:clear 

Hearing:normal 

 [Throat]

--> Tonsil:normal 

Tongue:normal 

Pharynx:normal 

[Nose]

--> Discharge:no 

Smelling:normal 

[Thyroid]

--> Size:non-palpable  Nodule:non  Tender: - 

[Eye]

--> Conjunctiva: not anemic 

Sclera: not icteric 

Pupil size, R't: 2mm  Pupil size, L't: 2mm 

   Light reflex (R/L):+/+  Shape:regular

[Lymph Node]

--> Cervical:non palpable 

Axillary:non palpable 

Inguinal:non palpable

    Consistency:soft

[Chest]

--> Contour:normal 

Percussion:reasonant 

Breathing sound: coarse  

Heart beat:regular 

   Heart sound:no murmur 

 [Abdomen]

--> Liver: non palpable 

Spleen: non palpable 

Mass:no 

Tenderness:no 

   Bowel Sound:normal 

Rigidity:non 

Ascites:non 

Distension:no 

   Hernia:normal 

 [Spine & Extremities]

--> Spine:normal 

Upper extremities:normal 

Lower extremities:normal 

Nail:normal 

入院經過:

    The 54-year-old female patient, diagnosed with right lower lobe lung adenocarcinoma with lung-to-lung metastases, was admitted on 2024/12/05 due to symptoms of chronic cough, dizziness, sweating, and vomiting. Following evaluation, doctors confirmed her condition as stage IVA lung cancer and COPD, with potential drug resistance.

  Initial management included CT scans for further assessment, symptomatic treatment with diphenhydramine and metoclopramide, and monitoring of her cancer therapy's effectiveness. Diagnostic imaging revealed a stationary tumor in the right lower lobe and multiple metastatic nodules, some of which had enlarged since the last scan.

   On 12/06, the patient underwent several assessments. Laboratory results indicated stable renal function and mild hyperglycemia, prompting the temporary withholding of her oral hypoglycemic agents. The patient's condition was noted to be stable, though she experienced mild cough and intermittent symptoms such as dizziness and chest tightness.

 A brain MRI performed on this day indicated no significant abnormalities, other than a suspicious dissecting aneurysm, which appeared stationary. Preparations for a colonoscopy and gastroscopy began, with studies scheduled for 12/09. Orders included a PET/CT scan on 12/10 and a CT-guided biopsy on 12/11.

 On 12/10,she colonoscopy shows (1)Colonic diverticulosis.(2).Polyp of Tubular adenoma in Transverse colon. and gastroscopy shows Reflux esophagitis.Erosive gastritis ,AGML.Gastric polyp.Duodenal erosion.Management  :Polypectomy performed .

  On  12/17, CT-guided biopsy shows Adenocarcinoma --- lung, right lower lobe, CT guided biopsy ,The sections of the specimen show a picture of adenocarcinoma, consisting of clusters of moderately differentiated neoplastic cells in focal acinar pattern. The tumor cells are positive for TTF-1, and negative for p40 immunostains.Note: Tumor cells <100, 自費 ACT Lung 肺核克癌症基因檢測 ($47000) 送北檢 on 2024/12/17. because of her overall condition remained stable, she was discharged arranged on 12/17 and OPD follow-up prescrible.

15：30-16：00討論病例

Name: 李陳XX

Age : 77 year-old female

Chart NO: 1633151

C/C :

Past history :

hypertension ,Hyperlipidemia,anxiety,arrhythmia and dizziness (+)

Drug allergy: NKA

married, G1P1A0, C/Sx 1, LMP:97-09-21

drinking and smoking(+); Hx of hypotension(+)

OP: C/S x 1

Cataract in right eye s/p for years

hemorrhoidectomy on 2019/05/22

 

家族史：

Denied family history of Hypertension, Type 2 diabetes mellitus, CAD, CKD, cancer

旅遊史：

TOCC:

Travel history in recent 6 months ago: denied

Occupation:看護

Contact history: animal contacthistory: denied

Illness contact history:denied

Cluster: denied family and friend with the similar symptoms

個人病史：

[Personal History]-->

Occupation:Worker 

Education:junior-high 

Marital status:married 

Exercise:no 

Alcohol:no 

Tobacco:regular,30支/days 

Coffee:no  Tea:no 

Betel nut:no 

Drugs:Anti-H/T; Oral pill 

Allergy:never  動物接觸史:無 

理學發現：

[Vital Sign]--> BH:162 cm BW:62.2 kg Temp:36.5 度C BP:135/90 mmHg

             PR:66 /min RR:18 /min

[General appearance]--> Consciousness:alert  GCS:(E4V5M6 )  Development:normal  Nourishment:well 

[Ear]--> EEC:clear  Hearing:normal  TM:not-test 

[Throat]--> Tonsil:normal  Tongue:normal  Pharynx:normal  Mouth floor:normal 

[Nose]--> Discharge:no  Smelling:normal 

[Thyroid]--> Size:non-palpable  Nodule:non  Tender:- 

[Eye]--> Conjunctiva:not anemic  Sclera:not icteric  Pupil size, R't:2mm  Pupil size, L't:2mm  Light reflex (R/L):+/+  Shape:regular 

[Lymph Node]--> Cervical:non palpable  Axillary:non  palpable  Inguinal:non  palpable  Consistency:soft 

[Ophthalmosopic]--> Ophthalmoscopic:none test 

[Neck]--> Neck:supple  Jugular vein:0 cm from sternal notch

[Chest]--> Contour:normal  Percussion:reasonant  Breathing sound:clear  Heart beat:regular  Heart sound:no murmur 

[Abdomen]--> Liver:non  palpable  Spleen:non  palpable  Mass:no  Tenderness:no 

             Bowel Sound:hypoactive  Rigidity:non  Ascites:non  Distension:no 

             Hernia:normal 

[Genitalia]--> Genitalia:not-test 

[Rectal]--> Anus:none test  DRE:none test 

[Spine & Extremities]--> Spine:normal  Upper extremities:normal  Lower extremities:normal  Nail:normal 

入院經過 :       

   A 64-year-old woman who has hypertension ,Hyperlipidemia,anxiety,arrhythmia and dizziness for years with medication control. She suffered from Two lung lesion with progression in years , CT  guided  biopsy  for  RUL  mass on 2024/06/03. The pathologic diagnosis show Adenocarcinoma in situ, at least ---- lung, right upper lobe, CT-guided biopsy.

   She was come to our OPD , the following Physical examination findings :  con's alert, clear breathing sound, soft abdomen. Four extremities are freely movable. Image was follow as PET-Whole Body for plaining treatment, it shows 1.Primary lung cancer in the RUL (the  larger one) is compatible.2. Another low metabolic smaller ground-glass lesion in the RUL. 3.Favor reactive lymph nodes in the bilateral  mediastinal and pulmonary hilar regions. 4.Favor physiological  uptake or inflammation in the stomach.5.Favor mild inflammation in  the left wrist joint.6.The staging according to F-18 FDG PET/CT is  T1bN0M0 (8th AJCC system). 

   under the impression of adenocarcinoma of lung , RUL s/p CT guide biopsy ,she was admitted for further evaluation and management.

 

16：00-16：30討論病例

Name:  朱 xx

Age : 64 year-old 

Gender: male

Chart  NO: 2632483

C/C : CXR : dry cough about one year

Past history :

Hypertension : 10+ years ,estengy 1# qd  , Concor 1# qd , OISAA 1# qd

旅遊史：

T.O.C.C>:

Travel history:Denied

Occupation:Retire

Contact history: -

Pet/Animal:Denied

Cluster:共同居住的家人(或朋友、同學)是否有其他2人(含)有類似症狀:Denied

History of venereal disease (隱私'性'的疾病): Denied

家族史：

Family history:

- Month : hypertension

- Heart disease: nil

- Renal disease: nil

- HBV/HCV: nil

- Pulmonary disease: nil

- Cancer : nil

- Hypertension: nil

- Diabetes Mellitus: nil

個人病史：

[Personal History]-->

Education:junior-high 

Marital status: Marital

Exercise:no

Alcohol:no 

Tobacco:  guide 30+years

Coffee: no

Tea: no  

Betel nut: no 

理學發現：

[Vital Sign]

--> BH: 168cm BW:.67kg

Temp:36..0C   BP:163/68mmHg

   PR:68/min RR:18/min

 [General appearance]

--> Consciousness:alert  GCS:(E4V5M6 ) 

Development:normal 

Nourishment:well 

[Ear]

--> EEC:clear 

Hearing:normal 

 [Throat]

--> Tonsil:normal 

Tongue:normal 

Pharynx:normal 

[Nose]

--> Discharge:no 

Smelling:normal 

[Thyroid]

--> Size:non-palpable  Nodule:non  Tender: - 

 

[Eye]

--> Conjunctiva: not anemic 

Sclera: not icteric 

Pupil size, R't: 2mm  Pupil size, L't: 2mm 

   Light reflex (R/L):+/+  Shape:regular

[Lymph Node]

--> Cervical:non palpable 

Axillary:non palpable 

Inguinal:non palpable

    Consistency:soft

[Chest]

--> Contour:normal 

Percussion:reasonant 

Breathing sound: clear 

Heart beat:regular 

   Heart sound:no murmur 

 [Abdomen]

--> Liver: non palpable 

Spleen: non palpable 

Mass:no 

Tenderness:no 

   Bowel Sound:normal 

Rigidity:non 

Ascites:non 

Distension:no 

   Hernia:normal 

 [Spine & Extremities]

--> Spine:normal 

Upper extremities:normal 

Lower extremities:normal  

Nail:normal 

入院經過:

     This a 83  year-old man case have a  hypertension regualr medication for 10+ years by LMD .

  According to the patient, he have an dry cough about one year ,there was denied sputum , fever , chill , shortness of breath , chest tightness, rhinorrhea, sore throat, nasal obstuction,  headache , dizziness , cold sweating, night sweats, poot appetite , burning urination, myalgia, abdominal pain, taryy stool , hematuria , dysuria, painful urination or body weight loss were found. He had visited the clinic many times, but his symptoms did not improve. but chest CT imaging shows  a mass lesion in left upper lung were found, So he came to our thoracic medicine clinic for further evaluation on 02/24.follow-up chest image shows LUL  mass  with  left  hilar  lymphadenopathyEmphysematous change  in  the  left  lower  lung.  Normal  heart  size.No  pleural  lesion. 

 The  Physical examination revealed GCS: E4V5M6; heartbeat is regular without murmur; clear without wheezing in bilateral lung fields of breath sound , abdominal soft, no palpable mass, no tenderness, normal active bowel sounds; no flank knocking pain; the lower limbs move freely, and no pitting edema. under impression of  LUL mass  with  left  hilar  lymphadenopathy , high suspect malignanacy , he was admitted for further suvey on 2025/02/27.

     On 03/01, a contrast-enhanced chest CT confirmed the suspicion of lung cancer, showing a left upper lobe mass and bilateral mediastinal lymph node metastasis (preliminary staging: T4N3). Concurrent lab results revealed an elevated CEA level of 31.7 and an SCC level of 0.7. The patient was treated with acetylcysteine, benzonatate, and a liquid brown mixture for cough relief, and supplemental oxygen was provided as needed.

     A CT-guided biopsy conducted on 03/04 confirmed the diagnosis of non-small cell adenocarcinoma of the lung, characterized by neoplastic epithelial cells and tumor necrosis. Pulmonary function tests on 03/06 revealed severe obstructive ventilatory disorder with no significant response to bronchodilators. Further imaging through a brain MRI showed ischemic changes but no strong evidence of primary intracranial abnormalities.

      On 03/11, PET-CT results confirmed widespread cancer involvement, including local and distant metastases (T4N3M1a), confirming stage IVA lung cancer. Along with the initiation of targeted therapy with gefitinib (Iressa) since 03/11. Regular monitoring and follow-up were advised to assess the patient's ongoing response to treatment.

      The patient's overall condition remains stable, but the cancer staging indicates significant disease progression. Hypertension, managed with Amlodipine-Valsartan, Azilsartan, and Bisoprolol, remains an inactive problem. The patient is scheduled for outpatient follow-up after discharge on 03/12, pending results from ongoing genetic and immunohistochemistry studies related to his lung cancer.