Chapter 149: Non-Small Cell Lung Cancer: It Takes Your Breath Away Level II

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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

• Recognize the most common symptoms of non-small cell lung cancer (NSCLC).

• Identify potential complications associated with NSCLC.

• Design a treatment plan for patients with NSCLC.

• Recommend potential second-line chemotherapy agents and regimens for treating refractory and metastatic NSCLC.

• Design a pharmacotherapeutic plan for the treatment of hypercalcemia.

• Describe appropriate treatment strategies for brain metastases in NSCLC.

• Monitor carboplatin and paclitaxel therapy.

• Educate patients on the anticipated side effects of carboplatin, paclitaxel, radiation, nivolumab, and erlotinib therapy.

PATIENT PRESENTATION

Chief Complaint

“I have been coughing up blood.”

HPI

This 66-year-old woman presents to her PCP with complaints of a dry, nonproductive cough for 2.5 months, dyspnea on exertion, and hemoptysis for 1 week.

PMH

• Dyslipidemia

• HTN

• Anemia of unknown etiology × 1 year

• Type 2 DM

• PPD (–)

FH

• Father died of colorectal cancer at age 68.

• Aunt died of breast cancer at age 70.

SH

Married, lives with son and daughter; 30 pack-year cigarette smoking history (approximately 1 ppd × 30 years); occasional ETOH use; no known recent exposure to TB

Meds

• Folic acid 1 mg PO daily

• Ferrous sulfate 325 mg PO TID

• Simvastatin 20 mg PO daily

• Metformin 500 mg PO BID

• Pantoprazole 40 mg PO daily

All

• Penicillin (rash)

• Sulfa (rash)

ROS

(+) For pulmonary symptoms as noted in HPI; no headaches, dizziness, or blurred vision

Physical Examination

Gen

Mildly overweight Caucasian woman in slight distress. ECOG performance status of 1.

VS

BP 169/100 mm Hg, P 90 bpm, RR 30, T 37.2°C; Wt 82 kg, Ht 5′6″

Skin

Patches of dry skin; no lesions

HEENT

PERRLA; EOMI; fundi benign; TMs intact

Neck/Lymph Nodes

No lymphadenopathy; neck supple

Lungs

Wheezing in RUL; remainder of lung fields clear

Heart

RRR; slight systolic murmur on left lateral side; normal S₁, S₂

Abd

Soft, nontender; no splenomegaly or hepatomegaly

Genit/Rect

Normal female genitalia; guaiac (–) stool

Neuro

A & O × 3; sensory and motor intact, 5/5 upper, ...