05-09-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[05-09-2025 17:10] PPM 1: @PPM3 clinical details?
[05-09-2025 17:47] PPM 3: Pt was brought to the casualty in the state of unresponsiveness
HOPI
Pt was apparently asymptomatic 3 days back then he developed pedal edema insidious in onset, bilateral, pitting type, extending up to the shin associated with SOB-II to III (MMRC).no H/o orthopnea, no H/o PND, H/o cough with expectoration since 3 yrs sputum-whitish, no postural variation, No diurnal variation, H/O weight loss present, H/O fever present, then today H/o decreased urine output present, fever present low grade not associated with chills and rigor. Morning at around 8 AM today he developed slurring of speech and unresponsiveness.
GRBS - 39 mg/dL and was given 25% D following which GRBS was 343 mg/dL.
No H/o chest pain, palpitations
K/C/O T2DM on Tab Glimepiride 2 mg + Metformin 500 mg + Vogli 0.2 mg since 5 yrs
K/C/O HTN since 5 yrs on Tab Amlodipine 5 mg + Atenolol 50 mg
[07-09-2025 11:51] PPM 1: 👆Bone mets or did he have Diarrhoea?
[07-09-2025 11:52] PPM 1: Hemorrhagic pleural tap? Approximate date?
[07-09-2025 12:10] PPM 3: 27/8/25
[07-09-2025 12:11] PPM 3: He didn't have diarrhea, bone mets seems likely, he was complaining of lower back pain
F-18 FDG PET-CT
Clinical History: Presented with left sided pleural effusion – tapping : negative for malignancy,
CT chest: left perihilar lesion -? neoplastic. PET CT for evaluation.
Technique:
PET-CT imaging from base of skull to mid thighs was performed 60 minutes after injecting 8.0
mCi of 18F-FDG intravenously. The patient’s fasting blood sugar level at time of injection was
136 mg/dl.
Findings:
VISUALIZED BRAIN:
The cerebral &both cerebellar parenchyma shows normal tracer distribution.
Sub cortical structures, midbrain, pons and medulla shows normal tracer distribution.
Cortical sulci and cisternal spaces are normal.
No focal lesions noted.
(Suggested MRI to look for brain metastases due to inherent FDG uptake in brain, if clinically
warranted)
HEAD &NECK:
Naso, oro, hypopharynx and larynx appear normal.
Mild diffuse FDG uptake noted in both parotid glands – likely inflammatory.
Non FDG avid hypodense nodule noted in left lobe measuring ~ 1.1 x 0.5 cm. Rest of thyroid
gland is normal.
No significant cervical or supraclavicular lymphadenopathy.
CHEST:
FDG avid spiculated heterogeneously enhancing soft tissue density mass noted in the
infrahilar region of left lung measuring ~ 7.5 x 7.1 x 6.5 cm (AP x TR x CC), SUVmax 26.9. The
mass is encasing the left lower lobar bronchus causing luminal narrowing. The mass is
infiltrating pericardium, left atrium, left pulmonary veins and closely abutting the descending
thoracic aorta with ill defined fat planes, abutting LV.
FDG avid subpleural &parenchymal nodules noted in both lungs, largest measuring ~ 0.8 x 1.0
cm, SUVmax 6.8.
Emphysematous changes noted.
FDG avid prevascular, bilateral lower paratracheal (right, ~ 1.7 x 1.2 cm, SUVmax 13),
subaortic, subcarinal, costophrenic ¶cardiac lymph nodes noted.
Non FDG avid subcentimetric right upper paratracheal &thoracic paraaortic nodes noted.
Mediastinal vascular structures are within normal limits with age related non-FDG avid
atheromatous changes and vessel wall calcification.
ABDOMEN:
Liver, gall bladder, spleen and pancreas show normal physiological FDG uptake.
FDG avid necrotic right adrenal nodule noted measuring ~ 1.3 x 1.4 cm, SUVmax 5.4.
Non FDG avid nodularity noted in body of left adrenal gland with fatty attenuation within – likely
benign.
FDG avid heterogenously enhancing lesion noted in penis, measuring ~ 1.6 x 1.6 cm, SUVmax
8.6.
Right renal calculus. Left renal contour irregularity noted.
Bowel loops show normal FDG distribution. Peritoneal fat planes are normal.
Abdominal vascular structures are within normal limits with age related non-FDG avid
atheromatous changes and vessel wall calcification.
No free fluid noted in abdomen/pelvis. Foci of calcification noted in both scrotums.
No significant retroperitoneal/pelvic/inguinal lymphadenopathy noted.
BONES:
FDG avid lytic & marrow-based lesions noted in right 9th rib, L4 vertebra (with intraspinal
extension), S2 vertebra, right iliac bone, ischium and femur, few with soft tissue component.
IMPRESSION:
PET CT SCAN SHOWS METABOLICALLY ACTIVE PROBABLE LEFT LUNG PRIMARY
WITH LIKELY METASTATIC MEDIASTINAL NODES, LUNG NODULES, PLEURAL
NODULES, ADRENAL NODULES, PENILE LESION AND SKELETAL LESIONS.
[21-09-2025 18.54] PPM 1: Thanks @PPM3 for sharing this.
@CR if you can remove the identifiers and then add the above PET report to the case report it will be useful.
@PPM4 what do you think is globally feasible to offer to this patient at this stage after you go through the PET report?
Perhaps the next important step is to decide which tissue in this patient's body would be amenable to biopsy?
[21-09-2025 20.47] PPM 4: Based on the PET-CT report, this patient has *extensive metastatic disease* likely originating from a primary lung cancer. The findings are highly suggestive of *Stage IV non-small cell lung cancer (NSCLC)* or another aggressive malignancy.
### Globally Feasible Management at This Stage:
1. *Palliative Care Focus:* The primary goal is to improve quality of life, manage symptoms (like pain from bone lesions or shortness of breath from pleural effusion), and prolong survival, as a curative approach is not feasible with widespread metastases.
2. *Systemic Therapy:* The mainstay of treatment would be systemic therapy. The specific choice depends on the tumor biology, which requires a biopsy.
* *Targeted Therapy or Immunotherapy:* If the biopsy reveals a specific genetic mutation (e.g., EGFR, ALK, ROS1) or a high PD-L1 expression level, targeted therapies or immunotherapies are highly effective and often better tolerated than chemotherapy. This is the preferred first-line approach globally when criteria are met.
* *Chemotherapy:* If no targetable mutations are found, palliative chemotherapy remains a standard option to control disease growth and symptoms.
3. *Palliative Radiotherapy:* This could be very effective for treating painful bone metastases or locally symptomatic disease (e.g., the lung mass causing bronchial narrowing).
4. *Supportive Care:* This includes:
* Drainage of the pleural effusion if it becomes symptomatic (causing breathlessness).
* Strong pain management for the multiple bone lesions.
* Nutritional and psychological support.
---
### Next Important Step: Deciding the Biopsy Site
You are absolutely correct. The most critical next step is to obtain a tissue diagnosis. The choice of biopsy site is crucial for feasibility, safety, and yield. Here’s an analysis of the options from the report:
*1. Left Lung Mass (Most Likely Primary)*
* *Pros:* Highest chance of obtaining a definitive primary diagnosis and sufficient tissue for comprehensive molecular testing (which is essential for guiding targeted therapy). It is a large, accessible target.
* *Cons:* It is centrally located, encasing a bronchus and near major vessels and the heart. This makes a percutaneous (through the skin) biopsy *riskier* (potential for bleeding, pneumothorax). A bronchoscopic biopsy might be possible but challenging due to luminal narrowing.
* *Verdict:* *A primary target*, but requires an expert interventional radiologist or pulmonologist to assess the safest route. Often the first choice if feasible.
*2. Left Pleural Nodule/Thickening*
* *Pros:* Very FDG-avid (SUVmax 22.0). Can often be biopsied percutaneously under CT guidance. The procedure can often be combined with therapeutic drainage of the adjacent pleural effusion.
* *Cons:* May not be the primary site, though it will likely show metastatic carcinoma. Usually provides sufficient tissue for diagnosis and often for molecular markers.
* *Verdict:* *An excellent and common alternative.* Often safer and easier than biopsying a central lung mass.
*3. Right Adrenal Nodule*
* *Pros:* FDG-avid and a classic site for lung cancer metastasis. Percutaneous adrenal biopsy is a standard procedure.
* *Cons:* Deeper location, requires precise targeting to avoid other organs. Slightly higher risk than a pleural or peripheral lung biopsy.
* *Verdict:* *A very good and feasible option.*
*4. Lymph Nodes (e.g., Paratracheal or Subcarinal)*
* *Pros:* FDG-avid and accessible via *Endobronchial Ultrasound (EBUS)*. EBUS is a minimally invasive procedure with a high yield and excellent safety profile for sampling mediastinal nodes.
* *Cons:* Nodes are small (~1.7 cm). The procedure requires specialist expertise.
* *Verdict:* *An excellent choice.* EBUS is often the preferred initial biopsy method for lung cancer with mediastinal involvement as it stages the disease and provides a diagnosis simultaneously.
*5. Bone Lesion (e.g., Iliac bone or rib)*
* *Pros:* Superficial and easy to access percutaneously.
* *Cons:* Bone biopsies can yield necrotic or bony tissue that is sometimes insufficient for full molecular profiling, which is critical in lung cancer. They are primarily used for diagnosis when other sites are inaccessible.
* *Verdict:* *A viable alternative,* but not the first choice if a softer tissue site (node, pleura, adrenal) is available.
*6. Penile Lesion (Unusual)*
* *Pros:* Superficial and very easy to biopsy.
* *Cons:* This is a very unusual metastasis. While it would confirm malignancy, it's less certain to be from the lung primary than the other sites (though lung is a known, rare cause of penile mets). The team might prefer a site more classic for lung cancer spread.
* *Verdict:* *Technically feasible but low on the list of preferred sites* due to its rarity.
### Recommended Approach:
A multidisciplinary team (pulmonologist, interventional radiologist, oncologist) should decide. The most common and logical approaches would be, in order of preference:
1. *EBUS biopsy of an FDG-avid mediastinal lymph node.* This is often the best first step as it is low-risk and provides diagnostic and staging information.
2. *CT-guided biopsy of the FDG-avid pleural nodule/thickening.* A very safe and high-yield alternative.
3. *CT-guided biopsy of the right adrenal gland nodule.* Another strong alternative.
*In summary: The globally feasible offering is palliative-focused systemic therapy (prioritizing targeted therapy/immunotherapy if possible), supported by radiotherapy and best supportive care. The immediate next step is a biopsy, with the most amenable and informative sites being a mediastinal lymph node (via EBUS) or the pleural nodule (via CT-guided biopsy).*
[21-09-2025 21.33] PPM 1: Thanks. Very useful
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