Lung Cancer. Part 5
You see also all the time it crops up in board management questions from time to time; someone who has had a malignancy that has been managed for cure – let’s say a small breast cancer or colon cancer – and has the appropriate response and in three or five years later develops a pulmonary nodule. Don’t assume ever that that’s a metastasis from a previously treated, presumed cured, malignancy. In the case of breast cancer, which is my own area of specialty and the area that I know the best, I know that over half of pulmonary nodules that present in patients with prior breast cancers are unrelated to the prior breast cancer. So again, histologic class clarification is generally the way to go in these situations.
This is some data from the Mayo Clinic that just shows what happens if you operate on coin lesions. You remember how dismal the data was when I showed you, in general, for surgery in lung cancer but these are coin lesions specifically. If you look at small coin lesions that were operated on and have no nodal involvement, the surgical survival is much better than the data I showed you in lung cancer overall. So there’s real reward in operating on these small peripheral coin lesions. So you don’t want to ignore them and you want to get a pathologic diagnosis in virtually every situation.
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Fever in the setting of malignancy. The most important thing about fever in cancer patients is; what is the granulocyte count. If the granulocyte count is 500 granulocytes per cubic millimeter, or is the white count rapidly falling. For example, in patients who have a white count of 4,000 two days ago, white count of 2,000 yesterday and a white count of 1,000 today, even if the granulocyte count may be at 600 that patient is in some sort of granulocyte free-fall and is usually the result of chemotherapy. You can expect that that patient has no granulocyte reserve for falling rapidly. So the absolute number of about 500 or expend of rapid decrease is when you really have to worry and take extra precautions for these patients. If you have a patient like this they need to be seen in an emergency room setting, they need to be cultured very quickly, fully and very quickly. You get your cultures sent off in 30 minutes or an hour – not more than that – and then the patient should receive broad-spectrum antibiotics. Even if you identify a potential source of infection – let’s say they are coughing up sputum that looks infected – they must be covered broadly because many of these patients will have more than one potential source of infection. So infected sputum or an abnormal intravenous catheter site may not be all that patient is dealing with. So the watch-word is to cover the patient broadly with antibiotics and give them monotherapy with something like ceftazidime. There’s even some literature recently about using Cipro in the outpatient setting. But you have to be careful.