~ Case Studies ~
~ Case Studies ~
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Learning Outcome
Learning Outcome
Apply concepts to scenario based case studies to further solidify understanding
CASE #1
CASE #1
Estimated time: 5–7 minutes
Patient Information
Name: Mr. Path
Age: 64 years old
Gender: Male
Occupation: Retired factory worker
Medical History
Medical History
Hypertension (controlled with medication)
Social History
Social History
35 pack year smoking history
Former industrial exposure to dust and chemicals
Presenting Problem
Presenting Problem
Persistent cough, irregular hemoptysis (coughing up blood), chest pain and unintentional weight loss over the past 4 months
Self report of increased fatigue and mild shortness of breath
Hypertension
Hypertension
Controlled with medication
Presenting Problem
Presenting Problem
Persistent cough, hemoptysis, chest pain and unintentional weight loss
Clinical Examination
Clinical Examination
Decreased breath sounds in the right upper lobe
No peripheral edema
Mild digital clubbing
Vital signs are stable
Imaging Studies
Imaging Studies
Chest X-ray: Presence of a central hilar mass in the right lung.
CT Scan: confirmed a 4.2 cm mass in the right upper lobe with associated right hilar lymphadenopathy.
PET Scan: Increased metabolic activity in the lung mass and nearby lymph nodes, suggesting malignancy with regional spread.
Pathology
Pathology
Biopsy of the mass revealed malignant squamous cells.
Immunohistochemistry was positive for p40 and CK5/6 confirming squamous differentiation.
Histology showed keratin pearls and intercellular bridges (consistent with moderately differentiated squamous cell carcinoma).
Diagnosis
Diagnosis
Stage: II (T2N1M0)
Genetic alterations: TP53 mutation and KRAS pathway activation
Primary: Squamous cell carcinoma of the right upper lobe of the lung
Tumor Characteristics: Moderate mitotic activity with angiogenesis, loss of E-cadherin and increased matrix metalloproteinase activity
Treatment Plan
Treatment Plan
Multimodal treatment approach recommended
Surgical: Right upper lobectomy with mediastinal lymph node dissection.
Adjuvant chemotherapy: Cisplatin based regimen to reduce recurrence risk.
Radiation Therapy: Considered if surgical margins are positive or lymph nodes show extracapsular spread.
Lifestyle modification and supportive care: Nutritional support, monitoring for hypercalcemia, relapse prevention for smoking. Ideally optimization of cardiovascular health.
Prognosis
Prognosis
Moderate prognosis as it is Stage II squamous cell carcinoma
Recurrence risk depends on nodal involvement and response to adjuvant therapy
Close follow ups is essential with chest imaging recommended every 3-6 months for the first 2 years.
Summary
Summary
Mr.Path's presenting problem of persistent cough, hemoptysis and weight loss, combined with imaging and biopsy findings confirm squamous cell carcinoma of the lung. The tumor shows aggressive features including local invasion and lymphatic spread. Early detection and timely multimodal therapy offers the best chance for disease control and improved survival.
CASE #2
CASE #2
Estimated time: 4–6 minutes
Patient Information
Patient Information
Name: Mr. Stem
Age: 72 years old
Gender: Male
Occupation: Agricultural scientist
Medical History
Medical History
Hypertension and chronic lymphocytic leukemia
Social History
Social History
Extensive sun exposure
Former smoker
Presenting Problem
Presenting Problem
Rapidly growing nodule on left cheek over the past 4 weeks
Lesions appears purple
Chronic lymphocytic leukemia
Chronic lymphocytic leukemia
Extensive sun exposure
Extensive sun exposure
Clinical Examination
Clinical Examination
Firm dome shaped nodule on left cheek
Approximately 2.5 cm in diameter
No ulceration
Swollen preauricular lymph node
Imaging Studies
Imaging Studies
Skin biopsy: small round blue cells
Histology findings: Neuroendocrine features, frequent mitoses, high nuclear to cytoplasmic ratio
Immunohistochemistry: CK20 positive, chromogranin positive
Viral testing: positive for Merkel cell polyomavirus
PET/CT scan uptake in primary lesion and regional lymph node
Pathology
Pathology
Associated with Merkel cell polyomavirus infection
UV radiation exposure
Immunosuppression from the chronic lymphocytic leukemia
Production of oncogenic proteins by Merkel cell polyomavirus integration into host DNA
Rapid tumor proliferation and neuroendocrine differentiation
Tumor spread to lymph nodes
Diagnosis
Diagnosis
Primary diagnosis: Merkel cell carcinoma
Stage III
Treatment Plan
Treatment Plan
Primary: Wide local excision of the tumor
Lymph node dissection if positive
Adjuvant radiation to reduce recurrence risk
Immunotherapy (PD-1/PD-L1 inhibitors)
Prognosis
Prognosis
Guarded (outcome is uncertain)
High risk of recurrence and metastasis
Summary
Summary
Mr. Stem presents with rapidly growing facial nodule characteristic of Merkel cell carcinoma. This is an aggressive neuroendocrine tumor associated with Merkel cell polyomavirus, UV exposure and immunosuppression. Early treatment is critical due to its high metastatic potential.
Podcast
Podcast
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