Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Rachel Shur
PGY-2
October 16, 2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 56
woman who presented with 2
weeks of right foot numbness and
weakness
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient was in her usual state of good health
until approximately 1 month prior to presentation
when she started experiencing intermittent
headaches with associated nausea and vomiting.
•Headaches became more frequent, occurring
almost daily, worse in the morning
•2 weeks prior to presentation, pt noted right foot
numbness and weakness.
•Presented to NYU after she had difficulty driving
with her right foot.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•Gastroesophageal reflux disease
•Past Surgical History:
•none
•Social History:
•Lived with husband and 2 children, worked as real estate agent
•No smoking or drug use, drank 2 glasses of wine per week
•Family History:
•No family history of cancer or heart disease
•Allergies:
•No Known Drug Allergies
•Medications:
•Omeprazole 20mg daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: anxious, well appearing, no acute
distress
•Vital Signs: T: 97.8ºF BP:133/86 HR: 87 RR:14
and O2 sat: 99% on room air
•Right foot: decreased sensation to light touch and
pin prick on anterior and posterior aspect up to
ankle, 4/5 strength on flexion and extension
•Remainder of Physical Exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: Hemoglobin 11.8 gm/dL / Hematocrit 34.2%
•Remainder of CBC was within normal limits
•Basic Metabolic panel: within normal limits
•Hepatic panel: within normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•CT and MRI
brain revealed
frontal lobe
masses with
edema and
mass effect, but
no herniation
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
• The working diagnosis at this time
was Gliobastoma Multiforme (GBM)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 3:
– Pt underwent resection of the right sided
lesion (pathology was consistent with
glioblastoma multiforme)
• Hospital Day 10:
– Pt developed deep vein thrombosis and was
started on Lovenox/Coumadin
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Pre and post contrast
MRI obtained 1 week
post craniotomy
revealed post-operative
changes +/- residual
tumor
• Pt was discharged on
Hospital Day 15
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Disease Course
• Within one month of
surgery, she started
focal external beam
radiation therapy with
concurrent
temozolomide
chemotherapy for a six
week course (6480
cGy).
• Post radiation MRI
revealed increased
surrounding edema.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Disease Course
• The patient completed 6 cycles of adjuvant
temozolomide prior to having progression of
disease.
• She then had once cycle of BCNU
chemotherapy complicated by anemia
requiring transfusion.
• She was offered participation in a clinical trial
with bevacizumab, after an IVC filter was
placed and coumadin was discontinued.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Disease Course
• She had a
dramatic
response to
bevacizumab
therapy,
maintained for 6
cycles.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Disease Course
• A new lesion was
detected, but
additional treatment
had to be interrupted
in order to place a
ventriculoperintoneal
shunt for
communicating
hydrocephalus.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Disease Course
• The patient had further
treatment delays for shunt
related complications and
intractable seizures. She
was treated with enzymeinducing antiepileptic drugs
(EIAEDs).
• She developed clinical and
radiographic progression of
disease.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Disease Course
• Since her tumor over-expressed
epidermal growth factor receptor
(EGFR) and intact phosphate and
tensin homolog gene (PTEN), she was
treated with erlotinib despite being on
EIAEDs.
• There was no response to erlotinib and
she died several months later of
progressive disease (~18 months from
initial hospital admission).
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Gliobastoma multiforme
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS