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Case history

image A 69-year-old woman presented to her GP with a 2 month history of increasing back pain. She had no significant medical history. Her GP referred her for X-rays of her thoracic and lumbar spine. The reporting radiologist recommended a whole spine MRI scan, as sclerotic abnormalities were identified in the L1 and L4 vertebrae. An MRI requested by her GP was performed within 10 days and confirmed the presence of multiple bone metastases but no evidence of malignant spinal cord compression. The reporting radiologist contacted the acute oncology team by email and added the contact details of the acute oncology service on the bottom of the report for the GP to follow up.

The patient was seen in the oncology clinic within a week. Her performance status (PS) was 1 because of her bone pain. She denied any respiratory symptoms. She was a hardly ever smoker but had been a passive smoker due to her son's 20 pack-year smoking history. He was receiving treatment for paranoid schizophrenia. A staging CT scan of the thorax, abdomen and pelvis revealed a left lung primary with hilar node involvement. Histological analysis confirmed an adenocarcinoma, thyroid transcription factor 1 (TTF-1)-positive, EGFR wild-type and anaplastic lymphoma kinase (ALK)-negative, consistent with metastatic lung cancer. Her final staging was T4N1M1b. She presented to the emergency department with fever and new left chest pain, 10 days after her bronchoscopy. Her white blood cell count was elevated at 22×109/l and her C-reactive protein (CRP) was 3238 nmol/l. A chest X-ray revealed increasing left pleural effusion and patchy consolidation. A CT scan demonstrated a left-sided empyema. A pleural aspirate cultured Klebsiella pneumoniae sensitive to co-amoxiclav. A 6 week course of intravenous antibiotics was recommended. After a 2 week inpatient stay she was discharged, with a peripherally inserted central catheter in situ, to the care of the virtual ward and community palliative care team to complete her antibiotics and manage her symptom control.

What were the goals of cancer treatment for this patient?

What could be done to reduce the risk of a skeletal-related event?

What is the evidence base for her treatment options?

What other factors might influence her decision to accept active treatment?

What were the goals of cancer treatment for this patient?

The goals of treatment for this woman with metastatic lung cancer with bone involvement were to balance improvement in survival with gains in quality of life (QOL), symptom control and ability to remain at home with her son who had significant mental illness. Her personal goals and values should be sought to assist in joint decision making with regard to treatment, including any desire to undergo treatment as part of a clinical trial.

What could be done to reduce the risk of a skeletal-related event?

Most cases of lung cancer present with advanced disease at diagnosis. Bone metastases are the ...

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