Paraneoplastic suspect lung cancer

[Jublybubly81]

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Hi, fascinating subject of paraneoplastic syndromes. Patient has low sodium and fatigue going on two years. Suspected paraneoplasic syndrome and underlying small cell lung cancer. Followed patient 18 months with CT chest/abdomen. Finally ordered PET/CT which came back with no suspicions. What would be your next move?

 

[speedyxx626]

Hi, fascinating subject of paraneoplastic syndromes. Patient has low sodium and fatigue going on two years. Suspected paraneoplasic syndrome and underlying small cell lung cancer. Followed patient 18 months with CT chest/abdomen. Finally ordered PET/CT which came back with no suspicions. What would be your next move?

Maybe a water deprivation test, and a UA? Maybe go through their med list as some meds can cause SIADH as well.

 

[Jublybubly81]

Med list clear, only vitamin D supplementation. No leads from water deprivation test. Interesting case to follow. Thought PET/CT would have revealed a clue. Is lung cancer ruled out? Not sure, plenty of reading material out there around paraneoplastic syndromes, not much experience to be accessed though. Two years would seem a long time to have symptoms relating to small cell with nothing giving a clue on PET/CT.

 

[Jublybubly81]

I guess the question is when do you rule small cell lung cancer out? I have listened to so many different views, is there a best practice or most recommended one?

 

[Wordead]

You need to present more information dude. This sounds like your differential for hyponatremia is small cell lung cancer and meds. What other workup has been done? What was the point of scanning the abdomen? Why not scan the head?

 

[Jublybubly81]

You're right, more info on complex case. Patient initially complained of fatigue, muscle/weight loss disturbed sleep and G I bloating and increased bowel frequency. Labs picked up sodium 130, low vitD and slightly high 24 hr urine cortisol. Did not fully suppress on 24 hr dex (marginally over) but did suppress on formal low dose dex suppression test. MRI head normal, HR chest an CT normal. Symptoms continuedv18 months, input from neurology to order PET/CT. There was no evidence of malignancy. This sparked interest in paraneoplastic syndrome, but has PET/CT ruled this out...
No real decline in patient, paraneoplastic panel normal. Next move? What's ruled out or in?

 

[Psai]

Did you even go to medical school? Whats the patients volume status, that is the first thing you should have said

 

[Jublybubly81]

Hey, I am just picking up on notes in the case, volume status was indeterminate, as in reality is the sodium of 130. Seems to be interesting exchange with radiology who have reviewed all images and rule out malignancy and neurology who still have some suspicion. Endocrinology testing was indeterminate. So complicated picture.

 

[Psai]

Thread title is begging the question.

You can't even tell us if the patient is volume overloaded 😵

You really think someone with 2 years fatigue and mild hyponatremia has small cell with paraneoplastic manifestation and you get a pet/ct as your test of choice after a normal ct chest 😕

Might as well give me their name and mrn now because they will probably be coming to my hospital soon with mdr cauti after they've had a foley left in for 2 months for no reason, a dirty looking picc with the dressing falling off and the last set of daily labs with a 1/2 page discharge summary written by a resident from the caribbean that says nothing of value

 

[Jublybubly81]

I hear what you say, and the pet/ct was the test of choice from neurology. They justified the pet/ct to rule out paraneoplastic syndrome, which I have never encountered. Did I think small cell for 2 years without serious deterioration, of course not. Do I question my inexperience, intuition and being easily led by experienced neurologists, course I do. As has been said to me, you don't know nothing yet, but I am trying to rectify this by taking an interest out of my comfort zone, which is most cases! I had never heard of ordering a pet/ct after normal ct, but neurologists say it's good practice in paraneoplastic and in their view evidence shows value in ruling out disease.
Thank you for adding to the conversation, it has helped me in a safe environment.

 

[Psai]

I don't know why you would consult neurology in the first place especially with normal head imaging. This is completely a medicine case. Blaming a consulting service for your own bad judgment is pathetic

First step in evaluating hyponatremia is seeing whether it is true hyponatremia or a lab error from other solutes

Then you look at volume status and your differential narrows based on that
Volume down - look at reasons for why they're volume down. gi or kidney loss? look at the urine to see if it's coming from the kidney. then figure out the source, whether it's organic disease or external such as meds
volume up is obvious and left as an exercise for the reader
euvolemic has a limited differential

When you evaluate a patient, you do it systematically. You don't order ridiculous tests to go on a wild goose chase for a low probability diagnosis in which you can't do much anyway and your patient has a very high chance of being dead already

 

[Jublybubly81]

Neurology were consulted before I arrived on the scene, hence my interest in catching up on the case. You make a good point about the contents of the discharge summary though, they can be quite meaningless. Looking through before neurology there were questions regarding autonomic neuropathy.
I need more confidence to speak out my thoughts, I was thinking too that small cell would already have caused his demise. Neurology have recommended follow up CT in 6 months, which is where I had my doubts but was falling into the trap of not showing a questioning attitude, new guy and all that.
Still, I will remove that catheter and clean up the picc before sending him on to you. No need to pass notes, you can read this thread.
Seriously, wish I had come here earlier, you are making me ask questions of myself and others, everyone else is not always right.

 

[Vain Brother]

I guess the question is when do you rule small cell lung cancer out? I have listened to so many different views, is there a best practice or most recommended one?

i'm gonna go with.....when the patient has hyponatremia for 2 years and imaging is inconsistent with malignancy. lol

 

[Psai]

Neurology were consulted before I arrived on the scene, hence my interest in catching up on the case. You make a good point about the contents of the discharge summary though, they can be quite meaningless. Looking through before neurology there were questions regarding autonomic neuropathy.
I need more confidence to speak out my thoughts, I was thinking too that small cell would already have caused his demise. Neurology have recommended follow up CT in 6 months, which is where I had my doubts but was falling into the trap of not showing a questioning attitude, new guy and all that.
Still, I will remove that catheter and clean up the picc before sending him on to you. No need to pass notes, you can read this thread.
Seriously, wish I had come here earlier, you are making me ask questions of myself and others, everyone else is not always right.

I don't know the exam but neurology sounds stupid. What are you looking for with this repeat ct? To see that the normal chest ct is still normal? That the invisible lung cancer is still invisible?

With all this useless radiation you probably gave the poor patient cancer already

 

[breezy1245]

I would just correct the hyponatremia. Locked-in syndrome is temporary anyways.

 

[Jublybubly81]

i'm gonna go with.....when the patient has hyponatremia for 2 years and imaging is inconsistent with malignancy. lol

I did think it might have been a rhetorical question and I would have gone with a lot less than two years with hyponatremia, but maybe you are playing cautious, lol. As I said earlier, I have been doubting myself too much and need to grow some. Thanks, hope you enjoyed the question.

 

[Jublybubly81]

I don't know the exam but neurology sounds stupid. What are you looking for with this repeat ct? To see that the normal chest ct is still normal? That the invisible lung cancer is still invisible?

With all this useless radiation you probably gave the poor patient cancer already

I best order another scan to look for the radiation damage. Sorry, I got my facts wrong, neurology recommended a follow on pet/ct in 6 months. That must be better at confirming the invisible lung cancer is still invisible than a plain old ct.

 

[DrBowtie]

Beer potomania. Next case.

 

[Jublybubly81]

Beer potomania. Next case.

Nice suggestion, but subject is teetotal and other labs didn't scream this out. Potassium normal, though chloride and bicarb both low but still in range. Reading through the notes is an education in itself, do you guys ever read through old cases and do they usually make sense when a diagnosis is forthcoming?

Looking back, this case has been going on for a few years, in fact first investigations in April 2014. The first tests seemed pretty textbook stuff by endocrinology and I can follow it and second guess where they were going. Then a range of consultancy services tried to get a lead and it becomes harder to follow any thought process.

All joking aside, is it ever appropriate to rule out malignancy based on duration of illness? I was given words of wisdom that you should only rule out conditions based on concrete evidence. Without evidence, you are relying on clinical judgement gained through experience and that is something that can be hard to document and be consistent with.

 

[Jublybubly81]

Interesting update, the patient has finally been diagnosed with small cell lung cancer. There were some suspicions but detailed negative imaging reduced our suspicions especially with 3 years of symptoms. A few folk here were quick to mock me on this complex case, thought the update might help you learn and become a good physician.

 

[Redpancreas]

Interesting update, the patient has finally been diagnosed with small cell lung cancer. There were some suspicions but detailed negative imaging reduced our suspicions especially with 3 years of symptoms. A few folk here were quick to mock me on this complex case, thought the update might help you learn and become a good physician.

Congratulations but reading back you presented the case poorly. If you're going to present a case, start from the beginning and make it organized. There's a reason the process others have alluded to is in place.

 

[Psai]

They probably got cancer from all the radiation you gave them

 

[CherryRedDracul]

They probably got cancer from all the radiation you gave them

"If there isn't cancer on the CT, they'll make sure there's cancer next time."

- me every day reading unnecessary CT studies.

 

[group_theory]

Interesting update, the patient has finally been diagnosed with small cell lung cancer. There were some suspicions but detailed negative imaging reduced our suspicions especially with 3 years of symptoms. A few folk here were quick to mock me on this complex case, thought the update might help you learn and become a good physician.

Just because the diagnosis was ultimately SCLC presenting initially as paraneoplastic doesn't excuse the shoddy workup. If you even try to write this up as a case report, it will look more like an M&M case than an interesting clinical case

Paraneoplastic symptoms occurring years befor SCLC is a known clinical entity (it is a common USMLE as well as ABIM board question). The update didn't help us "learn to be a good physician". It was your presentation, as well as how the case was worked up by your mentors - that should be heavily criticized. Just because the diagnosis was ultimately SCLC doesn't excuse the poor clinical care that this patient received, as well as unnecessary imaging studies.

If this was a morning report case, the take home points (since we're all trying to be good physicians) would be on how to workup hyponatremia, the technical limitations of PET-CT, and that paraneoplastic symptoms can occur before a visible nodule/mass is found. The way the case is presented will be something to work on as well.

 

[Raryn]

Your descriptions are completely back-asswards.

Lets just reason our way through this case:

A patient presents with mild (listed value is 130), chronic (years) hyponatremia. We don't have an osmolality to state that they're definitely hypotonic, but we'll assume that was done at some point. No listed comorbidities, so we'll assume the patient doesn't have cirrhosis, nephrotic syndrome, or significant heart failure. Given the chronicity, it's fairly unlikely that it is a hypovolemic cause. We don't really have an exam or urine lytes to justify stating that the patient is euvolemic, but it's most likely.

Patient at some point sees an Endocrinologist. Presumably at that point or before, adrenal insufficiency and hypothyroidism are ruled out. I have no clue why you talk about dexamethasone suppression testing in the context of a workup of hyponatremia.

At that point, your working differential diagnosis is SIADH, beer potomania, polydipsia (which usually doesn't cause hyponatremia if you're not also avoiding solute, such as the "tea and toast syndrome") and "cerebral salt wasting" (which may really just be SIADH and isn't that chronic besides). Beer potomania and the "tea and toast syndrome" are presumably ruled out with history, if not urine electrolytes. A water deprivation test is not necessary for working up hyponatremia (it's part of working up hypernatremia if you're worried about DI). So you're down to just SIADH. Which is the answer 95 times out of 100 anyway, but you still have to work your way through the above reasoning to get to the point you just call it SIADH, or you'll be missing a number of other causes. Looking at how many assumptions we had to make to get to this point, your description was woefully incomplete.

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Your initial post starts only here. You have a patient with what appears to be chronic SIADH, and you've ruled out other causes of hyponatremia. Your question was more appropriately phrased as "I have a patient with SIADH of unclear etiology and we have ruled out drug causes. We are currently fishing for more esoteric causes like malignancy. How is this workup best addressed?" That's actually a fairly interesting question, but you have to get to it the correct way. And the answer to the question is a big fat shrug on my part. I usually have some random etiology to blame it on. If I didn't, I suppose a plain old chest CT and brain MRI would be reasonable places to start. I certainly wouldn't be ordering random PET/CTs.

 

[Cura_te_ipsum]

Your descriptions are completely back-asswards.

You redeemed the thread. I learned more from your reply than from the OP

 

[Jublybubly81]

Thanks for your replies. I agree, case was poorly presented, however easy to criticise me and my mentors when the answer is revealed. The pet/ct was conducted after 18 months of invest and paraneoplastic syndrome being a possibility. At what point would you have ruled lung cancer in or out? Yes, paraneoplastic syndromes can present years before a visible tumor, but at the 2 year point most will have been found, especially with sclc.
I still admire my mentors and learnt a lot from this case.

 

[Donald Juan]

This is why all of my patients with a Na of 130 first get q6month PET-CTs for 3 years to r/o malignancy.

 

[Jublybubly81]

This is why all of my patients with a Na of 130 first get q6month PET-CTs for 3 years to r/o malignancy.

Thank you Donald Juan, I appreciate you posting and feel somewhat vindicated for not questioning the imaging studies ordered in this case. One seasoned physician was prepared to go for 4 years of imaging.
Have you found much small cell at 3 years or beyond?

 

[Jublybubly81]

I do understand irony, just in case there was any doubt.

 

[Raryn]

This is why all of my patients with a Na of 130 first get q6month PET-CTs for 3 years to r/o malignancy.

Is this a joke?

It's pretty clearly sarcasm.

 

[Jublybubly81]

I didn't think many folk in the USA understood sarcasm. This has reinforced my belief.

 

[jdh71]

Interesting update, the patient has finally been diagnosed with small cell lung cancer. There were some suspicions but detailed negative imaging reduced our suspicions especially with 3 years of symptoms. A few folk here were quick to mock me on this complex case, thought the update might help you learn and become a good physician.

Hm. How were they diagnosed?

 

[Psai]

Hm. How were they diagnosed?

Q6month petct

 

[Jublybubly81]

Sorry, 6 month ct and bronchoscopy gave diagnosis. Do you think you would have found it quicker? Many ruled out sclc a long time ago. Personally my respect for the physicians has increased. They had suspicions of malignancy and decided regular imaging was the way forward to rule in or rule out a diagnosis. The patient was well informed throughout his care.
Would you feel better if he was told malignancy was ruled out based on a negative scan and then presented back with extensive disease?

 

[Jublybubly81]

Just because the diagnosis was ultimately SCLC presenting initially as paraneoplastic doesn't excuse the shoddy workup. If you even try to write this up as a case report, it will look more like an M&M case than an interesting clinical case

Paraneoplastic symptoms occurring years befor SCLC is a known clinical entity (it is a common USMLE as well as ABIM board question). The update didn't help us "learn to be a good physician". It was your presentation, as well as how the case was worked up by your mentors - that should be heavily criticized. Just because the diagnosis was ultimately SCLC doesn't excuse the poor clinical care that this patient received, as well as unnecessary imaging studies.

If this was a morning report case, the take home points (since we're all trying to be good physicians) would be on how to workup hyponatremia, the technical limitations of PET-CT, and that paraneoplastic symptoms can occur before a visible nodule/mass is found. The way the case is presented will be something to work on as well.

I still don't get why you feel that the imaging studies were unnecessary? With suspicion of malignancy, 6 month period for scanning is a reasonable approach.

 

[masaraksh]

Check insurance, replace both hips, replace both knees, Occiput-Iliac crest posterior fusion, SI screws. This patient just needs to be more solid.

 

[Jublybubly81]

Not sure of the relevance of this. I think that there may be some envy from you, as in the above sclc case the physicians did everything in the patient's interest and got to a diagnosis as quick as possible.
I accept my poor presentation of the case but no one can explain why the imaging studies ordered were not necessary.

 

[jdh71]

Sorry, 6 month ct and bronchoscopy gave diagnosis. Do you think you would have found it quicker? Many ruled out sclc a long time ago. Personally my respect for the physicians has increased. They had suspicions of malignancy and decided regular imaging was the way forward to rule in or rule out a diagnosis. The patient was well informed throughout his care.
Would you feel better if he was told malignancy was ruled out based on a negative scan and then presented back with extensive disease?

What occurred with the patient here was pretty nonstandard.

SCLC isn't the only cancer that can give you an SIADH phenomenon. And I wonder at this point if this is all confirmation bias to be honest. Go looking for cancer in someone long enough there is a good chance you find it given its incidence, risk factors, and age of any given patient.

I personally would have clinically ruled out the patient with the first scan if it was indeed negative for any signs of lung cancer. I don't know if I would have done subsequent scans as I'm not sure in this case if there would have been any indication. I also wouldn't have even investigated a sodium of 130. But I don't do primary care, so maybe this was at some kind of threshold that made them suspicious.

Sometimes things in medicine have to declare themselves. I have a have a good 5 or 6 patients right now who have something weird going on in their lungs that doesn't really have a good definition or diagnosis. Something is wrong. Clearly inflammatory. No good specific markers from all the weird labs you can think of both from National Jewish and Mayo Clinic Labs (yet) neither I nor any consultant I've tried to get an opinion from knows. Yet here we are. Sometimes there is just something "fishy" about a patient and a clinician's intuition is just alarming. That happens. A perhaps was exactly what was going on in this case. Good for them in that sense that they finally found *a* diagnosis. I'm just not convinced I would have done what they did based on information. But you never know. Medicine is so very NOT black and white.

 

[Jublybubly81]

What occurred with the patient here was pretty nonstandard.

SCLC isn't the only cancer that can give you an SIADH phenomenon. And I wonder at this point if this is all confirmation bias to be honest. Go looking for cancer in someone long enough there is a good chance you find it given its incidence, risk factors, and age of any given patient.

I personally would have clinically ruled out the patient with the first scan if it was indeed negative for any signs of lung cancer. I don't know if I would have done subsequent scans as I'm not sure in this case if there would have been any indication. I also wouldn't have even investigated a sodium of 130. But I don't do primary care, so maybe this was at some kind of threshold that made them suspicious.

Sometimes things in medicine have to declare themselves. I have a have a good 5 or 6 patients right now who have something weird going on in their lungs that doesn't really have a good definition or diagnosis. Something is wrong. Clearly inflammatory. No good specific markers from all the weird labs you can think of both from National Jewish and Mayo Clinic Labs (yet) neither I nor any consultant I've tried to get an opinion from knows. Yet here we are. Sometimes there is just something "fishy" about a patient and a clinician's intuition is just alarming. That happens. A perhaps was exactly what was going on in this case. Good for them in that sense that they finally found *a* diagnosis. I'm just not convinced I would have done what they did based on information. But you never know. Medicine is so very NOT black and white.

Thanks for adding such a well formed reply with helpful information. Knowing why you would not have ordered further imaging adds balance to the argument. There was a lot of criticism on this thread for my presentation of the case (well deserved) but also about the poor care for the patient and mocking of the CT scans at 6 month intervals. Clinician's intuition was a factor here and I thought that it was a key element in getting to the diagnosis. Maybe, when I am more experienced, I will see clinician's intuition failing more times than not.
For the others who mocked the 6 month CT scans, it would be good to understand why this was so wrong in your eyes. On one screening program they are repeating CT scans every 6 months for a period of two years (5 scans in total) on asymptomatic patients who were initially screened with the Early CDT immunobiomarker test. I have not heard any great criticism that the patients testing positive on CT quote from

@Psai "probably got cancer from all the radiation you gave them"

I do take on board the confirmation bias and this was an excellent point to raise and a very relevant reminder.

Thank you

 

[jdh71]

Thanks for adding such a well formed reply with helpful information. Knowing why you would not have ordered further imaging adds balance to the argument. There was a lot of criticism on this thread for my presentation of the case (well deserved) but also about the poor care for the patient and mocking of the CT scans at 6 month intervals. Clinician's intuition was a factor here and I thought that it was a key element in getting to the diagnosis. Maybe, when I am more experienced, I will see clinician's intuition failing more times than not.
For the others who mocked the 6 month CT scans, it would be good to understand why this was so wrong in your eyes. On one screening program they are repeating CT scans every 6 months for a period of two years (5 scans in total) on asymptomatic patients who were initially screened with the Early CDT immunobiomarker test. I have not heard any great criticism that the patients testing positive on CT quote from

@Psai "probably got cancer from all the radiation you gave them"

I do take on board the confirmation bias and this was an excellent point to raise and a very relevant reminder.

Thank you

I personally think clinician intuition is more often right that than wrong. But I'm a terribly intuitive person and most people in medicine are not (at least at the student and trainee level). So the mocking of the intuition doesn't surprise me here.

I do watch nodules of a certain size for two years in high risk patients. And I have the appropriate patients screened by low dose CT. While the immunomarker stuff is interesting, I'm not convinced its ready for prime time nor 6 month scans until something is found. I'll probably wait for either ACCP or ATS to make a recommendation on the biomarker data or one big trial that will convince me it's worth the cost, time and radiation exposure.

 

[Jublybubly81]

Check insurance, replace both hips, replace both knees, Occiput-Iliac crest posterior fusion, SI screws. This patient just needs to be more solid.

So are you saying the imaging studies were unnecessary? If so, when do you think this patient would have received their diagnosis?

 

[Jublybubly81]

"If there isn't cancer on the CT, they'll make sure there's cancer next time."

- me every day reading unnecessary CT studies.

Does this mean you would invent a finding on a patient that is being followed for a suspected malignancy or disagree with the notion that those presenting with paraneoplastic syndromes should not be screened regularly?
I do think that this is where experience gained in the profession will influence your view one way or another. Having seen a positive result, I am leaning towards the screening being beneficial. Have you had experience that makes you against screening?

 

[Jublybubly81]

You redeemed the thread. I learned more from your reply than from the OP

Great that you learned something, this is what these forums are all about. I don't think the imaging was ordered on a random basis though as there was a suspicion of an underlying malignancy and paraneoplastic scenarios justifies periodic scans. My concerns (not voiced) was when to know when to stop ordering scans, and I hope that is something I will gain in experience. These syndromes can go on for years, so can be quite an early warning sign to pick up on. Would you have waited until more definitive signs of lung cancer presented? It was a very difficult case to follow, but I am glad I had some visibility of it.