Case Presentation

1
Case Presentation
NCI Grand Round Medical Oncology Department

• Dr. Hatem A.Azim
• Resident of medical oncology, NCI, Cairo
  University

Supervised by Prof. Rabab Gaafar
Dr. Ola Khorshid
2

• A 37 years old healthy premenopausal lady was
  diagnosed with right breast cancer in 1996
• MRM 3/96 IDC GII (T2m N0/8)outside NCI
• ER, PR ve. Her2/neu NA
• Abd U/S, Bone scan normal
• Chest x-ray a cystic lesion in the right lower
  lung zone
• PS I
• Past history unremarkable.
• Family history ve for paraspinal malignancy
  (father) and cancer pancreas (uncle)

3

• 4-5/1996 adjuvant local radiotherapy
  (4500cgy/25ttt/5wks) outside NCI
• 6/96 presented to NCI (hospital no. 3947/96)
• 6-11/96 CAF x 6 cycles
• 12/98 5th delivery
• 1/99 Menses stopped
• Chest x-ray done every six months since the end
  of treatment showed stationary course as regards
  the right lower lobe cystic lesion.

4

• She was kept healthy on regular follow up till
  August 2005 (age 46) when she developed
• Productive cough with yellowish sputum
• Dyspnea on mild exertion progressing to orthopnea
• Night sweats progressive weight loss

5

• Examination
• BP 110/70, Temp 37
• Performance status II (ECOG scale)
• Pale, toxic, non-icteric and distressed
• Lying on her back with two pillows
• Congested non-pulsating neck veins
• Dilated veins over the left chest wall
• No air entry on the right lung except an area of
  bronchial breathing over the lower lung zone
• Enlarged right lobe of the liver 5cm below costal
  margin
• No splenomegaly or lymphadenopathy

Mediastinal Syndrome
6
Chest x-ray progressive right pleural effusion
compared to previous films with underlying lung
collapse and contralateral mediastinal shift of
the trachea and heart

• Pleural drainage (1L) was done and cytology
  revealed no malignancy with cellular features of
  inflammatory exudates.
• Z-N stain was negative
• CT scan was requested

7

• CT chest
• Right pleural effusion with an associated
  encysted component with marginal calcification
• Anterior mediastinal mass markedly displacing the
  heart and great vessels to the left.
• Bone scan and abdominal U/S normal
• Laboratory workup
• Microcytic hypochromic anemia (Hb 9.1, MCV66)
• Leukocytosis (13,000), PNL (90)
• Low prothrombin concentration (69).
• Otherwise, LFTs, KFTs were normal

8

• A pigtail catheter was inserted for drainage and
  a CT guided biopsy from the anterior mediastinal
  mass was performed. october 19th
• Cytological examination
• Bacteriological examination
• TB by PCR

9
Cytology -ve for malignancy
TB-PCR -ve
Culture gram ve cocci
10
Biopsy squamous cell carcinoma