1

1. Subjective data Objective data

- Subjective data
65
CC : Non small cell lung cancer stage IV with bone and liver metastasis
F/U
FH :

SH : , 1 / 20 1 ,
- Objective data
65.5 kg 166 cm (ECOG 1)
HPI : 1/8/57

Ultrosound : Multiple hypo-hyperchoic lesion 2-5 cm at right

lateral neck R/O lymphoma refer
9/8/57 Fine Needle Biopsy (Right cervical lymph node 1/8/56)
Inflammatory cell
CXR: Right hilar mass with right upper lung atelectasis
PE: CLN + at right upper jugular
10/8/57
CT chest - 3 cm RUL mass encasing RUL bronchus
about 2 cm distal to carina
multiple mediastinal and
ipsilateral superior hilar lymphadenopathy
- Evidence of obstructive pneumonia RUL
15/8/57
CXR : Right upper lung mass with infiltration right lower
lung
Bone scan : Bone lesion at left femoral neck is highly suspicious
metastasis
CT whole abdomen: multiple mass at liver
Pathology result (9/8/57)
Right cervical LN biopsy : adenocarcinoma carcinoma, moderate
differentiated, ALK rearrangement negative, EGFR negative
Physical examination :
GA : A man looked illness, dyspnea
V/S : BP120/80, BT 37.5 C, HR 70 bpm, RR 28 tpm
HEENT : Mild pale, no jaundice, Cervical LN positive
CVS : PMI at 5th ICS in MCL, normal S1S2, no murmur

Lung : Crepitation right lung

Abdominal : soft, not tender, L0S0, spleen dullness negativ

Medication : Folic (5 mg) 1 tab oral pc, FBC 1 tab TID pc

Premedication before chemotherapy Medications
1.Day 0
Ondansetron
Dexamethasone 20 mg IV 12 hrs
Sig 16 mg IV q 12 hr x 1
and
dose after finished
6 hrs before paclitaxel
carboplatin infusion
2. Day 1
30 min before pacitaxel
2.1 Dexamethasone 20 mg IV
2.2 Chlorpheniramine 1 amp
IV
2.3 Ranitidine 50 mg IV
2.4 Ondansetron 8 mg IV
3. Day 2
30 min before carboplatin
3.1 Ondansetron 16 mg +
dexamethasone
8 mg in NSS 50 cc IV drip 15
mins
3.2 Ranitidine 50 mg IV
Chemotharapy Order
1. Day 1
Paclitaxel 200 mg/m2 in 5D/W
500cc IV drip in 3 hours (use glass
syring, special IV set)
2. Record BP q 15 min x 4 when
starting and then q 30 min x 2 if
stable may off record
4. Day 2
Carboplatin AUC 5 in
5D/W 200 cc IV in 2 hours
5. After completion of Carboplatin,
give D5N/2
1000 cc IV 80-100 cc/hr

2. Omeprazole(20mg)
Sig. 1 cap po OD ac
3. Lorazepam (1mg)
Sig 1 tab PO hs
4. Paracetamol
(500mg)
Sig 1 tab oral prn for
myalgia or arthralgia
Metoclopramide
Sig 1 tab oral tid ac
Home medication
1. MTV 1*2 pc
2. Metoclopramide(10)
1*3 ac
3. Lorazepam(1) 1*1 hs
4. Omeprazole(20) 1*1
ac

Lab :
Hb = 11,
Hct = 33
Platelet = 250,000 Neutrophil = 60

WBC = 9,000
Scr = 0.6

2.
Goal : Palliative care :

3.

- Performance status : ECOG = 1 (ECOG 2)

- CBC
1. RBC : Hb =11, Hct = 33 (Hb>10, Hct>30)
2. WBC : WBC = 9,000, ANC= 5,400 (WBC>3,000,
ANC>1,500)
3. Platelet : Plt = 250,000 (platelet >100,000)

4.

NSCLC stage IV with bone and liver metastasis cell type

non-squamous cell (adenocarcinoma) ALK rearrangement
EGFR negative
- Doublet chemotherapy (Platinum based) Bevacizumab +
chemotherapy 6 cycle
regimen

Carboplatin AUC 5-6 day1 q 21 d Paclitaxel 200 mg/m2 day1 q

21 d

Efficacy monitoring

Toxicity monitoring
- Carboplatin : myelosuppresion, nausea/vomiting, alopecia

- Paclitaxel : myelosuppression, hypersensitivity, bradycardia,

hypotension
5.
(
)
Carboplatin 30-90%
(moderate)
Paclitaxel < 30% (low emetic risk)
moderate emetic risk
Day 1
Palonosetron 0.25 mg IV
Dexamethasone 12 mg IV/PO
5-HT3 antagonist (1st gen)
ex. Ondansetron
Dexamethasone 12 mg IV/PO

Day 2-3
Dexamethasone 8 mg PO OD
5-HT3 antagonist (1st gen) ex.
Ondansetron
Dexamethasone 8 mg PO OD

Hypersensitivity paclitaxel
- Dexamethasone 20 mg 3 dose >> 12 hr before, 6 hr before and
0 hr before paclitaxel
- H1 and H2 antagonist use before paclitaxel

6.

-
-

7.


crepitation
, chest x-ray infiltration
38.5 c
(38.3) ANC= 400 (<500 cell/mm3)
febrile
neutropenia chest xray
pneumonia MASCC criteria =
17 = high risk IV
antibiotics
Empiric treatment
1. Cefepime 2 g IV q 8 hr for 14-21 days or until neutropenia
resolves
2. Vancomycin 2-3 g/d IV for 14-21 days

1. Subjective objective data

Subjective data

62
CC :

FH :

SH :

- Objective data
HPI :
10/8/56 :
55
mammogram
Mammogram : mass at left breast size 1-2 cm (BIRADS 5)
15/8/56 : Core needle biopsy : Invasive ductal carcinoma
2/9/56 :
Left breast lumpectomy with sentinel lymph node and
auxiliary lymph node dissection :
- Invasive ductal carcinoma grade II
- Tumor size 1.5 cm
- Free surgical margin
- Sentinel LN biopsy : positive metastasis 3 out of 5 nodes
- Axillary LN dissection : positive metastasis 1 out of 20
nodes

Staning : ER staining 80%, PR staining 0%, Ki-67 25%, HER2 IHC

3+
15/9/56 : CT chest include upper abdominal
-

No lung mass or infiltration

No mass was seen in liver
Bone scan : No metastasis
EKG : normal
Echocardiogram : LVEF 65%

Physical examination :
67 kg 165 .
GA : A woman looked well, good conscious, ECOG 0
V/S : BP120/80, BT 37.0 C, HR 70 bpm, RR 21 tpm
HEENT : Not pale, no jaundice, Cervical LN negative
CVS : PMI at 5th ICS in MCL, normal S1S2, no murmur
Chest : surgery lesion at left breast (lumpectomy)
Lung : Clear
Abdominal : soft, not tender, L0S0, spleen dullness negative
Lab :
Hb = 12.0Hct = 35 WBC = 7,000
Plt = 300,000 Neutrophil = 50
Scr = 0.7
2.
Goal : Extend life
3.
- Performance status : ECOG = 0 (ECOG 2)
- CBC
1. RBC : Hb =12, Hct = 35 (Hb>10, Hct>30)
2. WBC : WBC = 7,000, ANC= 3,500 (WBC>3,000, ANC>1,500)
3. Platelet : Plt = 300,000 (platelet >100,000)

4.

breast cancer Invasive ductal
carcinoma (IDC) Left breast lumpectomy with sentinel lymph
node and axillary lymph node dissection tumor 1.5 .
2 no metastasis TNM

staging
stage IIA (T1c, N1, M0)
hormone status ER positive 80% (1%), PgR negative,
0% (20%), KI-67 25% ( 20%) HER2 positive
B

St. Gallen criterias prognosis

Luminal

Surgery (
), Radiation
Systemic treatment (Conventional chemotherapy, Hormonal therapy
Targeted therapy)

Radiation
Systemic therapy
1. Radiation : standard 50 Gy in 25 fractions
2. Systemic therapy : Conventional chemotherapy+ Hormonal
therapy + Targeted therapy Regimen
AC 4 q 3 wk followed by Paclitaxel + trastuzumab 12 weekly then
trastuzumab for 1 yr and AIs for 5 yr
Doxorubicin 60 mg/m2 IV day1
Cyclophosphamide 600 mg/m2 IV day1
* cycle for 21 day(3 wk) every 4 cycle then followed by
Paclitaxel 80 mg/m2 by 1 hr IV weekly for 12 wk with
Trastuzumab 4 mg/kg IV with first dose of paclitaxel followed by
Trastuzumab 2 mg/kg IV weekly to complete 1 yr of treatment
Anastrozole 1 mg/day for 5 yr
Calcium 1200-1500 mg (elemental) + Vit D 400- 800 IU
Efficacy monitoring

progress
Toxicity monitoring
1. Doxorubicin : cardiac toxicity, myelosuppression, mucositis,
nausea/vomiting, Vesicant
2. Cyclophosphamide : Hemorrhagic cystitis, nausea/vomiting,
myelosuppression, sterility
3. Paclitaxel : Hypersensitivity, myelosuppression, bradycardia,
hypotension
4. Trastuzumab : Infusion related effect, cardiac toxicity, interstitial
pneumonitis

5.
(
)

Doxorubicin+ cyclophosphamide 90% (High risk)

Day 1
NK-1 antagonist
Apprepitant 125 mg PO
Fosaprepitant 150 mg IV
5- HT3 antagonist
1st gen OD
Palonosetron 0.25 mg IV OD
Dexamethasone
12 mg IV/PO
20 mg IV/PO (W/O NK-1)

Day 2-4
NK-1 antagonist
Aprepitant 80 mg D2-3
Dexamethasone
8 mg PO D2-4 (for aprepitant)
8 mg PO D2 then 8 mg bid D34
(for fosaprepitant )
8 mg bid (w/0 NK-1)

Hypersensitivity Paclitaxel
- Dexamethasone 20 mg 3 dose >> 12 hr before, 6 hr before and
0 hr before paclitaxel
- H1 and H2 antagonist use before paclitaxel
Hemorrhagic cystitis
Hydration : IV 1.5 2 L/d oral 2-3 L/d
keep urine output > 100ml/hr (2.4 L/d)
6.
-
-

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