Status Date: 11/112015 7:22:12 AM

Approved By: Shirley, Kathy, NP

Status: Approved

1100377
- BABU, .,.,..,.,.
-~ 31yo
PITCT
Ao

H 10/28/ 1113 C11!5.0ca 80.2Jcf &lAc 1.11a' 08/11/15)

CONTRAaRD 8UB80 'l'X '7881S 10

a.t.on: 1353t120

121/2015 1D12JsOO ltH

FULL RESULT:
Examination: FOG PET/CT, 10/21/2015 10:25 AM
Tumor Type: Sarcoma

Clinical History: 31-year-old Asian male with paratestlcuJar rhabdomyosarcoma with epitheUoid featUres.
Patient Is status post resection with recurrence and metastasis to the lungs he is also status post 8 cydel of
VAC chemotherapy. Most recenUy the patient has been treated with gemcitablne and Taxotere.
Indication: Evaluate treatment response, Subsequent treaament strategies.
Comparison: PET/CT scan of 08/1712015.
Technique:
RadiopharmaceutiCal: f.18 fluorodeoxyglucose
Administered activity: 10.0 mCi
Route of administration: Intravenous vJa the left basilfc vein
Localization time: 64 minutes
Serum blood glucose: 98 mglcfl
Scan
range: Skull vertex to teet The patient received lodi181ed fntraWIIOUS contrast mllferial. Oral conlrall
material was not administered.
Findings:~

Head amlNectc:
- portions of the brain.,. normal ~n appearance "" JIOIHll)lllrast CT -nning.
Brain:
The visUalized
Mucosa: Tracer uptake fn the head and neck mucosa 11
Lymph Nodes: There is no nodal hypllllllllfllbolllm or ad..,...,..thY mlhe""""""' chains.
The paranasal sinuses are clear.

normal~ syrnn.J~

Bilateral pulmOIIIIIY metasfa- are Jlllllin noted.

~noduleS for comparison ere nollld

below:
.
.
taSt8Sis that had a maximun ' SUV of 28.8 0 nage 16t of the n ...
The nght apiCSI 2:1 em me
mum siN of 18.9 (Image 170).
measures 1.9 em and has a rnaXJ

';~ n_-:_

I
r

Status~
Appr~Kathy,

Status: Appro

The.
f:etl'
brrnec::mss_
~lobe
..a

en the

1.3 em mass Wfth 8 maximum SlN of 12.9 (image 169) hiS enlarged and shcwl
I
as 8 ~area it now measures 3.5 an and has a central area of photopen 1
PET portion of the study, the rnaxirmn
Is 13.8 (mage 173) not significantly changed.

as

sw

'!J.'!t;ft infrahBar lesion that measurect 3.7 em and had

maximum

sw of 24.6 (image 208 of the prior

--..,now rneasunts 3.9 an and has a maximum suv of 19.1 (image 215).

A lfs!ht lower lobe (superior segment) lesion that had 8 maximum sw of 7.2 fs IITI&Ier and now has a
maximum SW of 3.4 (mage 197 of the prtor atudy and mage 200 of todaY stud~).
Lymph Nodes: No progressive intrathoracic nodal hypermetabOlism or adenopathy.

Esophagus: Nonnal
Pleural Spaces: Normal
HeartiPericard'JUm: Chamber size is normal There 11 no evidence of pericardfal effusion. The central
pulmonary arteries are wei opacified and show no fiJiing detects.
A right centraJ venous port Is noted with its tip at the atriocavaJ junction.
Abdomen and PaM&:

Liver: Thete Is no parenchymal, vascular, or bifiary tree abnonnalfty noted on the contrast enhanced liVer.
Distribution of radiopharmaceutical Is uniform.
Spleen: The spleen Is normal In sa and FOG avidity.
Adrenal Glands: There is a mom obvious focal area of hypennetaboJism In the region of the right adrenal
gland apex maximum SW is 5.9 (image 274). In rewspect a small focal area of hypermetabolism Is noted
In the same area on the prior scan maximum SUV was 3.3 (rmage 271 of the prior scan). The left adrenal

gland is normal.

'ancreas: Normal

1dneys: The kidneys are free of morphologic abnonnarllies. They excrete radiopharmaceutical and contrast

raterial symmefrlaatty. -

-.

mph Nodes: No aggressive subdiaphragmatic nodal hypermetabolism or adenopathy.

Ttact: The stomach, small bower, and colon are nonnalln caliber, with physiOlogic FOG uptake.
nnourlnary: Patient is post right orchiectomy. The 2 x 2.4 em peripherally enhancing lesion In the right
:Jtum that had a maximum SUV of 14.1 (fmage 455>is today seen on Image 456 it measures 2.6 x 2.4
and the maximum SUV has Increased to 227

,08" 11 ctn FDG avid nodule In the right Inguinal canal that had a maximum sw of 3.8 (image 428 0
~r sWcly)Js foda~ seen on Image 431 Jt measures 1.5 x 0. 7 em and has a maximum
of 42 nat

sw

~--,-----------~~-----

~cc:

llABU, JOSB 3lyo

C:0N'l'RAsTBD suaso
ion,
1JS34120

TX 7

M 10
r 08/17/lSJ
/29/1983 (l7s.ocm eo.2kg BS~; 1.97m

auuo/21/2015 10:25roo I'M

significantly changed.
Musculoskeletal:
Bones There is 1 t
nd th
Prcxl
n ense diffuse bone marrow hypermetabolism Involving the central skeleton a
e
mal portions of the humeri and femora.

No suspicious lytic or sclerotic osseous lesions are seen on CT scanning.

Soft nssues: The soft tissue nodule in the right lower atJdomjnal waU located wJthin lhe right Internal oblique
muscra that had a maximum sw of 22.6 (fmage 3711 has responded favorably to therapy, it is no longer
dlscemlble as a separate nodule maximum suv of a representative area is 2.9 omage 381 of today'&
study).
IMPRESSION:
The lesion in the right scrotum has shown metabolic progression since the prior study and some slight

increase In size as well.

There 14 a right adrenal hypermetabolic lesfon that has shown sJlght metabolic progression since the prior
study.

The bilateral pulmonary metastases are either stable or have shown a positive thel8peutfc response.
Findings are that of a mfxed response.

Read by: DONALD A. PODOLOFF,M.D. on 10!Z1fl01611:35

SIGNED BY: DONALD A. PODOLOFF,M.D. on 1012112015 11:32

D: 10/21/2015 11:35

T: 10121/2015 11:32

- - - , - - - - - - - - - - - - - ---------

AUSTIN CANCER CENTER

Experienced specialists. Advanced treatment. The standard for compassionate care.

MRN:
PATIENT:
DOS:
DOB:
TOV:
Chief Complaint:
Dictator:
Supervising Physician:

A150448
BABU,JOSE
10/27/2015
10/29/1983
Follow Up Visit
"I still have my cough."
Kathy Shirley, FNP-C
Benjamin J. Downie, M.D.

HEMATOLOGIC-ONCOLOGIC PROBLEM LIST:

1. Rhabdomyosarcoma of the epididymis, right sided, metastatic, with pulmonary involvement, diagnosed in
the setting of a right-sided testicular mass, prompting testicular ultrasound on 10/24/2014, revealing an
extratesticular mass on the right side with CT imaging of the abdomen and pelvis on 12/03/2014 revealing an
incidental finding of gallbladder sludge but no evidence of metastatic disease with repeat ultrasonography on
12/26/2014 revealing a new heterogeneous extratesticular mass in close proximity to the previous,
communicating with the previously seen smaller mass, prompting right-sided orchiectomy performed on
12/31/2014 by Dr. Koushik Shaw, revealing what was initially reported as an epithelioid leiomyosarcoma,
measuring 8.5 em in maximal dimension, grade 3, diffusely involving the peritesticular space with necrosis
involving approximately 50% of the total tumor volume with all margins negative for tumor and no evidence of
LVI noted with subsequent review at M. D. Anderson altering this diagnosis to rhabdomyosarcoma of the
epididymis. PET/CT imaging performed on 03/13/2015 revealed multiple pulmonary metastases with several
foci of markedly increased activity seen in the lungs bilaterally, corresponding to pulmonary nodules seen on
the CT portion of the exam with a maximum SUV ofwhich was seen in a lesion of the infrahilar left lower lobe,
measuring 16.4, with a suspicion for small soft tissue metastases in the scrotal raphe, as well as a suspicion for
small metastases in the left prostate, though this could not be confirmed on CT and was not clinically palpable
at the time ofPET/CT imaging by Dr. Koushik Shaw.
- Status post initiation of induction chemotherapy with Cytoxan, doxorubicin, and vincristine on 03/10/2015,
alongside- Neulasta growth factor support and dexrazoxane, as cardioprotectant. The patient developed a
neutropenic fever one week after his first cycle of therapy.
- Status post progression documented on PET/CT imaging at MD Anderson.August 2015, prompting transition
to gemcitabine/Taxotere therapy on 08/25/2015.

PAST MEDICAL HISTORY:

1.
Seizure disorder, suffered initially in 2011 while driving, prompting initiation of Keppra, which the
patient remains on to this day.
2.
Status post right-sided orchiectomy, as detailed above.
MEDICATIONS: Keppra twice per day .

RADIATION ONCOLOGY: Terry Boyle, MD I George R. Brown, MD I Stephen L. Brown, MD I Shannon Cox, MD
Paiman Ghafoori, MD I Matthew McCurdy, MD I Douglas J. Rivera, MD I Kirsten A. Warhoe, MD
HEMATOLOGY I MEDICAL ONCOLOGY: Benjamin l Downie, MD I Allison E. Gorrebeeck, MD
Gerald Hagin, MD I Brian l Shimkus, MD I Sanjay Yin (Vinjamaram), MD
NEURO ONCOLOGY: Brian Vaillant, MD
SURGEONS: Jane C. Nelson, MD, FACS I Caroline H. Coombs-Skiles, MD, FACS I Sherrie Parker, MD
Phone: Appt. Line 512.505.5500 I Medical Records 512.334.2724 I Fax: 512.334.27021 www.AustinCancerCenters.com

Page 2 of4
PATIENT: BABU, JOSE

DOB: 10/29/1983

MR: A150448

ALLERGIES: No known.
INTERVAL HISTORY: Mr. Babu recently had a visit toM. D. Anderson Cancer Center and had a PET scan
while there. The bilateral pulmonary mets are stable. The lesion in the right scrotum has shown metabolic
progression since the prior study and some slight increase in size as well. There is a right adrenal
hypermetabolic lesion that has shown slight metabolic progression since the prior study. Dr. Araujo advised
him to stay on this current chemotherapy regimen for two more cycles and then she would reimage. The patient
feels well except for a persistent cough. He very rarely has sputum and if so, it is clear. He has had no fever or
other infectious symptoms. His wife and daughter have both had allergy symptoms.
FAMILY HISTORY: Negative for known oncologic conditions.
SOCIAL HISTORY: The patient is married and had a daughter born in 2014. He was married in 2012. He
and his wife are from India. The patient works in IT. He denies any tobacco, alcohol, or illicit drug use. He
lives in North Austin with his family.
REVIEW OF SYSTEMS:
GENERAL: See above in the Interval History.
SKIN: No reported skin, hair, nail changes; no reported itching, rashes, sores, lumps, nor moles.
HEAD, EYES, EARS, NOSE and SINUSES: See above in the Interval History..
NECK: No reported swollen neck, mass, nor goiter.
LYMPHATIC:
No reported anterior or posterior cervical, supraclavicular, axillary, nor inguinal
lymphadenopathy.
CHEST: See above in the Interval History.
CARDIAC: No reported syncope, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, nor chest
pam.
BREAST: No reported masses, lumps I bumps, skin changes, nor discharge.
GI: No reported abdominal pain, nausea, vomiting, diarrhea, constipation, change in stool color or bleeding,
nor jaundice.
GENITAL: No reported discharge, bleeding, nor pain.
URINARY: No reported change in urinary output, frequency, hesitancy, hematuria, nocturia, nor incontinence.
EXTREMITIES: Reports some achiness to his hands which.could possibly be some neuropathy.
NEUROLOGIC: No reported focal paralysis, change in mental status, seizures, headaches, loss of sensation,
numbness, tingling, tremors, nor vertigo.
PSYCHIATRIC: No reported change in mood, anxiety, nor memory.
HEMATOLOGIC: See above in the Interval History.
PHYSICAL EXAMINATION:
Vital Signs: The patient's weight is stable at 176 at 176, blood pressure 115/71, heart rate 100, respirations 16,
temperature 98.6.
GENERAL: The patient is a pleasant 31-year-old male in no distress.
SKIN: Some darkening of his fingernails.
HEAD: ~ormal size and shape, no trauma noted.
EYES: Pupils equal, round, and reactive to light. No evidence of conjunctival pallor. No scleral icterus.
NOSE/SINUSES: Symmetrical, nontender, normal mucosa without turbinate inflammation. Sinuses nontender
to palpation.
MOUTH/THROAT: Moist mucous membranes. No ulceration or thrush noted. No pharyngeal erythema.

Page 3 of4
PATIENT: BABU, JOSE

DOB: 10/29/1983

MR: A150448

NECK: Supple. No masses, goiter, tracheal deviation, nor bruit appreciated.

LYMPHATIC: No anterior I posterior cervical, supraclavicular, or axillary lymphadenopathy.
CHEST: Clear to auscultation. No evidence of crackles nor wheezes. Breathing appears nonlabored. The
patient denies any shortness ofbreath.
CARDIAC: Regular rate and rhythm. No murmurs, gallops, nor rubs appreciated.
BREAST: Deferred today.
ABDOMINAL: Normal bowel sounds, soft, nontender and nondistended. No masses nor organomegaly
appreciated.
GENITAL-URINARY: Deferred.
EXTREMITIES: No cyanosis, clubbing, nor edema appreciated. Adequate perfusion noted. No muscle atrophy.
NEUROLOGIC: Deferred today.
DATA: White count is 3.95, ANC 2.52, hemoglobin 10.7, hematocrit 32.6, platelets 201,000.
IMPRESSION & PLAN: Mr. Babu is a 31-year-old male with metastatic rhabdosarcoma of the epididymis
with pulmonary involvement who has completed three cycles of gemcitabine/Taxotere and tolerated it relatively
well. He has possibly some neuropathy to his fingers. He denies any fevers. No infectious symptoms. His
doctor at M. D. Anderson Cancer Center recommended the patient stay on two more cycles of
gemcitabine/Taxotere before reimaging. He has a persistent cough, which he feels is related to allergies. He
has some Tessalon Perles which helps him somewhat at night. He is able to sleep throughout the night. He has
sinus drainage. He occasionally uses Flonase.

My plan is as follows:
1.

Basic labs.

2.

PET/CT results were reviewed with the patient again.

3.

The patient was recommended to use Flonase one squirt to each nostril twice a day.

4.

Tapering steroids will be called in for the patient to see if this decreases his cough.

5.

Gemcitabine day 1 will be given today. He will receive

- day 8 next week followed by Neulasta.

6.

The patient is aware to let us know of any fevers, any new infectious symptoms. Hopefully, he will
have a decrease in his cough with the steroid use.

~.

The patient will follow up with Dr. Downie with his next cycle of treatment.

Electronically Approved By: Kathy Shirley, FNP-C on 10/28/2015 5:05:24 PM

Electrqnically Co-Signed By: Benjamin J. Downie, M.D. on (Co-signature Req)

D: 10/27/2015 15:56

----- ----- -------,-----------T--- ---

Page 4 of4
PATIENT: BABU, JOSE

DOB: 10/29/1983

T: 10/28/2015 06:53
cc: Koushik Shaw, M.D., FAX: 512-973-3036
Natalie Burger, M.D., FAX: 512-451-0977
Dejka Araujo, M.D., FAX: 713-794-1934

MR: A150448

AUSTIN CANCER CENTER

Experienced specialists. Advanced treatment. The standard for compassionate care.

PATIENT: BABU, JOSE

Attending MD:

MR# A150448

DOB: 10/2911983

Date of Service: 10/17/2015

The patient has emailed me reporting a scant amount of some red blood in his mucus that he coughs up in the
mornings. It is scant, per his report, and he feels otherwise well. I have made him aware to present to the
emergency room immediately if he develops a teaspoon full of blood or more in what he coughs up. We will
plan to rescan as previously scheduled provided this remains only scant in amount as it could of course be
allergy related.

Electronically Approved By: Benjamin J. Downie, M.D. on 10/19/2015 5:51:17 PM

D: 10119/2015 10:31
T: 10119/2015 12:43

RADIATION ONCOLOGY: Terry Boyle, MD I George R. Brown, MD I Stephen L. Brown, MD I Shannon Cox, MD
Paiman Ghafoori, MD I Matthew McCurdy, MD I Douglas J. Rivera, MD I Kirsten A. Warhoe, MD
HEMATOLOGY I MEDICAL ONCOLOGY: Benjamin J. Downie, MD I Allison E. Gorrebeeck, MD
Gerald Hagin, MD I Brian J. Shimkus, MD I Sanjay Vin (Vinjamaram), MD
NEURO ONCOLOGY: Brian Vaillant, MD
SURGEONS: Jane C. Nelson, MD, FACS I Caroline H. Coombs-Skiles, MD, FACS I Sherrie Parker, MD
Phone: Appt. Line 512.505.5500 I Medical Records 512.334.2724 I Fax: 512.334.2702 I

www.AustinCancerCenters.com

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