COLORECTAL CANCER: JESSA

Diane B. is a 72-year-old retired elementary school teacher from UP IS. Her prior medical history is notable
for stage I cervical cancer at age 20 years, treated with cobalt therapy and total hysterectomy. The patient
was diagnosed with metastatic colorectal cancer in January of 2013, after presenting to her PCP with
progressive fatigue of 3 month’s duration and irregular bowel movements; Patient’s performance status
was 1.
 CT scan revealed a large nonobstructive mass in the sigmoid colon with multiple large hepatic lesions;
the patient’s CEA level was 158 ng/mL
 Patient was not indicated for surgery due to minimal symptoms and presence of metastatic disease
 Biopsy of the sigmoid mass and hepatic lesion showed adenocarcinoma, and mutational testing
showed KRAS WT; BRAF negative; RAS status was not determined
 Diane underwent initial therapy for metastatic disease with FOLFOX + bevacizumab
 Following 6 cycles, patient had a response with a decrease in several stable hepatic lesions the
primary mass on CT; her CEA decreased to 25 ng/mL
 At 4 months, the patient had developed sensory neuropathy (grade 2), and oxaliplatin was
discontinued from her regimen; 5-FU, leucovorin, and bevacizumab were continued
In January of 2014, she presented to her oncologist for evaluation after her CEA had increased to 77
ng/mL.
 The patient was asymptomatic at the time of recurrence, and her neuropathy had improved to grade 1
Following her first-line recurrence, Diane is switched to FOLFIRI, and bevacizumab is continued.
 After 3 cycles, her CEA decreased to 19 ng/mL. The patient remained asymptomatic, and her hepatic
lesions were stable

In July of 2014, she presents to her oncologist with fatigue, dyspnea, and worsening performance status,
and her CEA had increased to 180 ng/mL.
 CT scan revealed progression of multiple hepatic lesions, with several new nodules noted in the lung
right upper lobe. Biopsy of the lung and liver lesions was consistent with metastatic disease, and both
samples were sent for mutational analysis.
Based on results of her mutational analysis, which showed KRAS WT; BRAF negative; RAS WT, the
patient is considered eligible for treatment with an anti-EGFR agent, and she is initiated on cetuximab +
irinotecan.
 Cetuximab infusion was delayed after the first cycle for 1 week due to rash. After 4 cycles, she shows a
response with her CEA decreasing to 32 ng/mL, and a reduction in hepatic lesions and stable lung
lesions on CT. In November of 2014, the patient presents with dyspnea, increasing CEA and
worsening performance status. Her CT scan is consistent with progression of lung lesions. Her present
weight is 48 kilograms and stands 5’3”.

Chemistry  Normal Values  Urinalysis

Sodium  139 136-146 mmol/L  pH 6.0
Potassium  3.2 3.5-5.3 mmol/L  Specific gravity 1.010
Protein 1+
Chloride  94 98-108 mmol/L 
Glucose negative
Total CO2 24  23-27 mmol/L  Acetone negative
BUN 10  7-22 mg/dl  Occult blood negative
Creatinine  1.0  0.7-1.5 mg/dl  Bile negative
Glucose  108  70-110 mg/dl 
Calcium  8.8 8.9-10.3 mg/dl 
Phosphorus  6.0  2.6-6.4 mg/dl
Alkaline Phosphatase  108  30-110 IU/L
Parathyroid Hormone  62 10-65 pg/ml
Hemoglobin  12 14-17 gm/dl
Waxy casts
Hematocrit  27.4  40-54 %
 
Mean cell volume  88  85-95 FL  

 
LUNG CANCER: EFEFANY

 SR is a 58 year-old female, former smoker 20 PPY (stopped smoking 5 years ago), presents with
cough and SOB. She experienced an unintended 10 lb weight loss over a 3-month period. Her present
weight is 52 kilograms and stands 5’7”.

 Tissue analysis identified adenocarcinoma, EGFR, ALK, ROS1 negative.

 PD-L1 expression was < 50%.
 Patient has stage IV disease with metastasis to the liver.
 A chest CT scan confirmed the primary mass in the upper lobe of the right lung, with several pleural
metastases and malignant pleural effusion.
 MRI of the brain was negative for intracranial metastases.
 Patient has not complained of blood in the sputum.
 Patient has history of well controlled HTN.
 Her performance status was 1 at diagnosis.
Patient was started on carboplatin/paclitaxel/bevacizumab for 4 cycles.  Patient showed partial response
and was continued on bevacizumab until progression.

Chemistry  Normal Values  Urinalysis

Sodium  148 136-146 mmol/L  pH 6.0
Potassium  3.0 3.5-5.3 mmol/L  Specific gravity 1.010
Protein 1+
Chloride  94  98-108 mmol/L 
Glucose negative
Total CO2 24  23-27 mmol/L  Acetone negative
BUN 10  7-22 mg/dl  Occult blood negative
Creatinine  1.0  0.7-1.5 mg/dl  Bile negative
Glucose  108  70-110 mg/dl  Waxy casts
Calcium  8.5  8.9-10.3 mg/dl 
 
Phosphorus  6.0  2.6-6.4 mg/dl
Alkaline Phosphatase  115  30-110 IU/L
Parathyroid Hormone  60 10-65 pg/ml
Hemoglobin  10.0  14-17 gm/dl
Hematocrit  27.4  40-54 %

 
Mean cell volume  88  85-95 FL
 

HIV/ AIDS: NEIL

A 43-year-old male with stage C3 HIV/AIDS presents with loose, watery stools, abdominal cramping,
sweats, fevers, poor appetite (2 months) and 15 lbs weight loss. He is taking Combivir one tablet bid and
Nelfinavir 1,000 mg tid, and trimethoprim/sulfamethoxazole for secondary pneumocystis carinii pneumonia
(PCP) prophylaxis. He reports good adherence, with an undetectable viral load and a CD4 count of 100
cells/mm3. He was diagnosed with HIV and PCP when he entered the U.S. from Mexico one year ago, at
which time he had a CD4 count of 2 cells/mm 3 and "high" HIV-1 viral load. He is an injecting drug user and
has sex only with men. He reports unprotected sex with two anonymous partners two to three months ago
when he traveled abroad. He weighs 130 lbs and is afebrile with normal blood pressure, genital and
neurologic exam. His pharynx was without thrush; there was no scleral jaundice, some temporal wasting,
no rash, abdominal tenderness, organomegaly, lymphadenopathy, or peripheral edema. He stands 5’6”.

Chemistry  Normal Values  Urinalysis

Sodium  138 136-146 mmol/L  pH 6.0
Potassium  3.2 3.5-5.3 mmol/L  Specific gravity 1.010
Protein 1+
Chloride  100  98-108 mmol/L 
Glucose negative
Total CO2 24  23-27 mmol/L  Acetone negative
BUN 10  7-22 mg/dl  Occult blood negative
Creatinine  1.0  0.7-1.5 mg/dl  Bile negative
Glucose  108  70-110 mg/dl  Waxy casts
Calcium  8.5  8.9-10.3 mg/dl 
 
Phosphorus  6.0  2.6-6.4 mg/dl
Alkaline Phosphatase  108  30-110 IU/L  
Parathyroid Hormone  62 10-65 pg/ml
Hemoglobin  10.0  14-17 gm/dl  
Hematocrit  27.4  40-54 %  

Mean cell volume  88  85-95 FL