Henry Kan 16505083

Presenting Hx:
RR is a 91 year old Caucasian Male with a past history of advanced metastatic melanoma with history of active IHD, quiescent AF, hypertension and osteoarthritis presenting with right shoulder pain, back pain and unsteadiness gait due to lower limb weakness in the last 2 weeks. Prior to onset of symptoms patient was high functioning and physically active.

History of presenting illness:
Right Shoulder Pain: - The right shoulder pain began 7 sessions into his current radiotherapy for pain in his left shoulder. - The shoulder pain was described as ‘sharp and very debilitating’ - Rated 8/10 when aggravated, 2/10 at rest - Insidious onset - No recent histories of falls or physical trauma Back Pain: - A back pain which is gradually worsening for the last 3 weeks, - pain is straight down the midline of the back at mid-level, it is rated a 8/10 - It is aggravated by recumbence, coughing or sneezing. - Both shoulder and back pain have forced the patient to sleep in a chair to not aggravate the shoulder or the back pain. Lower Limb Weakness: cannot stand up from a sitting position without help for the last 2 weeks, Unsteady gait immobilized.

Oncology History:
Patient discovers a black lump in the right heel in 2008 The lesion was excised and biopsied by a plastic surgeon staged initially T4a N0 M0 [Stage IIB] and the wound was graphed Due to his age, and the solitary nature of the lesion; systemic chemotherapy was not used. Patient was asymptomatic from an oncology POV until another lesion developed in Oct 2010 after the initial excision in the same spot, surgeon was not sure if the lesion was melanoma and decided to re-examine 6 weeks later

NKDA Social and Psychological Hx: ECOG 3 Social Hx: . patient received cortisone and was put on Rad therapy for 10 fractions. Operation was performed to remove ilio-femoral lymph nodes and the lesion was excised After the operation. renal angiography was performed to exclude renalvascular causes. - - Medications: Paracetamol 1000mg Q6h Coloxyl and Senna 2PO nocte Irbesartan 150mg PO mane Movicol 1 sachet BD Atenolol 50 mg Digoxin 250mg Frusemide 200 mg Allergies: . After 7th fraction patient presents with right shoulder pain and back pain. The melanoma does not have a BRAF mutation - Other medical/Surgical Illness’: Ischaemic Heart Disease o Diagnosed in april 2006 o No previous history of angina pectoris o Sudden onset of crushing chest pain. admitted to ER in april 2006 o Underwent Quad CABG o No diabetes or cholesterol problems o Stage A Heart Failure. with no orthopnoea and no PND o Managed by beta blockade and Frusemide Atrial Fibrillation 2008 diagnosed by ECG at cardiologist check up. managed by Digoxin and beta blockade Idiopathic hypertension diagnosed 2002 by regular GP visit.Henry Kan 16505083 After 6 weeks it was found that the second lesion was indeed malignant (T4a N1 M1) [Stage IV] and has spread into the groin and surrounding lymph nodes and has also has MET in the liver. Currently managed by single agent hypertensive Irbesartan Osteoarthritis of left knee 2000 diagnosed by X-ray at GP. knee replacement was put in 2001. imaging revealed a MET near the region. patient developed left shoulder pain.

commonly went to construction site and frequently exposed to the sun without much protection.9C HR: 84. The patient is alert. and despite the fact that the pains are quite severe and bothering him to rest. his wife who is 15 years his junior is his primary caretaker. responsive and is cognitively intact. regular BP: 135/75 RR: 16 Sats: 98% on RA . he still feels a positive attitude due to the strong family support he has. he does not believe he has been exposed to dangerous chemicals/inhalants. Physical Examination: On inspection Mr RR is an averaged size gentleman who is comfortably sitting in his chair. He also shows a level of anhedonia consistent with suspected depression - - Family Hx: Mr RR father passed away due to lung cancer at the age of 78 Mr RR has a sister who he has not kept in touch who had a gynaecological cancer although he is not sure what precisely. However after further discussion reveals that he is guilty of the burden he has put on his family especially his wife. he also shows signs of depression due to his rapid deterioration in his function level.Henry Kan 16505083 - - Non drinker Smoker 30 pack years Worked as a civil engineer for 35 years. his two sons aged 55 and 60 visit every afternoon Lived in Epping for his whole life Mr RR currently lives in a two storey house however his lower limb weakness has prevented him from going up stairs and hence his bedroom has been moved to downstairs. Social support is excellent. he does not appear to be short of breathe or in pain. Performs all ADLs sufficiently Financially Mr RR is well off living off his superannuation and savings Psychological History: Mental Status: Mr RR initially describes himself as optimistic and content that he has lived such a long and fulfilling life. Vitals:      T: 36.

extension and flexion of the shoulder joint Reduced ROM in abduction 90 degrees. Lower: Inspection: Tone: Intact Tone Power: Hip: Flexion : 3/5 Extension 3/5 Adduction: 3/5 Abduction 3/5 Knee: Flexion 4/5 Extension 4/5 Ankle Unsteady gait Loss of muscle bulk in quadriceps .Henry Kan 16505083 Right Shoulder: No overlying skin changes Decreased right deltoid muscle bulk No changes in posture Palpation of shoulder reveals tenderness in infraspinatus and teres minor Joint line tenderness and AC joint tenderness Pain upon abduction. Tone and power for shoulder joint could not be tested accurately due to pain. and flexion at 45 degree Reduced laxity in joint upon passive movement Thoracic: No obvious trauma in overlying skin Pain on palpation in T3 level Pain reproduced with cough and valsalva manoeuvre Neurological Examination: Upper: No positive signs.

Query for bone metastasis from melanoma in shoulder and T3 vertebral body Query for Spinal cord compression Immobilization (patient’s quality of life depends greatly on mobility) Possible depression . raised Normal breathe sounds Air entry equal bilaterally. The lungs are resonant to percussion bilaterally. 4. Carotid Bruits were not heard The abdomen     No palpable masses Soft non tender Liver edge palpable and smooth Bowel sounds present Legs:   Slight pedal oedema (mid shin) Pedal Pulses felt Also: No lymphadenopathy. scored a 27/30 for MMSE Issues: 1. 3. Vocal fremitus is normal bilaterally. JVP 4cms. 2.Henry Kan 16505083 Plantar: 4/5 Doriflexion: 4/5 Eversion 4/5 Inversion 4/5 Sensation: Normal Proximal Weakness due to Spinal cord compression exacerbated by immobility Chest      Apex beat displaced 2 cms to the axillar from the midline of the 5th intercostal space Heart sounds dual. no murmur auscultated.

some age correlated eGFR changes. 5. CXR: Cardiomegaly. Spinal Cord Compression Bone metastasis in shoulder Rotator Cuff tendonitis/tear Vertebral Disk Hernia Articular surface degenerative disease in shoulder Joint and spine Initial investigations: FBC. LFT. no focal lesions in lungs. surgical sternal wiring consistent previous CABG surgery CT Brain: No METs CT Chest/Abdo/Pelvis: Widespread metastatic lesions throughout the bony structures and the liver MRI: Unable to perform due the patient inability to lie flat due to back pain Bone Scan R shoulder: Metastatic lytic lesion in the scapula (coracoid process). 3. No definite scan evidence for tears of any of the tendons surrounding the right shoulder were observed Discussion and Plan: . 4.Henry Kan 16505083 Ddx: 1. EUC CXR ECG Bone Scan CT Abdo/Pelvis/Chest/ MRI US Shoulder Investigation Results: FBC: Results all normal. 2. mild to moderate degenerative arthritis present in the cervical spine US R Shoulder: Acute tendonitis involving the right subscapularis and infraspinatus.

decrease spinal cord edema (improving short term neurologic function). radiosensitive tumors (lymphoma. however in Mr RR’s case he is already on an angiotensin II receptor antagonist and a diuretic. Dexamethasone was commenced immediately at 8mg PO Nocte as they decrease tumorassociated inflammation (analgesia effect).Hydromorphone 2mg PO Q1H PRN .Jurnista 8mg (long acting hydromorphone) PO Daily Radiotherapy can be considered however the standard radiation portal involves the diseased level with a 5 cm margin which effectively includes two vertebral bodies above and below the target. 4. 3. the symptom that takes most priority to investigate would the back pain as it is highly suggestive of spinal cord compression due to metastasis in the thoracic vertebra. it is thus not paramount for radiology confirmation. and the primary factor that limits radiation to the spine is the relatively low tolerance of the spinal cord for radiation damage. However given the patient’s inability to lie down due to severe back pain and orthopnoea to complete the scan and the highly suggestive history. multiple myeloma. New onset of severe back pain Not relieved and aggravated by recumbence Aggravated by increasing abdominal pressure Currently roughly 30% of patients with cancer develop symptomatic spinal metastases during the course of their illness. . In which Mr RR only fulfils 2 of criteria . RR was hence commenced on . Mr RR at this point needs an urgent radiological consult (MRI) to confirm/ exclude the diagnosis as it is the gold standard for diagnosis(2). aggressive treatment are the hallmarks of current treatment. NSAIDs usually are effective in managing bone pain. small cell lung carcinoma. and preservation of neurologic function.Henry Kan 16505083 Judging by the clinical presentation of Mr RR. Ewing's sarcoma) 2. adding an NSAID would be completely the “triple whammy effect” which shuts down renal function. The treatment at this stage should focus on pain relief. Early diagnosis and early. neuroblastoma. Additional analgesia should also be provided as the current analgaesia is clearly inadequate. and multilevel or diffuse spinal involvement. and up to 90% of cancer patients have metastatic lesions within the spine at the time of death(1). Indication for radiotherapy include Indications for XRT include 1. seminoma of testes. inability of patient to tolerate an operation. expected survival less than 3 months. and may be directly oncolytic(2). maintenance or restoration of spinal stability.

Systemic therapy o Single. Unfortunately the lower limb weakness did not improve. Mr RR’s shoulder pain on the right received a subacromial corticosteroid injection which provided relief.agent Chemotherapy o Combination Chemotherapy o Immunotherapeutic medication (Interleukin 2) Surgery: In the context of metastatic melanoma. immunotherapy or a combination approach. it may include chemotherapy. As standard Treatment usually involves one or more these: Surgery . . thus there is no evidence to show that it improves longevity however patients may benefit from radiation of symptomatic metastases for example consider Mr RR’s right shoulder MET. compared with 0% for patients with multiple lesions. We must keep in mind the aim of this treatment phase is to control symptoms and generally provide palliation for the patient. In terms of his Mr RR’s underlying cancer there is little we can do other than to manage his symptoms. Responses are seldom durable.3%. the side effects and the ECOG being > or equal to 3. Thus the benefit to risk ratio is of the utmost importance.(3) Radiation: Melanoma is considered to be quite radioresistant tumour. and fewer than 2% of patients treated with dacarbazine alone are alive at 6 years(1). surgery is only likely to provide benefits to those with a solitary lesion shown by a study where Patients with solitary lesions had a 5-year survival rate of 12%.Henry Kan 16505083 The back pain responded immediately and eventually settled on the 3rd day of treatment.2% partial responses.Radiation . radiation was considered for the lytic lesion in the coracoid process. The majority of these responses were partial (11. and fatigue. however given Mr RR’s life expectancy and the fact that it is not a weight bearing bone.2 % complete responses. the standard therapy is Dacarbazine and even it has less than stellar efficacy in improving survival. radiation was foregone. Systemic Therapy: It is the mainstay of therapy for most patiens with stage IV melanoma. Chemotherapy should not be advised. thus radiotherapy would be unsuitable. controlled trials showed that the objective response rate (ORR) for 1. 4. Common toxicities include mild nausea and vomiting. A pooled analysis of 23 randomized. Chemotherapy: There are a few chemotherapies we can give however none of them improve survival.390 patients receiving dacarbazine alone was 15. Given the poor efficacy. however Mr RR mobilized himself with a walker with the PT. myelosuppression.

However major toxicities are associated with HD IL-2 include fever. High-dose recombinant interleukin-2 therapy in patients with metastatic melanoma: long-term survival update. Sixty percent of the complete responders had durable responses that were ongoing at the time of the report (duration > 42 months to > 122 months)(4).Henry Kan 16505083 Immunotherapy: Unlike Cytotoxic chemotherapy. Surgical treatment of metastatic melanoma. 2. Non-U. Oncology (Williston Park). J P. 1995. Thompson JA. Mr RR is now at the terminal stage of his disease that has exhausted all his treatment options. Kunkel L. hypotension. [Review]. increased capillary permeability. Bhatia S. In which is just not suitable for Mr RR Impression: Mr RR is a 91 year old gentleman with progressive stage IV metastatic melanoma presenting with back pain in the level of T3 and lower limb weakness highly suggestive of spinal cord compression from vertebral metastasis. Gov't]. Tykodi SS. Treatment of metastatic melanoma: an overview. Sznol M.23(6):488-96. Atkins MB. volume overload. [Research Support.175(5):413-7. Wilmarth TJ. . 1. chills.S.S. 2009 May. 3. Rosenberg SA. 2000 Feb. cardiac arrhythmias.6 Suppl 1:S11-4. oliguria. Cancer J Sci Am. He also presents with right shoulder pain was diagnosed by bone scan and ultra sound to have metastatic lesion in the coracoid process of the scapula and rotator cuff tendonitis. the ORR was 16% (CR 6%. [Research Support. Philadephia: FA Davis. 1998 May. A pooled analysis of 270 patients treated with HD IL-2. Fletcher WS. Gov't]. PR 10%). although it has been challenging to predict which patients will respond to immunotherapy. Non-U. Neurological Complications of Cancer. thus all treatment onwards should focus on improving quality of life and provide the patient a pain free and dignified end to his life. Am J Surg. and rash. delirium. Pommier RF. some immunotherapeutic approaches have led to durable complete responses in a small subset of patients. 4. Lum S.

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