Q. After analysis of pleural effusion fluid, diagnosed with Stage 4 Cancer.

Answered by Dr. Prasad Eswaran and medically reviewed by iCliniq medical review team.

 

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Dear Doctor,

After analysis of pleural effusion fluid, my mother has been diagnosed with Stage 4 Cancer - CUP, poorly differentiated carcinoma.

She has exhibited lower lobe fibrosis for at least three years, has normal kidney lab work at this time, previous breast carcinoma ductal in situ with removal and radiation; multiple broken bones over the last three years - however no bone density scan or Vitamin D treatment until last few months; mild anemia and leukopenia for over two years, low albumin since June 2013; degenerative arthritis, scoliosis, stenosis, spontaneous fracture of t11, numerous treatments for UTI that were positive for WBC, leukocytes, but not nitrates or positive cultures.

She developed c-diff with significant pseudomembranous colitis in July 2012; MRSA infection on skin outside of spine near fracture and under armpit but resolved. CT in last few weeks did not identify mass in lungs, breast or esophagus; doctor failed to order the CT to include abdominal area despite onset of chf, weight loss, and prior squamous cell cancer of the anus.

I need a diagnosis - this is unconscionable on so many levels. Could the medical community be trying to cover its failure to diagnose a cancer that has been there for some time.

Bone scan revealed nothing despite her significant bone pain, broken bones and arthritis. Unfortunately - my 76 year old mother's quality of life is so poor that she is very accepting of this treatment as long as they keep her out of pain. Other sisters do not want to "upset the doctors" by asking further questions and getting copies of results.

Please advise.


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Dr. Prasad Eswaran
MBBS., DMRT., MD., DM (ONCOLOGY)., FELLOWSHIP IN BRACHYTHERAPY (USA)., INTERNATIONAL FELLOW IN GYNEC ONCOLOGY
Hematology, Medical Oncology, Pain Medicine, Radiotherapy

Hi,

Welcome to icliniq.com.

Thanks for the information given. To get the facts right, patient is a 74 year old female with prior history of Anal canal cancer and Breast cancer (DCIS) treated with surgery and radiation. Her co-morbidity includes osteoporosis / prior UTI / Lung fibrosis / multiple fractures ? metastatic disease ? weak bones. Is it possible to do a PET/CT scan which can give a clear idea on the extent of the disease? Your doctor would be able to give much more clear idea on it based on the need and present health status permitting it. Based on your information, I feel that it is currently a stage 4 disease with pleural effusion.

  • Is she suffering from breathlessness now? 
  • Was pleural fluid tapping done?
  • If so, how much fluid was removed?
  • Has the fluid been submitted for analysis?
  • Is it re-accumulating in the pleural space?
  • How soon does that happen?

If fluid is too much, she may require a drain to keep her breathing comfortable. After a complete drain, she may undergo pleurodesis to prevent re-collection again. This will help her definitely. But the doctor should decide based on her present health condition.

Regarding further treatment (chemotherapy/targeted therapy), it may not be possible for me to comment without physically seeing/examining the patient. Your doctor may guide you better after discussions. She would need pain killers either oral or as replaceable patch based on the intensity of pain and requirement of pain relief.

But at one point of time, I am afraid to say that all treatment have to be stopped just to continue hospice care and this is unavoidable. Hope I have answered your queries. I would be available to answer more of your questions, if any.

Take care.

 

Thank you doctor.

Yes, they drained the pleural effusion. I believe 1200c's of dark blood tinged fluid. Positive for malignant cells but pathology only revealed poorly differentiated carcinoma. They punctured her lung in process and she has a partial pneumothorax. Initially breathing was vastly improved but in last few days has become quite difficult.

She is in a great deal of pain but managed by hospice care to the extent possible. My real frustration is not knowing her primary site and suspecting that the doctors are being vague to cover for their incompetence. Shouldn't the bone scan have revealed something?

I asked for a PET scan last week on the day she was admitted - Wednesday and he said that Medicare would not pay for an inpatient to get a PET scan. She just went to her primary two weeks ago and she sent her home on lasix and an increased dose of amitriptyline 50mg for her depression. This was done with no blood work and a history of low sodium, chloride and albumin.

She entered hospital with hyponatremia, severe weakness and dementia. That is when they decided to drain the fluid. She also had two enlarged lymph nodes for the past 4 months in her chest area behind her heart. Echo revealed 35% - cannot remember which side.

They never tested her for lupus, HIV, sarcoidosis. Is it also possible that she has pulmonary fibrosis? What are other causes for lower lobe bilateral scarring? I accept that she is dying but I have issues with her being all of a sudden stage IV with no primary, and poorly differentiated carcinoma and no answers from imaging to date.

Her liver enzymes have been fine. Her white count has never gone up with prior infections. Only a slight left shift when she had the pseudomembranous colitis with the cdiff. She has been mildly anemic for years. Receives vitamin B12 shots regularly. Her illnesses always come on when she is doing well and starts getting out more.

She lives in warm, very humid climate. Her furnace was disintegrated with broken metal burning in the pilot light and soot or particulate matter all over it. I moved her out in June after she fell coming back to bed and broke her tibia and fibia straight through with separation right above the ankle.

 

Dr. Prasad Eswaran
MBBS., DMRT., MD., DM (ONCOLOGY)., FELLOWSHIP IN BRACHYTHERAPY (USA)., INTERNATIONAL FELLOW IN GYNEC ONCOLOGY
Hematology, Medical Oncology, Pain Medicine, Radiotherapy

Hi, I do understand your situation now. You are trying your possible extent to help your mom get relieved from suffering of terminal illness. But the true fact is sometimes, we could not help her.

I am not sure why PET scan was not done. If medicare does not cover it, is it possible for you to pay for it? Though PET scan would show extensive disease the stage does not change. It is stage 4 disease now and the management is only palliation. Since the pathology had been reported as poorly differentiated carcinoma most probably the primary would have been from one of the prior cancers she had. Stage and treatment does not change for both type of cancers since the disease is already spread throughout the body and treatment would be just symptom control and possible try for relief. EF is 35 % which means her heart is not quite good to tolerate any kind of chemotherapy. She also had electrolyte imbalance in addition to few serious infections and multiple fractures. Please understand and accept that this condition is serious and she is terminally ill (which may be my inference based on the clinical conditions you have given me - I MAY STILL BE WRONG - YOUR DOCTOR IS THE BEST PERSON TO JUDGE THE TREATMENT. Any amount of investigation is not going to help her at present as she may not be fit for any form of treatment. Please discuss with your doctor about a peaceful end of life care procedures in case if your doctor had not discussed with you earlier. Hope I could clear your doubts. I will be available to answer any of your queries online --> https://www.icliniq.com/ask-a-doctor-online/medical-oncologist

 
 
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