Document info

Result type: Oncology Outpatient Provider Note

Result date: Feb 02, 2023, 09:54 a.m.
Result status: authenticated
Performed by: Kavitha Narayanan
Verified by: Kavitha Narayanan
Modified by: Kavitha Narayanan

Oncology Office Visit Note

Patient: KRISTIAN AGUJA DOB: Nov 02, 1977

Chief Complaint Language Used and Translator

Metastatic small cell lung ca, s/p gross total resection of brain mets x2 English
(8/12/22, 8/19/22), s/p IMRT to R and L post-op cavity, started
Problem List/Past Medical History
Carboplatin/Etoposide/Atezolizumab on 11/7/22, now on maintenance
Ongoing
Atezolizumab starting 01/30/2023. Seen today for follow up.
Brain mass
History of Present Illness Metastasis to brain
44 yo M with 10+ pack yr hx tobacco use and new diagnosis of metastatic Obesity
small cell lung cancer w/ brain mets. Initially presented 8/2022 w/ worsening Small cell lung cancer
headache and acute L-sided weakness, found to have 2 large intracranial Historical
masses at L and R parietal lobe w/ vasogenic edema, mild midline shift. s/p No qualifying data
gross total resection x2 (8/12/22, 8/19/22); pathology c/w metastatic
Procedure/Surgical History
carcinoma of unknown origin. Initial PET 9/2022 with hilar mass SUV 6.9
and cervical/mediastinal LAD, c/f lung primary given hx of smoking. Tempus • Craniotomy Tumor Resection
Image-Guided (08/19/2022)
NGS panel resulted with TP53 94.9% VAF, RB1 90.8% VAF, DAXX 8.5%
VAF, TMB 15.3 m/MB, MSI stable, strongly suggesting small cell lung • Craniotomy Tumor Resection
Image-Guided (08/12/2022)
primary. s/p IMRT to R and L post-op cavity (27 Gy/3fx, 9/23, 9/27, 9/29/22).
started Carboplatin/Etoposide/Atezolizumab on 11/7/22, now on Medications
maintenance Atezolizumab starting 01/30/2023. Inpatient / In-Clinic
No active inpatient medications
Subjective: Home
Confirmed identity using 2 identifiers, full name and DOB. Reports mild ondansetron 4 mg oral tablet, 4 mg=
nausea after last atezolizumab infusion, otherwise no other additional 1 tabs, Oral, Q8H, PRN, 1 refills
symptoms. Denies fever, chills, cough, SOB, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, unintentional weight loss, loss of Allergies
appetite, headache, vision changes, dizziness, or peripheral neuropathy.  No Known Medication Allergies
ECOG 1. Health Maintenance
Oncologic History      Satisfy
PMH: denies Expectati Date Reason
PSH: denies
Meds: denies
on of
Allergies: NKA Satis
Fam Hx: Maternal GM: asthma, Paternal GF: DM, cardiac problems, Father:
MI
Soc Hx: history of smoking approx 10 cig/day from ages 15-44yo, previous facti
social ETOH use (though heavier drinker when he was younger), denies rec
drugs, occupation: clerk, Currently lives with his brother
on
 Colon  11/0  Fecal
Presented with headache and difficulty with ambulation.
8/7/22: CT CAP – nonspecific enlarged LNs of the mediastinum/left hilum up
Cancer 7/20 Occult Bld
to 2cm Screenin 22
08/07/22 - MRI shows 5.3cm right parietal mass and 3.9cm left parietal g
mass
08/12/22 - GTR of right parietal mass Lab Results
08/19/22 - GTR of left parietal mass WBC: 4 K/cumm Low (01/30/23
8/20/22 – MRI brain continued to show GTR without residual nodular 10:54:10)
enhancement RBC: 4.12 M/cumm Low (01/30/23
8/31/22 -pathology reported metastatic carcinoma – no specific 10:54:10)
entity – potential primaries include urothelial, pancreatobiliary, lung, renal, Hgb: 12.7 g/dL Low (01/30/23
hepatic, or salivary gland (TTF-neg, AFP-neg) 10:54:10)
9/12/22: PET Scan: Hypodense mass in the left hilum measuring up to 2.3 Hct: 37.9 % Low (01/30/23 10:54:10)
cm in long axis (1.7 cm in short axis) with max SUV of 6.9.  Cannot MCV: 92.1 fL (01/30/23 10:54:10)
distinguish whether this represents primary lung lesion versus hilar node MCH: 30.9 pg (01/30/23 10:54:10)
containing metastatic disease. Multiple other enlarged cervical and MCHC: 33.5 g/dL (01/30/23 10:54:10)
mediastinal lymph nodes, Platelet: 240 K/cumm (01/30/23
with the five most hypermetabolic examples detailed above. Postsurgical 10:54:10)
changes from bilateral craniotomies with photopenia of the resection beds. RDW: 21.5 % High (01/30/23
10:54:10)
Path 8/16/22 MPV: 6.9 fL Low (01/30/23 10:54:10)
Final Pathologic Diagnosis
BRAIN, RIGHT BRAIN TUMOR (INCLUDING SPECIMENS A AND B): Lab - Chemistry
- Metastatic carcinoma AGAP: 14 mmol/L (01/30/23 10:54:10)
  - See COMMENT Albumin Lvl: 4.8 g/dL (01/30/23
Comment 10:54:10)
An extensive immunohistochemical panel was performed to further Alk Phos: 93 U/L (01/30/23 10:54:10)
characterize this malignancy; however, the immunoprofile is not diagnostic of ALT: 34 U/L (01/30/23 10:54:10)
a specific entity. Stains (outlined below) show the tumor cells stain with CK7, AST: 16 U/L (01/30/23 10:54:10)
CK20, CD10, and uroplakin. Potential primaries include, but are not limited Bili Direct: 0.2 mg/dL (08/06/22
to the following; urothelial, pancreatobiliary, lung, renal, hepatic, or salivary 20:20:00)
gland. Bili Total: 0.3 mg/dL (01/30/23
This case was shared with multiple pathologists and discussed at the 10:54:10)
LAC+USC Pathology consensus conference. Overall a pancreatobiliary BUN: 11 mg/dL (01/30/23 10:54:10)
origin was favored. Notably, papillary architecture and uroplakin positivity is Calcium Lvl: 9.8 mg/dL (01/30/23
suggestive of urothelial origin, however not diagnostic. Urine cytology was 10:54:10)
performed (30-NG-22-1649) and was negative for high grade urothelial Chloride Lvl: 103 mmol/L (01/30/23
carcinoma, however an upper urothelial tract lesion cannot be ruled out. 10:54:10)
Additional considerations include middle-ear primary, however the location CO2 Lvl: 28 mmol/L (01/30/23
does not appear to be involved on imaging. Clinical and radiologic 10:54:10)
correlation is advised. Creatinine Lvl: 0.94 mg/dL (01/30/23
Immunohistochemical study results 10:54:10)
Block          Antibody      Results eGFR 2021 CKD-EPI Cr: >90
B2    CK7      Positive (01/30/23 10:54:10)
        CK20      Positive Glucose Lvl: 105 mg/dL High (01/30/23
        CD10      Positive 10:54:10)
        Uroplakin*      Positive Hgb A1c: 5.5 % (11/04/22 10:08:36)
        GATA3      Negative LD: 233 U/L High (08/23/22 16:19:00)
        AFP      Negative Magnesium: 2.2 mg/dL (11/04/22
        PAX8      Negative 10:08:36)
        TTF1      Negative Phosphorus: 3.3 mg/dL (08/12/22
        Napsin      Negative 04:47:00)
        CA9*      Negative Potassium Lvl: 4.3 mmol/L (01/30/23
        PAX2*      Negative 10:54:10)
        RCC*      Highlights degenerating cells/necrosis Protein Total: 7.9 g/dL (01/30/23
10:54:10)
        P504S(Racemase)        Negative (Questionable Control) PSA Total: 0.26 ng/mL (11/04/22
        CDX-2*        Negative 10:08:36)
        S100*      Highlights peripheral brain Sodium Lvl: 141 mmol/L (01/30/23
        SOX-10*       Highlights scattered peripheral neurons 10:54:10)
        Synaptophysin*        Highlights peripheral brain
        Vimentin*       Highlights peripheral brain 
        P63*      Negative (non-nuclear)
        PAX-2*      Negative 
        PAS-D*        Highlights basement membrane of tumor

Path 8/19
Final Pathologic Diagnosis
A. BRAIN, LEFT BRAIN TUMOR:
- Metastatic carcinoma
  - See COMMENT
Comment
This case is associated with 30-SP-22-7921 (Right sided brain tumor) on the
same patient. The histomorphology is similar. Select stains were repeated in
this case and show that the tumor is similarly diffusely positive for CK7,
uroplakin, and CD10, and has weak staining with CK20. Gata3 is negative. 
Immunohistochemical study results
Block        Antibody      Results
A1        CK7      positive
        CD10      positive
        CK20      faint/weakly positive
        GATA3      negative
A2    Uroplakin*      positive

Final Pathologic Diagnosis

URINE:
- Negative for high grade urothelial carcinoma
Review of Systems
Constitutional:  No fever, No chills.
Respiratory:  No shortness of breath, No cough, No wheezing.
Cardiovascular:  No chest pain, No palpitations.
Gastrointestinal:  No nausea, No vomiting, No diarrhea, No heartburn.
Genitourinary:  No dysuria, No urinary frequency, No urinary urgency.
Musculoskeletal:  No joint pain, No muscle pain.
Neurologic:  Alert and oriented X4.

See subjective note for symptoms.

Physical Exam
General: NAD, AOx4, well-nourished
HEENT: NC/AT, EOMI, +trismus, no LAD
CV: RRR, no murmurs/rubs/gallops
Lung: CTAB, no wheezes/rales/rhonchi, non-labored respirations on RA
Abdomen: soft, non-tender, nondistended, +BS
MSK: moving all 4 extremities, no peripheral edema
Skin: warm, dry, intact; no visible rashes/lesions/ecchymoses
Neuro: CNII-XII grossly intact, no gross deficits
Psych: full affect, appropriate mood, intact judgment
Assessment/Plan
Small cell lung Ca
45 y/o male presented w/ neuro sx related to brain mets of unknown primary.
Since last clinic visit, Tempus results have revealed high VAF for TP53 and
RB1, raising clinical suspicion for small cell lung primary in this patient with a
hilar mass and smoking history. TMB 15.3 m/MB. Plan to initiate
Carbo/Etop/Atezo based on the IMPower 133 trial, where there was
significant OS benefit in patients who received Carbo/Etop with Atezo vs
Carbo/Etop alone (median OS 13.9 mo vs 12.3 mo, HR OS 0.7 CI
0.54-0.91).

#Small Cel Lung CA w/ Brain metastases (Stage IV, T1cN3M1)

- Initially presented 8/7/22 with metastatic disease w/ brain mets of unknown
primary
- 8/7/22: Initial  CT CAP – nonspecific enlarged LNs of the mediastinum/left
hilum up to 2cm
- 8/07/22 - MRI Brain w/ 5.3cm right parietal mass and 3.9cm left parietal
mass
- s/p GTR of right parietal mass (8/12/22) and L parietal mass (8/19/22);
post-resection MRI 8/20/22 w/o residual nodular enhancement
- 8/31/22 - pathology reported metastatic carcinoma – no specific
entity – potential primaries include urothelial, pancreatobiliary, lung, renal,
hepatic, or salivary gland (TTF-neg, AFP-neg). However, urine negative for
urothelial carcinoma.
- 9/12/22: PET Scan: Hypodense mass in L hilum measuring up to 2.3 cm in
long axis (1.7 cm in short axis) with max SUV of 6.9.  Cannot distinguish
whether this represents primary lung lesion versus hilar node containing
metastatic disease. Multiple other enlarged cervical and mediastinal lymph
nodes.
- Tempus (resulted 10/11/22): TP53 94.9% VAF, RB1 90.8% VAF, DAXX
8.5% VAF, TMB 15.3 m/MB, MSI stable
- Case discussed w/ Dr. Nieva 10/20/22, high suspicion for small cell
pathology given TP53 and RB1 mutations
- Started Carboplatin/Etoposide/Atezolizumab on C1D1 11/7/22. C2D1
11/29/22, C3D1 12/20/22, C4D1 01/10/23
- will continue maintenance Atezolizumab that transitioned on 01/31/2023,
tolerating well with mild nausea.
- will continue to monitor CBC CMP and TSH, 01/30/2023 labs stable
- Brother is 7D floor nurse who often takes night shift and may have difficulty
assisting with transportation.
- Per patient radiology told to schedule MRI Brain in other facilities, patient
was hesitant, called RLA Downey and scheduled it on 2/17/23, patient has
instructions given.
- ordered repeat PET/CT, instructed patient to call radiology to schedule
appt. 
- For progression after first line, consider clinical trial 20-22-3 (PhI-135/ NCI
10445: Phase 1 Dose Escalation and Expansion Study of Tazemetostat in
Combination of Topotecan and Pembrolizumab in Recurrent Small Cell Lung
Cancer).
- Patient said he is also looking into doing some natural treatments such as
diet modification and looking into joining some groups. Explained the
prognosis of his cancer and recommended to continue the treatment offered
here. Patient verbalized understanding.
- RTC 6 weeks in person visit with fellow MD or NP with labs, MRI Brain, and
PET/CT.

Regimen:
Atezolizumab 1200mg IV D1
Carboplatin AUC 5 IV D1
Etoposide 100mg/m2 IV D1,2,3
q21 days x4 cycles (COMPLETED ON 01/10/2023)

followed by

Maintenance Atezolizumab (STARTED ON 01/31/2023)

Atezolizumab (Tecentriq) 1200 mg IV once on day 1
q21days
IMPower133: Horn L et al; IMpower133 Study Group. First-line atezolizumab
plus chemotherapy in extensive-stage small-cell lung cancer. N Engl J Med.
2018 Dec 6;379(23):2220-2229. Epub 2018 Sep 25

Kavitha Narayanan NP
DWA Dr. Hsu