1 CASE #2 Sam Shahpar, MD Instructor, Feinberg School of Medicine at Northwestern University Attending Physician, Cancer Rehabilitation Program at RIC

2 DISCLOSURE  I have NO RELEVANT financial disclosures.

3  L lung nodule identify incidentally in CT imaging  Initially needle biopsy was non-diagnostic but PET imaging revealed enlarged nodule and smaller R upper nodule  Underwent mediastinoscopy, B VATS with R upper lobe nodule/wedge resection and L upper lobe nodule resection/segmentectomy Pathology revealed grade 2-3 L lung adenocarcinoma with neg margins and R lung adenocarcinoma with positive margins (Requiring R upper lobectomy subsequently) BACKGROUND

4  Staging work-up notable for brain lesion c/w meningioma v. brain mets but no other systemic metastases  Thought to have 2 separate lung primary malignancies and initiated on adjuvant chemotherapy with cisplatin, pemetrexed with course notable for severe debilitating neuropathy requiring transition to carboplatin for last cycle BACKGROUND

5  Neuropathy started after 1 st cycle of chemotherapy with numbness/tingling and burning of feet but soon progressed to hands/wrist  Associated weakness in hand grip and impaired balance, falling up to 4x/week  Lab work and EMG/NCS was WNL BACKGROUND

6  Seen by Physiatrist on Oct 2013 (started chemotherapy in April 2012 ) and reported decreased sensation of vaginal, perineal, and rectal areas  Had been present since initial neuropathy symptoms but had not told any other healthcare providers  Associated urinary incontinence managed with timed toileting and decreased bowel sensations BACKGROUND

7  Lives in home with husband with 1 daughter with cerebral palsy  Acts as primary caregiver to daughter  On disability due to lung cancer  Sister passed away from Lung cancer during the week she initiated chemotherapy (had same Oncologist) BACKGROUND

8 What would be your be the recommended treatment plan? 1.Refer to Neurologist and/or another specialist 2.Refer to physical and/or occupational therapy 3.Initiate medication 4.All of the above DECISIONS, DECISIONS

9 9/2/11 2 A Neural Interface for Artificial Limbs: Targeted Muscle Reinnervation

10  Medications Gabapentin 300mg QID Nortriptyline 25mg HS Hydrocodone/Acetaminophen 5-325mg q6hr PRN Multivitamin daily BACKGROUND

11 What changes, if any, would you make to medication regimen? 1.No changes 2.Increase Gabapentin 3.Increase Nortriptyline 4.Increase Opioids 5.Trial New Medication DECISIONS, DECISIONS

12 9/2/11 2 A Neural Interface for Artificial Limbs: Targeted Muscle Reinnervation

13  Moderate recommendation for treatment with duloxetine Tricyclic antidepressants, Gabapentin, Compounded Topical gel (baclofen 10 mg, amitriptyline 40 mg, and ketamine 20 mg)  May be offered on the basis of data supporting their utility in other neuropathic pain conditions given the limited other treatment options  Further research on these agents is warranted ASCO TREATMENT GUIDELINES

14  Increase Gabapentin to 300/300/300/600mg Patient hesitant to increase further due to possible sedation/side effects  Further work-up with imaging for saddle anesthesia, bowel/bladder changes  Referred to intensive therapy program given significantly impaired function INITIAL RECOMMENDATIONS

15  Referral to Chronic Pain Program - enrolled in a Full day program  Includes M-F, 8 hours per day for 4 weeks  Team members include: Physiatrist, Pain Psychologist, Occupational Therapists, Physical Therapists, Relaxation Therapists, Nursing Education experts, Clinical Care Manager and Vocational Rehabilitation specialists NEXT STEPS

16  Medications Gabapentin 600mg QID Nortriptyline 25mg HS Hydrocodone/Acetaminophen 5-325mg q6hr PRN Multivitamin daily START OF PAIN PROGRAM

17 What changes, if any, would you make to medication regimen? 1.No changes 2.Increase Gabapentin 3.Increase Nortriptyline 4.Increase Opioids 5.Trial New Medication DECISIONS, DECISIONS

18 9/2/11 2 A Neural Interface for Artificial Limbs: Targeted Muscle Reinnervation

19  Medications Gabapentin 600mg QID Nortriptyline 25mg HS Hydrocodone/Acetaminophen 5-325mg q6hr PRN Multivitamin daily  Increased Gabapentin to 800mg QID START OF PAIN PROGRAM

20  No clear standard of care  Guidelines may help direct decision making  More research is needed TAKE HOME POINTS