1. Case 2: A case of advanced Non-Small Cell Lung Carcinoma
Texte courant
Shane O’Hanlon (IE) and Andrea Luciani (IT)

2. No conflict of interests
Disclosure
No conflict of interests

3. Learning objectives:
Explain how a CGA can help optimise patients before treatment
Describe the management of advanced Non-Small Cell Lung Carcinoma
Explain the role of immunotherapy in advanced Non-Small Cell Lung Carcinoma
Describe the role of supportive care, including palliative care, in advanced lung cancer

4. Case abstract:
Rosa is an 82 year old lady who is in generally good health. She enjoys gardening and still writes part-time for a seniors blog. She is widowed and lives alone.
She has had increasing shortness of breath for a few months, despite being treated with diuretics for a presumptive diagnosis of heart failure. She had been started on frusemide after a chest x-ray showed bilateral pleural effusions.
She also complains of increasing fatigue, reduced appetite and has started sleeping in a chair in the afternoon.

5. She was referred for admission to have further investigation
She was referred for admission to have further investigation. Unfortunately her pleural aspirate showed an exudate, so she was referred to a respiratory specialist.
The workup reveals that she has non-small cell lung cancer, with metastases to the liver, the opposite lung, and malignant pleural effusions, T3N3M1b.
Her performance status is currently 3. She is referred to a geriatrician for assessment before the possibility of treatment.

6. Geriatric assessment:
Cognition – normal at baseline. Currently 26/30 on MoCA, losing marks for orientation and attention.
Mobility – usually independent; has not mobilised since admission 5 days ago.
Medications:
Frusemide 40mg bd
Zopiclone 7.5mg nocte
Ramipril 10mg od
Oxycodone 5mg BD
Chlorphenamine 4mg tds
Aspirin 100mg
Bendroflumethiazide 2.5mg od

7. Geriatric assessment:
Comorbidities
Hypertension
Arthrosis
Insomnia

8. On examination Drowsy but responsive. Looks dry. Slightly confused.
Needs assistance of two people to transfer from bed to chair
Orthostatic blood pressure drop from 110/80 to 86/55
 Never smoker
Weight loss: 5kg in last month

9. Investigations Bloods: Hb 78 g/L (130-180), Mcv 76 fL (80-100)
Urea 14 mmol/L ( ), Creat 90 mcmol/L (59-104)
Na 122 mmol/L ( ), K 3.6 mmol/L ( )
Albumin 25 g/L (33-50)
Echo – normal ejection fraction

10. 1. Which interventions do you think the geriatrician made?
The geriatrician makes several alterations to her medications and some other important interventions. As a result, after two weeks her performance status is 1.
Case 2 questions for Course students:
1. Which interventions do you think the geriatrician made?
2. Given her PS of 1, what treatment should she have?
3. What is the role of molecular testing in classifying and treating NSCLC? How are the relevant treatments tolerated in older people?
4. How can palliative care help and when should we refer?

11. Optimisation Stop bendroflumethiazide (low Na)
Stop frusemide (no heart failure)
Stop ramipril (low BP)
Stop zopiclone and chlorphenamine (drowsy)
Stop aspirin (no previous stoke or MI)
Dietician r/v for nutrition
Physiotherapy r/v for mobility
Consider palliative care r/v (SOB)

12. Optimisation
Regular reorientation, allow family extended visiting hours, optimise hydration (delirium)
Check iron levels, consider IV iron
Consider blood transfusion if symptomatic
Add laxatives if still on oramorph, ensure bowels open each day
Check for urinary retention
OT r/v to promote independence

13. What really happened Fall -> hip fracture
Persistent delirium post-op
Immobility continued
Low oxygen level acutely - Bilateral PE
Subsequent hospital acquired pneumonia
Died 10 days after surgery
Never treated for her lung cancer