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

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. Operation was performed to remove ilio-femoral lymph nodes and the lesion was excised After the operation, patient developed left shoulder pain, imaging revealed a MET near the region, patient received cortisone and was put on Rad therapy for 10 fractions. 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, renal angiography was performed to exclude renalvascular causes. Currently managed by single agent hypertensive Irbesartan Osteoarthritis of left knee 2000 diagnosed by X-ray at GP, knee replacement was put in 2001.

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:
- NKDA

Social and Psychological Hx:

ECOG 3 Social Hx:

Henry Kan 16505083

Non drinker Smoker 30 pack years Worked as a civil engineer for 35 years, commonly went to construction site and frequently exposed to the sun without much protection, he does not believe he has been exposed to dangerous chemicals/inhalants. Social support is excellent, his wife who is 15 years his junior is his primary caretaker, 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. 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, and despite the fact that the pains are quite severe and bothering him to rest, he still feels a positive attitude due to the strong family support he has. 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. 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.

Physical Examination:
On inspection Mr RR is an averaged size gentleman who is comfortably sitting in his chair, he does not appear to be short of breathe or in pain. The patient is alert, responsive and is cognitively intact.

Vitals: T: 36.9C HR: 84, regular BP: 135/75 RR: 16 Sats: 98% on RA

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, extension and flexion of the shoulder joint Reduced ROM in abduction 90 degrees, 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, Tone and power for shoulder joint could not be tested accurately due to pain. 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

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. JVP 4cms, raised Normal breathe sounds Air entry equal bilaterally. Vocal fremitus is normal bilaterally. The lungs are resonant to percussion bilaterally. 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. 2. 3. 4. Query for bone metastasis from melanoma in shoulder and T3 vertebral body Query for Spinal cord compression Immobilization (patients quality of life depends greatly on mobility) Possible depression

Henry Kan 16505083

Ddx:
1. 2. 3. 4. 5. 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, EUC CXR ECG Bone Scan CT Abdo/Pelvis/Chest/ MRI US Shoulder

Investigation Results:
FBC: Results all normal, some age correlated eGFR changes. CXR: Cardiomegaly, 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), mild to moderate degenerative arthritis present in the cervical spine US R Shoulder: Acute tendonitis involving the right subscapularis and infraspinatus. No definite scan evidence for tears of any of the tendons surrounding the right shoulder were observed

Discussion and Plan:

Henry Kan 16505083 Judging by the clinical presentation of Mr RR, 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. 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, and up to 90% of cancer patients have metastatic lesions within the spine at the time of death(1). Early diagnosis and early, aggressive treatment are the hallmarks of current treatment. 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). . However given the patients inability to lie down due to severe back pain and orthopnoea to complete the scan and the highly suggestive history, it is thus not paramount for radiology confirmation. The treatment at this stage should focus on pain relief, maintenance or restoration of spinal stability, and preservation of neurologic function. Dexamethasone was commenced immediately at 8mg PO Nocte as they decrease tumorassociated inflammation (analgesia effect), decrease spinal cord edema (improving short term neurologic function), and may be directly oncolytic(2). Additional analgesia should also be provided as the current analgaesia is clearly inadequate. NSAIDs usually are effective in managing bone pain, however in Mr RRs case he is already on an angiotensin II receptor antagonist and a diuretic, adding an NSAID would be completely the triple whammy effect which shuts down renal function. RR was hence commenced on - 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, and the primary factor that limits radiation to the spine is the relatively low tolerance of the spinal cord for radiation damage. Indication for radiotherapy include Indications for XRT include 1. radiosensitive tumors (lymphoma, multiple myeloma, small cell lung carcinoma, seminoma of testes, neuroblastoma, Ewing's sarcoma) 2. expected survival less than 3 months; 3. inability of patient to tolerate an operation; 4. and multilevel or diffuse spinal involvement. In which Mr RR only fulfils 2 of criteria

Henry Kan 16505083 The back pain responded immediately and eventually settled on the 3rd day of treatment, thus radiotherapy would be unsuitable. Unfortunately the lower limb weakness did not improve, however Mr RR mobilized himself with a walker with the PT. Mr RRs shoulder pain on the right received a subacromial corticosteroid injection which provided relief, radiation was considered for the lytic lesion in the coracoid process, however given Mr RRs life expectancy and the fact that it is not a weight bearing bone, radiation was foregone. In terms of his Mr RRs underlying cancer there is little we can do other than to manage his symptoms. As standard Treatment usually involves one or more these: Surgery - Radiation - Systemic therapy o Single- agent Chemotherapy o Combination Chemotherapy o Immunotherapeutic medication (Interleukin 2) Surgery: In the context of metastatic melanoma, 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%, compared with 0% for patients with multiple lesions.(3) Radiation: Melanoma is considered to be quite radioresistant tumour, thus there is no evidence to show that it improves longevity however patients may benefit from radiation of symptomatic metastases for example consider Mr RRs right shoulder MET. Systemic Therapy: It is the mainstay of therapy for most patiens with stage IV melanoma, it may include chemotherapy, immunotherapy or a combination approach. We must keep in mind the aim of this treatment phase is to control symptoms and generally provide palliation for the patient. Thus the benefit to risk ratio is of the utmost importance. Chemotherapy: There are a few chemotherapies we can give however none of them improve survival, the standard therapy is Dacarbazine and even it has less than stellar efficacy in improving survival. A pooled analysis of 23 randomized, controlled trials showed that the objective response rate (ORR) for 1,390 patients receiving dacarbazine alone was 15.3%. The majority of these responses were partial (11.2% partial responses, 4.2 % complete responses. Responses are seldom durable, and fewer than 2% of patients treated with dacarbazine alone are alive at 6 years(1). Common toxicities include mild nausea and vomiting, myelosuppression, and fatigue. Given the poor efficacy, the side effects and the ECOG being > or equal to 3. Chemotherapy should not be advised.

Henry Kan 16505083

Immunotherapy: Unlike Cytotoxic chemotherapy, some immunotherapeutic approaches have led to durable complete responses in a small subset of patients, although it has been challenging to predict which patients will respond to immunotherapy. A pooled analysis of 270 patients treated with HD IL-2, the ORR was 16% (CR 6%, PR 10%). 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). However major toxicities are associated with HD IL-2 include fever, chills, hypotension, increased capillary permeability, cardiac arrhythmias, oliguria, volume overload, delirium, and rash. 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. 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. Mr RR is now at the terminal stage of his disease that has exhausted all his treatment options, thus all treatment onwards should focus on improving quality of life and provide the patient a pain free and dignified end to his life.

1. Bhatia S, Tykodi SS, Thompson JA. Treatment of metastatic melanoma: an overview. Oncology (Williston Park). [Review]. 2009 May;23(6):488-96. 2. J P. Neurological Complications of Cancer. Philadephia: FA Davis; 1995. 3. Fletcher WS, Pommier RF, Lum S, Wilmarth TJ. Surgical treatment of metastatic melanoma. Am J Surg. [Research Support, Non-U.S. Gov't]. 1998 May;175(5):413-7. 4. Atkins MB, Kunkel L, Sznol M, Rosenberg SA. High-dose recombinant interleukin-2 therapy in patients with metastatic melanoma: long-term survival update. Cancer J Sci Am. [Research Support, Non-U.S. Gov't]. 2000 Feb;6 Suppl 1:S11-4.