- What is demonstrated by radiologic imaging?
The chest radiograph shows a diffuse reticular and nodular pattern typical of involvement by metastatic carcinoma spreading into the lymphatic channels of the lung. The more recent CT scan shows bilateral pleural effusions. If a thoracentesis is performed, malignant effusions often prove to be serosanguinous.
- What are the clusters of cells seen in this section? Where are they located?
Clusters of malignant cells are seen primarily in lymphatics which run around the bronchovascular bundles and in the interlobular septa, but you can also see tumor in vessels and a few nodules in the parenchyma.
- Look carefully at the smaller arterioles in image 3.4 What changes do you see in the vessels? What is the mechanism?
This section demonstrates changes of pulmonary hypertension as well as the lymphatic and vascular spread of cancer. The change you see is marked thickening of vessel walls, with luminal compromise, due to intimal proliferation and medial hypertrophy. The likely mechanism in this case is obstruction downstream in the vessels by cancer.
- What is/has gone on in the alveolar spaces in image 3.5? What is the brown
pigment?
Hemorrhage is present in the alveoli. The brown pigment is hemosiderin.
- What do you think this woman's respiratory symptomatology was during her terminal phase?
She was likely quite dyspneic and hypoxemic. The result of severe hypoxemia is tachycardia and lactic acidosis. There can be mental confusion.
- What is the most common tumor in the lung?
Metastatic cancer.
- When should hospice care be considered?
The average stay in hospice is two weeks, and in many communities even less time than that. Yet the insurance coverage may extend for 6 months. The tragedy is so many patients don't want to admit they are dying until the very end, and many doctors don't want to give a prognosis of 6 months and be wrong, and so tend to wait too long as well. Thus, many patients never fully take advantage of the benefits of hospice.
When should you refer someone to hospice? Soon after a bad diagnosis, you should reassure the patient that there is still some hope of remission, and that even if there is no remission there is still hope for some meaningful life to be lived for a period of time. And explain that hospice will help them with the latter goal. Keep preparing them so that when the day comes, it isn't taken as the worst news they ever got, but just a part of a well-planned, and even rehearsed, series of events in the progression of their disease.
But WHEN to make that recommendation? The goal should be to give the patient as much time in hospice as possible, not to predict the time of their death as accurately as possible. The latter is what causes all those two week stays. If their disease limits them to life at home, and no longer going out, it is time for hospice. If their disease limits them to their bed, then it is long past time. (There are more exact guidelines available from http://www.nhpco.org)
