Thank you to the great Sam Brondfield for joining us AND presenting a fascinating case! We discussed an older woman with metastatic lung adenocarcinoma on erlotinib transferred from OSH with shock with markedly elevated uric acid, LDH, and renal failure.
- Erlotinib is an EGFR inhibitor and used in the treatment of metastatic lung adenocarcinoma with positive EGFR mutations. In general, these medications are tolerated very well. The primary side effects experienced include folliculitis and diarrhea. See below for more details about specific lung cancer mutations.
- Not all cancers have equal bleeding risk. Guidelines suggest avoiding anticoagulation in patients with RCC, melanoma, choroid germ cell, and medullary thyroid cancer if they have brain metastases as they are at high risk for intracranial hemorrhage.
- Lung cancer is the only cancer for which guidelines recommend brain imaging as part of the initial screening (in patients with metastatic disease or any patient with small cell lung cancer).
- 5% of lung adenocarcinomas can transform into small cell lung cancer. Small cell cancers are a subset of neuroendocrine cancer, and can arise from multiple types of cells. We are most familiar with discussing small cell lung cancer, but this is also seen in the setting of prostate cancer.
Lung Cancer Targeted Treatment
There has been great progress over the years in treatment of lung cancer. We now routinely test for a variety of specific mutations in metastatic lung adenocarcinoma and in squamous cell carcinoma. See the pie chart below for a breakdown of the various known mutations. Many of these now have targeted therapies. This image comes from the Lung Cancer Initiative, a great resource that also outlines the various treatments to target distinct mutations.
Refresher on the Etiologies of Shock
- Adrenal insufficiency
- Hypovolemic/Hemorrhagic (crystalloid vs. blood)
- Abdominal compartment syndrome
Spontaneous Tumor Lysis Syndrome
Check out this case series and review of TLS in small cell lung cancer. This is a rare, but highly morbid complication of small cell lung cancer. While TLS is more commonly seen in hematologic malignancies, namely Burkitt lymphoma, AML and ALL, there are reports in the literature of its association with various solid tumors.