All right, my talk is creatively titled Diffuse Large B-Cell Lymphoma Leading to Destruction of Tracheal Rings. My name is Paul Montgomery, I'm a Pulmonary Critical Care Fellow at Harbor UCLA Medical Center in Torrance, California, and I have nothing to disclose. So we'll start with a case presentation. This is a 65-year-old woman with a history of Hashimoto's thyroiditis and 40-pack years of cigarette smoking who presented with two weeks of dyspnea. Her symptoms were exacerbated by laying on her side and alleviated while upright. She endorsed progressively worsening symptoms to the point where she felt like her throat was closing up. She said that she had a nonproductive cough and a hoarse voice, but she had no wheezing, no chest pain, no fevers, chills, or sweats. Her medical history was pretty minimal. She was recently diagnosed with a Hashimoto's. She had no surgical history. She was taking levothyroxine. She had no allergies, no personal or family history of malignancy. For her social history, she recently quit smoking. She had a distant history of cocaine use, and she sings in a local choir, which makes the hoarse voice and shortness of breath particularly distressing for her. Objectively, her vitals were within normal limits. Her exam was really notable for non-tender thyromegaly, and then she had diffuse wheezing in all lung fields with some low-pitched ronchorus sounds that when you listened to her, it really seemed to be loudest when you auscultated her neck. The remainder of her exam was within normal limits. For her lab, she had a mild leukocytosis and some derangements in her thyroid labs, but the remainder of them were within normal limits. She had a chest x-ray that had no acute cardiopulmonary process, and she also had spirometry that was essentially within normal limits. The next step was for her to get some cross-sectional imaging. She had a CT scan of her neck, which showed about 50% stenosis of the trachea within the subglottic space, as well as what the radiologist called some granulation of unclear etiology. At this point, the pulmonology team got involved, and we scheduled her for a bronchoscopy, and I'll show you some pictures from that next. Just to orient you, we're already through the vocal cords here in the subglottic space within the proximal trachea. Some of the tissue kind of looks like false vocal cords, the areopaglottic folds, but that's not the case. That's actually some tissue extruding into the lumen of the trachea. And then on the left, that white band in the center is actually exposed tracheal cartilage. So when we saw this, our differential that we were thinking about was definitely malignancy is something we were concerned about. We also thought about relapsing polychondritis and other autoimmune diseases, especially given her recent diagnosis of Hashimoto's. So we decided that we need to get some biopsies. So we performed some forceps biopsies of the sort of soft tissue that you can see extruding into the lumen. And after we took several biopsies, the picture on the right is what we saw. So actually, we saw a second tracheal ring that was exposed, and it was no longer in continuity. It was actually, there was a fracture in it. So obviously, this is concerning to us, but she was tolerating the procedure fine. We extubated her and waited for the biopsy results. Unfortunately, the results of our biopsy were non-diagnostic. She had some focal areas of granulation tissue, as well as some squamous metaplasia. So at that point, we referred her to the ear, nose, and throat physicians. And after a few weeks, they decided to take her for a tracheal resection. So they actually resected her tracheal rings, her first and second rings, and did a reanastomosis of her trachea. And they sent all of that tissue for pathology, and the resulting diagnosis was a diffuse B-cell lymphoma with germinal center type. So just a bit on tracheal tumors, primary tracheal tumors are extremely rare. They're about 0.1 to 0.4% of all tumors that develop, with an incidence of about 2.6 cases per million patients annually. Within tracheal tumors, they do occur in children, but those are usually benign, whereas in adults, most tumors that develop are malignant. The majority of cases are either squamous cell carcinoma or cystic adenoid carcinoma. But there have been reports of non-Hodgkin's lymphomas, such as this case, but they're extremely rare. It looks like it's about 0.2% of all cases in the literature. And of those non-Hodgkin lymphomas, typically the subtypes seen are plasmacytoma, malt lymphoma, and then a diffuse large B-cell lymphoma. So tracheal lymphomas, usually they present as an endobronchial mass and or mucosal infiltration with some associated lymphadenopathy. Often they're polyploid in appearance. So this is actually an image that I took from a different case report in 2015 to give you an example of what is more typically seen. But there have been some reports of irregular mucosal appearance, sort of like granulation tissue. I didn't see any other cases reported where they reported sort of this destruction of tracheal rings. So that's something I think that's unique to this case. In terms of treatment for lymphoma of the trachea, the therapy sort of focuses on optimizing local control. So that usually either means radiation therapy or surgery. And generally surgery is the recommended course if it can lead to complete resection of the disease. And for a couple of reasons, one because you can sort of have a curative case as well as you can alleve the airway obstruction for the patient. So following up on this patient, they tolerated the tracheal resection with the reanastomosis. She had an uneventful recovery. Her dysthmia resolved. She's been followed by oncology closely. And she's had serial PET scans that have all been negative. So really a positive outcome for this patient. In conclusion, tracheal malignancies are rare. And of this rare condition, lymphomas are an even more rare subtype. And this diffuse large B cell lymphoma in particular can destroy tracheal rings leading to symptoms of shortness of breath. So I want to just thank you, give thanks to my program director, Dr. Shah, as well as one of my co-fellows, Annie Chen, who participated in this case. Okay, I have a question. So we know that this non-Hodgkin type B-cell lymphoma are common in Hashimoto's. Have you seen, or in the reported literature, how many, or what's the incidence of involvement of trachea in that situation? It does happen, usually, you know, I'm not sure about the incidence, to be honest, but it is definitely a common thing where the lymphoma of the thyroid enlarges to the point where you get some obstruction of the trachea. They did specifically send, they did an excision of the thyroid in this case, and it did not have any lymphoma, so it was truly a primary tracheal lymphoma. But that is a very common occurrence, is that with the Hashimoto's, you can get a B-cell lymphoma that can lead to some airway obstruction. Okay, awesome, thank you so much. Thank you. Hi there, guys. Today I'm going to be presenting a case report on high-grade non-small cell lung cancer presenting with rare metastasis to the subcutaneous tissue as well as cardiac invasion. So I'm Kyle DeVault, I'm PGY2 at SUMA Health Center in Akron, Ohio. I have nothing to disclose. So starting with case objectives. So we're going to review the incidents. We're going to recognize non-small cell presenting as these nodules and then also review the prognosis as well. So case presentation, we have a 41-year-old male. He's got a past medical history of polysubstance abuse with a 60-pack-year history. He actually presented to the ED with left lower quadrant abdominal pain. On review of systems, it looked like for the past eight months, he had had a 40-pound unintentional weight loss. He had also developed hemoptysis for about three weeks prior to his presentation. And he noted that these nodules that were diffusely scattered throughout his body had developed about six weeks prior to his presentation. He actually went to a free clinic at that time when they first developed and had an ultrasound of these nodules ordered and it showed multiple heterogeneous vascular lobular subcutaneous nodules, but then he was lost to follow-up. On physical exam, it was noted these nodules as well as normal sinus tachycardia at 120 as well. So here's a picture of the nodules. They were diffusely across his chest, abdomen, back. He also had some on his arms, some on his legs, and some in his inguinal area. Some of them were excoriated to the point where there was actually skin breakdown and they were sort of oozing a little bit as well. Those ones were obviously painful, but the other ones were not painful. Some of them were freely mobile. Some of them were not freely mobile. It just varied. So the ED did a CT chest, abdomen, and pelvis. I included a few images here. There's, when you review the CT scan, he's got nodules all throughout on imaging. Here you can see the large mediastinal tumor and then they also noted this lymph node over here in the left on the pelvis that looked necrotic in nature. They said it looked like it was most likely cancerous. So underwent a TTE as well because he had what looked like disintegration of the fat plane between the atria and the mediastinum and so there was concern that there was some invasion into the atria. Here you see this large tumor. It looks like there's bilateral atrial invasion as well of the tumor. They ended up measuring at 4.5 by 4.6 on the TTE. So on day one, we actually consulted general surgery for an excisional biopsy. Unfortunately, they performed a punch biopsy. They thought that they had gotten all of the tissue, but unfortunately the pathology results just showed normal skin tissue and was non-diagnostic. He ended up signing out against medical advice, presented back to hematology oncology. When he presented there, they actually referred him back to the ED for an expedited workup. So he went back to the ED, was readmitted. Pulmonology was consulted for an E-bus at that time. So underwent E-bus with biopsy. This was on day four of his second admission. You can see his post-biopsy down here at image 13 after they actually were able to get some of the tissue. They had the rapid on-site pathology evaluation as well, which was suggestive of non-small cell carcinoma. They sent off a bunch of IHC stains. Some of them resulted right away and some of them did not. But they, and their differential before all of these had resulted, they said it could be germ cell, could be patocellular, also could be some other high-grade tumor as well. Final pathology, his AFP and HCG were both negative. His final pathology actually resulted in high-grade, poorly differentiated carcinoma. And then the patient ultimately, unfortunately, passed away about 43 days after his initial presentation in the emergency department. So the takeaways on this case, I included both here, the incidence and the prognosis not only for non-small cell but for all lung cell cancers, or lung cancers. So you can see that the incidence, it's exceedingly rare, 0.6 to 3.4 in all lung cancers, and 0.6 to 2.8 in just non-small cell. It looks like the median survival time from diagnosis is 3.9 to 4.9 months, and that's in all types of lung cancer, and then in non-small cell, it's a little bit less at 3.9 months. And the one-year survival is 3.3%. So I think that this case just reinforces that we know if you present with lung cancer and metastasis to the skin, it's poor, it's a poor prognosis, and your survival time is very limited at that time. So here are my references. Questions? Any questions from anybody? Okay. What was the treatment plan proposed? So it's actually interesting. Before his OCT 3 slash 4 and one other germ cell marker came back, speaking with the hematologist oncologist, they were actually offering him chemo for germ cell because it was so aggressive and so diffused throughout. Speaking to the hemon guy, he said, you know, this is really the only shot that we've got at this point. So he ultimately, he declined, and it is unfortunate because it sounds like maybe three days before his passing, he ended up calling the hematologist oncologist and requesting treatment at that time, but he was so late in the game. It was tough. And what was the ultimate cause of his death? After, was he admitted, or did he go to his family? So he was not admitted. He actually, because he was polysubstance, he actually, there was some issues surrounding possible drug use while he was admitted to the hospital. So hospice refused to take him. So he ended up passing away at home. So I'm not exactly sure. Okay. All right. Thank you so much, Kyle. Thank you. Okay, we have our next presenter. Hi, good morning, everyone. So I'm going to talk about a case, it's titled Cannabis is the New Tobacco, Small Cell Lung Cancer in a 34-Year-Old Male with Significant Cannabis Exposure. So I saw this case with two of my medical students, Ina and Sam, and with my two interns, Dr. Abdul-Wallop and Dr. Matthew, and with my attending, Dr. Eckes, who's actually here in the audience today. So my name's Arnavi, I actually just finished my internal medicine residency at Garner Health Medical Center in Middletown, and I have nothing to disclose. So today we'll kind of just talk about small cell lung cancer, about our patient, how he presented to us, and kind of why this is an important case overall to keep in mind for our future practices, and then we'll talk about our patient today. So small cell lung cancer is a neuroendocrine tumor, commonly presents usually by the time it's diagnosed, it's usually a disseminated disease itself. The main risk factor that is identified so far is mainly just tobacco use. And in terms of the five-year survival rate, it really just depends on the disease state itself at the time of diagnosis. So if it's a localized disease, it's usually 30%, regional is 18%, which really just means that it's in the same lung cavity itself and around that area, and if it's metastasized, then it is about 3%. Our usual patients in this category are usually elderly population, average age about 70 years old, and like I said, the main thing is that they have significant tobacco smoking history. So our patient, very different from this average patient that we see, he is a 34-year-old male. He had no known past medical history at the time that we saw him, no surgical history, he's actually never had any hospitalizations prior to this one. His social history is really significant for marijuana use, so it comes out to about 63 joint year history, since he started smoking marijuana at the age of 12. His family history is significant for some cancers, his maternal grandmother, which they're not sure about which kind, and his father actually was diagnosed with prostate cancer maybe a year prior to us seeing him. And his allergies just have dust mite extract and pork-derived products. So the way he presents to us is his main complaint is shortness of breath. He said that it's been going on for about three weeks with dyspnea and exertion, dizziness, and he had sharp right side of shoulder pain, arthopnea, facial swelling, and night sweats. So a week prior to us seeing him, he actually went to urgent care with the same amount of symptoms and at that time he was presumed for an asthma exacerbation, even though he has no known history of any asthma at that time. And he was treated with apitropium and teatropium nebulizers, prednisone, and amoxicillin clavinate acid. Given the fact that he had no improvement in his symptoms, he actually presented to our emergency room for further evaluation. So at that time, he actually had a chest x-ray that showed a large paratracheal and super high alert lung mass with some mass effects. So then he had a CT scan with contrast to follow up, which I'm actually going to show you in the next slide, and then it was decided that patient was going to be admitted for further evaluation. So here you have the CAT scan. So this is the CAT scan with contrast, and you can see on the bottom image, you can see the apical emphysema and the significant bullet burden disease that he has. And then on the left-hand side, you can see the huge mass that we see. So it's about 8.7 by 9.1 by 8.5 centimeters. So it's in the medial right upper lobe, and you can see that it's actually displacing the superior vena cava anteriorly, and then some of the mediastinal contents are actually getting moved to the left because of it. And there's some narrowing of the trachea itself. So he had a CAT scan of the abdomen, pelvis, and MRI brain just for risk stratification. Didn't show any obvious signs of METs at that time. So he was evaluated by our oncologist, and given the extensive size of the mass itself, we decided that we were going to do a CT-guided lung biopsy in-house itself. And so the pathology showed that it was a high-grade neuroendocrine tumor that came back positive for CD56. And given the size, and there was no METs or nodes at the time, he was qualified as stage 3A at that time. They placed a left metaport, and they actually started immediately on treatment. So he got cisplatin, one dose of cisplatin topazide in the hospital stay itself, and then he had plans for radiation therapy before his second cycle of chemo. So he was followed up, he was discharged with close follow-up with our oncologist, and he was actually referred for genomic sequencing of the tumor that actually confirmed that this is small cell lung cancer. And he also got tested for alpha-1 antitrypsin deficiency at that time, which came back negative. So he didn't have the deficiency. So just to kind of talk about small cell lung cancer, it constitutes about 13% of lung cancer worldwide. And like I mentioned already, it's usually a disease of the elderly with heavy tobacco use. But given the more extensive use of cannabis now, there have been some case studies that have been done. There was a case study that was a similar situation. He was about 26 years old, and he had very similar symptoms. And his main risk factor was that he had extensive cannabis use. They also did a case control study in New Zealand with residents, compared them to control population that didn't have cannabis use compared to these patients that did have significant cannabis use. And they kind of found out that about one joint here, which is the equivalent of one joint per day for a year, increases the risk of lung cancer by about 8%. And they said smoking one joint per day is almost equivalent in terms of risk of malignancy if you're smoking about 20 cigarettes per day, which is about half per day. And of course, underlying lung disease will also increase your risk of malignancy. And so when we look at substance abuse data, this is the data from 2019, they're saying about 11.5% of the individuals have used marijuana in the past month compared to tobacco use, which is about 16.7%. So it's kind of very similar percentage of people who are using marijuana compared to tobacco. And since 2019, there's about 10 additional states that have gotten approval for the use of and purchase of recreational marijuana, which makes about 22 states as of January of this year. So there's not a significant amount of studies that have been done that looks at the connection between marijuana use and the development of lung cancer, but I think it's important for us to kind of recognize that it could be a potential risk factor in terms of screening these type of patients. So given that our patient was so young and he had such extensive use of cannabis, and he also had some abnormal lung parenchyma, which we're not really sure what the underlying cause of that was, and it's possible that it's mainly from the cannabis use, I think providers overall should be mindful in screening these patients the same way we kind of have a set guidelines for screening patients with tobacco use. Maybe there needs to be some sort of guidelines of when we start screening these patients with cannabis use. So our patient today, this is about six, seven months now since his initial diagnosis. He is in remission. He's been having close follow-up with the oncologist to just monitoring for metastatic disease. He had a bunch of MRIs of the brain, actually, that have shown a seven millimeter left parietal lobe, and I'm actually going to show it to you in a couple of slides. They're not sure the actual significance of that, but it's been stable from prior images, and he actually had a PET scan very recently that actually showed that the right upper lobe mass that I'd shown you earlier has a decrease in size, and there's less radio tracer activity, which kind of is consistent with good response. And given his young age and the patient's preference itself for right now, there's no further plans for any repeat chemo or radiation therapy, but we're just going to do some repeat imaging every couple months for just surveillance. So here's our repeat scans. So the CAT scan on the left, it's about two months post from his initial diagnosis. You can see, if you remember, the initial mass was about eight to nine centimeters wide, and now it's showing about 4.1 centimeters, and then the image on the right, bottom right that you see, is the PET scan about five months after his initial diagnosis. Again, very consistent with the size decreasing overall from the initial PET scans, and they do see some ground glass capacities, which they're presuming that might be a reactive process from his radiation therapy. Here you can see the MRIs of his brain. So the initial one was done in February of this year, so you do see that seven millimeter like parietal lobe abnormality, but it is consistent despite repeat images for right now, and so for right now they're not planning on any further treatment for this abnormality right now. They're just going to do some follow-up MRI scans. And lastly, here is his latest PET scan. You can see that shows low radio tracer activity, and just overall just showing that he has some good response to our treatment. That's pretty much it. Thank you. Any questions? Hi, good morning, thank you for the case. How was his cannabis use addressed concurrently with his treatment? Did he end up quitting? I actually don't know specifically, because I just took care of him when he was hospitalized itself, so I'm not sure about the follow-up, but the plan at that time when we had talked to him at the time of discharge was to eventually quit, and he was pretty responsive to that. Thank you. Any other questions? Yes. Do you have PFQ results regarding cannabis lung functions? No, unfortunately I don't. Of the studies that you ran across that looked at cannabis use and just lung cancer incidents, do you know if these patients have similar incidence rates of the individual subtypes of lung cancer, adenoma, swanginess? Right, so the study that they did in New Zealand, it was about 20% for small cell, and about 80% about non-small cell. So it's kind of consistent with the distribution that we see already. And also it was a case control study from New Zealand you were talking about in 2008. Yes. So it's very important for us to know that when we kind of ask history, we also need to make sure that we ask about their joint use and categorize them as joint years, as we do for cigarette, because for each joint year it increases your incidence by 8%, and for cigarette smoking it's 7%, at least from that case control study. So, yeah, thank you. Thank you. Okay, we are on time. And we have our fourth presenter, James. Good morning, everyone. My name is James Bradley. I'm one of the third-year fellows at the University of Louisville in Louisville, Kentucky. So today I'm going to be talking to you about plasmablastic lymphoma. I'm just going to refer to it as PBL, since that's easier to say. We'll talk about some of the pathological characteristics and some of the treatment regimens that have been proposed. In this case, this is a 61-year-old gentleman. He had, essentially, he was relatively asymptomatic from a malignancy standpoint. He'd been having recurrent nephrolithiasis over the past year. He'd come to the ER for one or two times in the past year. And then this admission, he got a CT scan of his abdomen, showed this kind of large infrahilar mass, 10 centimeters by 8 centimeters. I didn't put a picture up on here because we've all seen large masses. Essentially, we got consulted by urology, and oncology was consulted as well. We performed an EBUS with FNA, and then he was essentially discharged with antibiotics. The pathology from the FNA came back as just these crushed necrotic cells. And then probably about a week after the initial admission, he represented at the hospital because he'd been having abdominal pain again. And so we got consulted again to perform another biopsy. And so this time we did transbronchial biopsies which showed these malignant epithelioid and plasmacytoid cells. Oncology, because of the high concern for malignancy, they sent this gene assay which eventually came back as kind of a 90% probability for a sarcoma. And because the pathology was sent to another tertiary care facility, Indiana, just for kind of a second opinion, and eventually the diagnosis came back as plasmablastic lymphoma. So with plasmablastic lymphoma, this is a case, a literature review of about 600 cases from 1997 to 2014. It's the largest that's out there in the literature right now. Most cases of PBL are actually in the oral cavity, and most of the cases are associated with HIV. As you can see, it's not showing up. Anyway, as you can see, I've circled the lung there just to show you that it's pretty rare for it to show up in the lung. But of the 11 cases that have been shown up in the lung, the majority of them are associated with HIV as well. And then just one case that's been shown in an HIV-negative patient. On further review of the literature, after the 2014, I found a few more cases. My case represents probably number 15, number 16, that's been published, or that we found in an HIV-negative patient. On histopathology, on the H&E stain there, you can kind of see these plasmablastic cells. And then with a high mitotic index, with the KI-67, it did stain positive for MYC, and then CD138 was positive as well, but notably negative for CD20. I mention that because the PBL is considered kind of a subset of diffuse large B-cell lymphoma. And this was another kind of large case series of 400 cases, just to highlight the immunostains that are pretty prominent. They typically stain positive for CD38, 138, MUM1, and VS38C, and then negative for CD20. And then in terms of treatment, this is a very rare tumor. There are no standard, kind of standard care treatment regimens that have been proposed. Most people, about 90%, 90% receive chemotherapy, and then roughly 20% have received surgery and radiation treatment in this case series. In terms of the chemotherapy regimens that are most commonly used, it's typically a CHOP or a CHOP-like chemotherapy. In this case series, about 50% of the patients receive that. In terms of survival, the median survival is about a year and a half, with the mean is actually quite higher, about four years or so. So that just means that you've got a lot of outliers that are kind of changing the curve a little bit there. It has been shown in patients all the way from age of one up to age of 90, that are out there in the literature. So in conclusion, although typically these cases of PBR are associated with HIV and also EBV, there are more and more cases that are starting to be reported in immunocompetent patients. These are the kind of prototypical IHC markers to remember, and then although there is no specific chemotherapy regimen that's considered standard of care, most experts, just expert opinion, feel that EPOC is better than CHOP in HIV-associated PBL, so a lot of oncologists will extrapolate that to the non-HIV population as well. Our patient received V-EPOC and with bortezomib and methotrexate. That was about two years ago. He's still alive, doing well. He did receive some radiation treatment as well, and that's kind of the end of the case there. Thank you. Any questions? Okay, I have a question. So how long was the chemo regimen that you decided for this patient? So he received chemo in total probably for about six months. Okay, and so still now it's been in remission? Yeah, it's been in remission. Our patient was worked up for a stem cell transplant. I think in that one case series I showed, about 20% of people are treated with stem cell therapies as well. He has not required the stem cell transplant yet, but they kind of are in the middle of that right now. Okay, thank you so much. And the last speaker for the day is Aisha. Good morning, everyone. My name is Aisha. I am a third-year internal medicine resident from Jamaica Hospital in Queens. Here I'm presenting a case of lung adenocarcinoma that had high pleural and serum amylase levels. So I have no disclosures. All right. So our patient was a 73-year-old female. She had a past medical history of asthma, diabetes, hypertension. She initially presented to us because she was having shortness of breath. It had been persistent for about one to two months, worsening in the last month, and she also had an associated 10 to 15-pound weight loss over the past year. The shortness of breath was consistent, but she was unable to lie flat over the past five days, so that's why she presented to us. She had no associated fever, cough, chills, or any other sick contacts, and it's important to note that she was a lifelong non-smoker. On physical exam, there was negative. Besides, there was decreased lung sounds on the left lower lung fields, and the patient was short of breath. We did some lab work. All our lab work was unremarkable. A couple of things that stood out were the serum amylase levels. It was 176, and her serum lipase was 507. So we did some imaging. Her chest x-ray is shown on the left, which shows a significant left-sided pleural effusion with almost collapse of the entire lung. At the same time, we also did a CT chest and a CT abdomen. So CT chest, you can see it's demonstrating a large left-sided effusion, and the radiologist also read the report as there were some pleural nodules on the basis. So the patient underwent a thoracentesis, and I included an image of the CT post-thoracentesis, and the thoracentesis showed a pleural fluid amylase level was pretty significant of 16, 1,627, LDH of 1,928, and glucose 247, triglycerides were 27. So initially, we were thinking that maybe the patient had esophageal fistula or rupture or a peripancreatic fistula that was causing these symptoms. We did note that she had the nodules, so there was possible an underlying malignancy, but the pleural fluid, we were thinking that there was something going on like a fistula, essentially. So endoscopy and esophagogram were done, and they actually ruled out a perforation, esophageal perforation, lesion, malignancy, or even a fistula. So eventually, the pleural fluid cytology came back a few days later, and it revealed that the patient had malignant cells, which were consistent with a lung adenocarcinoma. At that point, VATS was done, and showed multiple metastatic implants on the pleural surface, and biopsy results did eventually end up coming back, which confirmed the adenocarcinoma, and the patient was started on appropriate treatment. So initially, when we saw the patient with these high amylase levels, our differentials were esophageal rupture, fistula, pancreatitis, peripancreatic pleural fistula, and malignancy was, we weren't considering it as one of the causes for the effusion. However, this case demonstrated that that should be one of the differentials. Although it's rare, it is common, and upon literature review, we did see that lung adenocarcinoma that produce high levels of amylase, it's sometimes used as a tumor marker or a serum marker to see how responsive the patient is to treatment. So this patient's pleural fluid had higher amylase levels, and a lot of the times, that is produced by the lung carcinoma primarily. And the exact pathophysiology of that is not well known. So again, like I said, this case highlights the importance of considering adenocarcinoma as a cause of high pleural amylase levels, and there's still studies, there haven't been too many studies to demonstrate the relationship between the cancer and what causes the development of the high amylase levels, but it is sometimes used, like I said, to monitor a patient's responsiveness to the treatment. So this patient currently, she's actually undergoing, still undergoing her chemotherapy regimen, and we are, she's monitoring closely with our pulmonologist and our hematology oncology. So, thank you. Any questions? Yes. So, the preliminary results came back early, but we were just being more aggressive, so she went in before all the results came back. Yeah. Yes. So we actually did a CT, and it didn't show anything, that's why we didn't pursue anything else. Thank you.

shortness of breath

weight loss

pleural effusion

pleural nodules

lung adenocarcinoma

VATS

chemotherapy

diagnosis