Treatment with erythropoietin can be successful if the serum levels of the hormone are under 500 mU/ml.

A 48-year-old Caucasian woman comes to the physician for a follow-up visit.  She was recently diagnosed of anemia.  She currently complains of chronic and frequent tiredness, and daytime sleepiness.  Her other medical problems include hypertension and rheumatoid arthritis.  She takes diclofenac, enalapril and ferrous sulfate.  She has no known drug allergies.  Her social history is not significant.  Her vital signs are within normal limits.  Examination shows no abnormalities.  Stool testing for occult blood is negative.  Two months ago, when she was started on oral iron therapy, her baseline hemoglobin and hematocrit values were 8 g/dL (n>12.0) and 26% (n>36), respectively.  Her most recent laboratory results are as follows: CBC Hb 8.2 g/dL Ht 27% MCV 88fl Platelet count 450,000/cmm Leukocyte count 6,000/cmm Segmented neutrophils 63% Lymphocytes 31% Monocytes 6% Hematology Iron, serum 80 μg/dL Iron binding capacity, serum 200 μg/dL (normal: 250-370 μg/dL) Ferritin 300 ng/mL Erythropoietin 1500 mU/mL (normal: 500-3600 mU/mL) ESR 40 mm/h Serum vitamin- B 12 level 440 pg/mL (normal: 200-800 pg/mL) Serum folic acid level 18 ng/mL (normal: 2.5-20 ng/mL) Bone marrow studies reveal decreased numbers of sideroblasts and normal amounts of storage iron. Which of the following is the most appropriate intervention in the management of this patient? Patients with chronic diseases may develop anemia (anemia of chronic disease, or ACD). Chronic conditions such as inflammation and malignancy gradually suppress red blood cell production in the bone marrow. Hematologic studies reveal a low serum iron (80 μg/dL) and elevated ferritin levels (300 ng/mL), and usually, normal transferrin saturation. (Approximately 25% of ACD patients can have low transferrin saturation.) Around 20% of ACD patients have a hemoglobin concentration lower than 8 g/dL. In those cases, the cause of the anemia may be mixed; thalassemia, sideroblastic and iron deficiency anemia, as well as myelodysplasia have to be ruled out. This patient has a definite diagnosis of ACD made by bone marrow studies. Bone marrow studies reveal normal or increased amounts of storage iron in the macrophages, and a decreased number of sideroblasts. Treatment of the underlying disease and frequent follow-up visits are essential in the management of patients with ACD. Apart from treating the underlying cause, the 2 major options for treating anemia in these individuals are, erythropoietin injections or periodic blood transfusion. However, patients of ACD with erythropoietin levels more than 500 mU/mL usually do not respond to treatment with erythropoietin or darbepoetin. When the anemia is severe, such as in this patient, blood transfusions are necessary. Iron supplementation may be useful in patients with rheumatoid arthritis with co-existing ACD and iron-deficiency anemia, which can result from gastrointestinal bleeding secondary to drug therapy. Otherwise, iron therapy does not significantly help in the management of patients with ACD. Treatment of the underlying disease (which is usually a chronic infection, autoimmune or inflammatory disease such as rheumatoid arthritis, lupus, and vasculitis) and frequent follow-up visits are essential in the management of patients with anemia of chronic disease. When the anemia is severe, blood transfusions are necessary. Treatment with erythropoietin can be successful if the serum levels of the hormone are under 500 mU/ml. If erythropoietin levels are normal and anemia is severe, periodic transfusions of packed red blood cells are indicated.

Accurate histological identification and staging of the tumor, along with preoperative physiologic assessment of lung function, is an important initial step in the optimal management of patients with lung cancer.

A 58-year-old Caucasian man comes to the office with complaints of cough for the past two months and blood-tinged sputum for the past three days.  He has lost approximately 25 pounds over the past six months.  He denies any history of low-grade fevers or night sweats.  He has a long history of heavysmoking and chronic obstructive pulmonary disease.  His temperature is 37.0C (99F), blood pressureis 120/62 mmHg, and heart rate is 82/min.  He is a thin, cachectic man who is in no acute distress. Lung auscultation reveals the presence of rales in the right upper lung fields.  His white cell count is8,000/cubic mm with normal differential count.  His serum calcium level is 12.8 mg/dL.  His chest x-rays shows a 3.2 cm mass in the right upper lung zone, which is suspicious for a lung malignancy. Sputum cytology reveals poorly differentiated squamous cell carcinoma.  Pulmonary function testing shows that his FEV1 is 1200 cc, while quantitative ventilation-perfusion scan shows that 65% of his pulmonary function comes from his right lung.  What is the next best step in the management of thispatient? Lung cancer is the most common cause of cancer death in the United States and throughout the world. The appropriate selection of therapy, as well as the patient's prognosis, depends on the histologic type and accurate staging of the tumor. The important components of the current TNM staging system include the extent of local tumor spread, the presence or absence of nodal involvement, and distant metastases. The presence of local or distant nodal spread or distant metastases to other body parts greatly influences the treatment approaches in patients with lung cancer. It is therefore important to accurately stage the patient before initiating any specific treatment. This is done through a detailed clinical assessment, radiographic imaging via CT scan or PET scan, and radionuclide bone scans. An initial CT scan should be obtained in all patients with lung cancer (small cell or non-small cell lung cancer) to aid in the initial staging work-up. It is extremely useful in detecting any mediastinal lymph node metastases and chest wall invasion. It also allows for accurate measurement of the tumor size, detection of small pleural effusions, and evaluation of liver and adrenal glands for metastatic disease. In easily accessible lesions, it can be useful in obtaining a CT-guided biopsy for tissue diagnosis of lung cancer. For these reasons, this patient should have a CT scan before planning or initiating any further treatment. Surgical resection is the treatment of choice for patients with stage I and some stage II non-small cell lung cancers; however, it is not as effective in patients with stage III disease, and most patients require adjuvant radiation and chemotherapy as well. The exact stage of disease in this patient is unknown, and he should not be referred for lobectomy or pneumonectomy at this point. Moreover, the patient in the vignette has a very low preoperative FEV1 (FEV1 is 1200 cc) and the quantitative ventilation-perfusion scanning shows that a significant portion of his pulmonary 65% reserve comes from his right lung. He would therefore be unable to tolerate a right pneumonectomy. Adjuvant radiation and chemotherapy has been shown to improve the outcomes in patients who undergo local tumor resection; however, radiation or chemotherapy should not be planned, unless a definite and accurate staging of the tumor has been done. Baseline CT scan is required to document the tumor response to chemo/radiation. Mediastinoscopy with mediastinal lymph node sampling is indicated to document the presence or absence of malignancy in patients with suspected nodal involvement on chest CT scanning.