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MD7019 Respiratory Medicine Question: The assessment is to be submitted as an evidence based case report. You will be expected to read around and build on information gained from the module sessions with self-directed study Choose any illness/disorder or an intervention related to Respiratory disease or Respiratory associated complications and write up an evidence based case report using primary literature as your evidence base to support your diagnosis, treatment and prognosis of the case. A Case Report On Broncho Alveolar Carcinoma You should follow Case Report Writing Template for authors (2013) to write your case report. Case Report Writing Template for authors (2013) The Structure Of The Case Report Introduction: the background should be brief, and it should have a rational and aim/s, for selecting this specific patient case. The majority of assignments last year have very long descriptive introduction without clear rationale or aim of the presented case report. Case presentation, and history: need to include relevant details avoid having un-necessary comorbidities, start with the chief complain.  Consider clinical reasoning in presenting each stage that your patients passing by, for example, you can’t send patients to do ECG, because he come to the clinic complaining from headache. Diagnostic procedure: should have logic behind doing them. Please considered presenting laboratory analysis in tables (with an appropriate title above the table), Additionally, ECGs, CT, x-ray etc. consider showing them in figures with arrows towards the abnormalities. Also, again consider what is the recommended by guidelines. Treatment and follow up need to write full doses and strength of the prescribed medication and what was the main outcomes. The discussion:  a common problem in the drafts I saw, was that the discussion was descriptive and did not demonstrate analysis of the literature, also some of them were writing in blocks, or lists I recommended to write the discussion in form of paragraphs and each paragraph should evaluate and analyse an idea using relevant literature, then by the end of this paragraph you need to discuss how this idea is applied or not applied on the presented patient case. You may consider starting the discussion with what is the main message behind presenting this case report.  I have noticed that some drafts starting with the limitation, which is not ideal to start with, you need to address the limitation by the end of your case report. You may consider looking at if there is a similar case report or other primary research was done about similar cases. Consider the limitation of your case report and avoid generalise the outcome/s, in the end, it’s a single patient case. Conclusion: should not have a new reference or a new information that was not discussed in the actual case report.  It is recommended to have suggested hypotheses based on your case report if possible.   Answer: Bronchioloalveolar Carcinoma: A Subtype Of Lung Cancer That Does Not Necessarily Have Any Distinctive Symptoms Introduction The aim of this paper is to make a detailed discussion on the disease named Bronchioloalveolar carcinoma and consider the case study of a patient with the same disease. Bronchioloalveolar carcinoma is a rather rare subtype of the lung cancer, which is now considered as a type of Adenocarcinoma and is recently known by the term of Adenocarcinoma in situ. Bronchioloalveolar carcinoma is considered to be a mild disease condition, which can be treated rather easily as compared to the other lung cancers (Butt & Allen, 2015). The reason behind this is that the Bronchioloalveolar carcinoma is not invasive in nature and tend to stay restricted to a small area of lungs adapting the appearance of a small patch of cells in a limited area of the lungs. The condition does not present with many symptoms in the patients in most cases and in the other cases the symptoms including chest pain, cough, fever, dyspnea and hemoptysis can be associated with this disease condition. The paper will start with presenting a case study on a patient who have bronchioloalveolar carcinoma along with his medical history. Then there will be a rationale given for selecting the case for including it in the case report. After that the diagnostic procedures and the treatment methods will be discussed for the same patient. Then the prognosis and the treatment methods will come into the focus of the paper. Case Presentation The case involves a 45 year old woman, named Maria who visited a healthcare facility, since she was experiencing slight chest pain along with coughing. She occasionally had fever but that was not on a regular basis. She assumed that she had developed flu and thus waited for a few days before seeking any professional help. Though she did not have any symptoms like stuffy or runny nose, diarrhea or vomiting. The patient did not have any history of smoking or consuming alcohol without limit. Maria was in excellent health condition for the past few years and did not have any disease condition that can trigger those symptoms. Her blood pressure was found to be 110/80 mmHg, pulse rate 80 and respiratory rate was 21 breaths per minute. There was no abnormality found in her routine checkup. Then she was advised to go through an X-ray examination. The laboratory examination of her blood sample found the white blood cell to be 8000, hemoglobin level to be 16.5 g/L, C-reactive protein to be negative, calcium level 9.4, and albumin level to be 3.7. No microbial presence could be found from the sputum test. WBC Hemoglobin level Calcium Albumin C-reactive Protein 8000 16.5 9.4 3.7 9.4     Rationale For Choosing This Case: The rationale behind choosing the case was to establish the fact that the bronchioloalveolar carcinoma does not have any alarming symptoms that can be readily detected. The patient also need not have the habit of smoking or some adverse behavioral habits that can be detected as the causal reasons for the development of this disease condition. The disease is very rare phenomena and does not present with any distinctive symptoms to make its detection easier. However, it is not a very adverse condition either to demand an immediate clinical attention to avoid the adverse effects on the patient’s health. In this report further discussion on this disease will be included in the later section. Diagnosis: The blood report of the patient detected a complete absence of microbial infection. Hence, the possibility of the patient developing pneumonia was ruled out. The next possibility from the set of symptoms was the possibility of a disease condition associated with the lungs. The patient was advised to take a chest X-ray report, which showed the presence of more than one bilateral nodular lesions along with the detection of a hypodense lesion in the right lobe of liver. Upon this finding, a CT scan of the lung was suggested for the patient, which reported the presence of a single nodule at the periphery of the lung. Another finding from the CT scan of the patient was that the nodules were found to have ground glass opacities (GGOs). At this point a possibility of lung cancer can be taken into consideration. The patient was suggested to perform a lung biopsy test, such as fine needle aspiration biopsy (FNAB) test. There was no malignancy detected in the report. There was also some CT scan of the abdomen area, MRI test of brain and a scan of the bones in the hips, back and rib area was performed to be certain of the absence of metastasis (Groheux et al., 2016). From all these test reports, it could be concluded that the patient have developed a cancerous condition in the lungs, which is either benign or slow progressing in nature. The patient did not have a history of smoking and there was only a single nodule could be detected from the CT scan report of the patient, which was also slow progressing and non-invasive in nature. Hence it can be concluded that the patient have bronchioloalveolar carcinoma or adenocarcinoma in situ. Treatment: This type of carcinoma condition is not a condition that requires any immediate attention, since it have a very slow progression rate. However if left completely untreated it may spread to all over the lungs eventually and trigger various adverse effects in the patient, such as hemoptysis and dyspnea. The disease condition is considered to be completely curable. The strategies adapted to treat the patients with bronchioloalveolar conditions include the surgical methods, chemotherapy treatments and various targeted therapies. There are various targeted therapies in place to treat the lung cancer conditions which are involved in targeting some specific cells or proteins, prevention of which would lead to stopping the progression of the cancer cells. The examples of those targeted therapies involve Xylori, Tarceva and various others (Mir, Sareen, Kulshreshtha, & Shah, 2015). Another treatment method for this condition is the transplant of lungs. The prognosis of this disease condition is that it has a very high survival rate in the patient. Especially in case of early diagnosis and the presence of only a single nodule in the lungs the survival rate is much higher than in cases of the progression of the disease to the later stages and lymph node involvement.   Discussion Bronchioloalveolar lung carcinoma falls under the category of adenocarcinoma category, which again falls under the category of non-small cell cancers. This category of lung cancer also known as the “mystery of lung cancer” (Emami & Kalantari, 2015). Bronchioloalveolar carcinoma used to be considered as a rare type of cancer, however the prevalence of this disease condition is increasing continuously at the present time. The mostly affected groups are the women of relatively younger age and the people who does not have a habit of smoking. The bronchioloalveolar carcinoma covers three categories of carcinoma conditions. The first one is the mucinous variety, the symptoms of which are often closely associated with the symptoms of pneumonia. The second one is the non-mucinous variety and the third one is the intermediate variety (Lee et al., 2016). The intermediate variety of the bronchioloalveolar carcinoma shows the histological pattern of both the mucinous and non-mucinous variety of the disease. There is a relatively new term in use for this disease condition, which is adenocarcinoma in situ. The reason behind dropping the old term is the argument that reasons that the old term does not specifically addresses the actual disease condition in relation to the lung cancer categories and it can be applied to both types of tumors which are mucinous in nature and which are non-mucinous nature (Butt & Allen, 2015). On the other hand the term adenocarcinoma in situ defines the position of the disease condition under a specific group, which are clearly non-invasive or only minimally invasive in nature. The diagnosis method to identify the disease condition as the bronchioloalveolar carcinoma is somewhat similar to the diagnosis method to identify any lung cancer. The principle problem presented by this disease condition is that in most cases it does not present with very distinctive symptoms (Basit, Niazi, Malik & Farooq, 2015). The non-symptomatic instances of bronchioloalveolar carcinoma is very difficult to detect, since the patient does not feel the requirement to perform a checkup, which involves various diagnostic tests such as X-rays, CT-scan, blood test, biopsy tests and various others. The symptomatic instances of the bronchioloalveolar carcinoma involves the symptoms like fever, chest pain, cough, bronchorrhea, hemoptysis, dyspnea and weight loss. The symptoms are often associated with pneumonia or common flu symptoms. Since the occurrence of this disease condition is more prevalent in the non-smokers, the symptoms cannot be readily associated with a lung cancer condition from the history of the patient’s behavioral habits. The progression of the carcinoma condition occurs by following a lepidic growth pattern (Strand et al., 2015). This pattern of growth means the proliferation of the cancerous cells along the surface of the alveolar cells without being involved in any kind of invasion inside the tissues or other organs. This is a common pattern followed by all the cancerous conditions under the adenocarcinoma condition.   To make a diagnostic approach to identify the bronchioloalveolar carcinoma, at first the patient must be interviewed for any possible display of the associated symptoms. After possible findings of the symptoms, such as fever, dyspnea, cough, chest pain or any others, the patient must be subjected to various laboratory analysis test. The tests include the routine blood test, a X-ray analysis, CT-scan, biopsy tests and various others to identify the distinct patterns and unique features of the particular disease condition (Binesh et al., 2015). Both the physical analysis and the blood test reposts of a patient with the bronchioloalveolar condition is supposed to be normal and should not deviate much from the report of a perfectly normal and healthy individual. The X-ray report though on the other hand should detect some possible lesions in the lungs. The CT-scan of a patient with bronchioloalveolar condition should detect a presence of a single and solitary nodule, which cannot be distinguished from the solid mass structure often presented by the other adenocarcinoma categories. There should be a lepidic growth pattern observed in that nodule along with a ground glass attenuation feature and the poorly defined margins (Strand, Rostad, Strøm & Hasleton, 2015). The ground glass opacity or the feature of ground glass opacity can be described as a finding that is found in the CT-scan tests, which have bubble-like appearances and results from the partial fillings of the air in the lungs (Zhang et al., 2017). Those bubble like appearances results from the partial filling of the air in the alveolar spaces, where the nodes and the lesions are already present. The biopsy test is mainly done in order to identify the malignancy of any suspected nodule, mass or any other tumor like appearances. It is possible that the biopsy test, especially FNAB test for the bronchioloalveolar carcinoma will be negative in most cases. Though that does not necessary nullifies the possibility of a cancerous condition. The reason behind the negative result might be the slow proliferation rate of the cells. The treatment procedures of the bronchioloalveolar carcinoma involves the chemotherapy procedures in order to stop the proliferation of the cancer cells. The method uses radiation or strong chemicals to kill the cancerous cells and to stop the rapid proliferation and the growth of the cells. Another procedure to treat the condition is the surgical methods, which can be achieved by either removing a whole lobe of the lungs or the partial portion of the lungs, where the nodule of the cancerous cells are present. There are countries where the treatment procedures involve the complete removal of a lobe of the lung but many health practitioners and physicians considers the practice to be completely unnecessary and it is possible to achieve the same result if only the partial removal of the lungs were done. As mentioned in the above sections the bronchioloalveolar carcinoma is not very fast proliferating in nature and it does not invade in the tissues or organs readily. Thus it is possible to get rid of the whole disease condition by only removing a portion of the lungs that contains the nodule or lesion, without the fear of metastasis or fast progression of the disease. This cancerous condition is very mild in nature and are not associated much complicated health conditions. Though upon the lung transplantation surgery, there might be some associated compilations arise from the condition. The conditions involve chronic obstructive lung disease (COPD), idiopathic pulmonary fibrosis (IPF) along with respiratory failures and various other conditions (Van Raemdonck et al., 2016). Hence to treat the condition, it is more advisable to perform only partial removal of the lungs in order to treat the bronchioloalveolar carcinoma condition. The survival rate of the bronchioloalveolar carcinoma is very high in the patients. The patients do not suffer from severe complications from this disease condition. The female patients are most likely to be affected by this disease condition as well as the non-smoking populations. The patients are supposed to achieve the full recovery though upon receiving the treatment with chemotherapy and the surgical procedures. There are not much evidences that suggest the cancer has a possibility to revert back in the same patients. It has been observed from the studies that the patients who have been diagnosed with the bronchioloalveolar carcinoma at the first stage, have a very high survival rate. The individuals though who have experienced a recurrence of the disease already are at lower risk of surviving though. Though the chemotherapy can always be associated with various complications that can create hazardous conditions to the health of the patient. The conditions associated with the weakened immune system, breathing problems, neuropathy (which involves dysfunction of various nerves), diarrhea or constipation, rashes and various others. The individual who has received the chemotherapy is also more like to be bruised easily and is also most likely to bleed easily. Another associated problem with receiving chemotherapy is the frequent loss of hair, which leaves the individuals emotionally vulnerable in most cases. There is also various painful occurrences that can be associated with the chemotherapy. The patients with compromised immune system, are most likely to be susceptible to autoimmune disease, various microbial infections and even the recurrence of the cancer. The surgical removal of the lungs can be associated with various risks. The risks can be differentiated in two broad categories. The first one can be the risk of various infections and the second can be the risk of rejection. The risks of infection involves the development of disease to which the causal agents are microorganisms. The possible organisms can be the yeast or various respiratory viruses mainly. The rejection phenomena will lead to collection of fluid in the lungs, dyspnea and decreased level of oxygen in the blood along with the fever. There might also be the complications like the blockage of the airways, blood vessels, blood clotting and the edema, resulting from the inflammation reactions. The case study observed in the patient named Maria was female and displayed only a few symptoms such as cough, slight pain in the chest along with some fever. Upon physical examination there was no abnormalities found in her physical condition. There was no abnormality in the blood report was found either. The bronchioloalveolar carcinoma condition was identified by the CT scan report and the X-ray report in the patient. The best method to treat the patient is to adopt the surgical approach, which will involve the partial removal of the lungs where the nodules are detected. The prognosis for the patient is that the patient is most likely to achieve the full recovery after the completion of the surgery. The report identified the bronchioloalveolar carcinoma as a subtype of lung cancer that does not involve many distinctive symptoms. The disease condition does not involve any preventive measures as well. In general there is a risk of the people developing the lung cancers who have the habit of smoking, though in case of this particular subtype, the non-smokers are at most risk of developing this condition. Hence there is no particular field of the preventive measures can be selected for this disease, which can be considered as one of the limitations of this report. The report failed to identify exactly which variety of the bronchioloalveolar carcinoma was developed by Maria. The stage of the cancer could not be identified for the patient either limiting the prognostic statement in regards to the patient. The possible reason for Maria to develop this disease condition was not identified in this report either, which can be considered as another limitation of this report.   Conclusion Hence it can be concluded from the above report that the bronchioloalveolar carcinoma, which is currently known as the adenocarcinoma in situ, is a subtype of adenocarcinoma group of lung cancer. The patient selected for this case study was named Maria, was 45 years old and displayed only a few symptoms such as cough, slight pain in the chest along with some fever. The patient did not have any history of smoking or consuming alcohol without limit. Maria was in excellent health condition for the past few years and did not have any disease condition that can trigger those symptoms. There was no abnormality in her blood report and in her physical examination. The bronchioloalveolar carcinoma condition was identified by the CT scan report and the X-ray report in the patient. The patient was also suggested to perform a lung biopsy test, such as fine needle aspiration biopsy (FNAB) test. There was no malignancy detected in the report. The rationale behind choosing the case was to establish the fact that the bronchioloalveolar carcinoma does not have any alarming symptoms that can be readily detected. The best approach to treat the patient is to adopt the surgical method, which will involve the partial removal of the lungs where the nodules are detected, due the lower risk of developing complications associated with this method.   References: Mir, E., Sareen, R., Kulshreshtha, R., & Shah, A. (2015). Bronchioloalveolar cell carcinoma presenting as a “non-resolving consolidation” for two years. Advances in Respiratory Medicine, 83(3), 208-211. DOI: 10.5603/PiAP.2015.0033 Butt, Y. M., & Allen, T. C. (2015). The demise of the term bronchioloalveolar carcinoma. Archives of pathology & laboratory medicine, 139(8), 981-983. Van Raemdonck, D., Vos, R., Yserbyt, J., Decaluwe, H., De Leyn, P., & Verleden, G. M. (2016). Lung cancer: a rare indication for, but frequent complication after lung transplantation. Journal of thoracic disease, 8(Suppl 11), S915. Lee, H. Y., Cha, M. J., Lee, K. S., Lee, H. Y., Kwon, O. J., Choi, J. Y., … & Shim, Y. M. (2016). Prognosis in resected invasive mucinous adenocarcinomas of the lung: related factors and comparison with resected nonmucinous adenocarcinomas. Journal of Thoracic Oncology, 11(7), 1064-1073. Basit, A., Niazi, M., Malik, N., & Farooq, M. A. (2015). Diffuse Bronchioloalveolar Carcinoma with Nodular Pulmonary Metastases. Journal of Islamabad Medical & Dental College (JIMDC), 4(1), 35-36. Groheux, D., Quere, G., Blanc, E., Lemarignier, C., Vercellino, L., de Margerie-Mellon, C., … & Querellou, S. (2016). FDG PET-CT for solitary pulmonary nodule and lung cancer: literature review. Diagnostic and interventional imaging, 97(10), 1003-1017. Emami, M., & Kalantari, E. (2015). Case report of the bronchioloalveolar carcinoma. Advanced biomedical research, 4. Binesh, F., Pirdehghan, A., Mirjalili, M. R., Samet, M., Majomerd, Z. A., & Akhavan, A. (2015). Comparative assessment of the diagnostic value of transbronchial lung biopsy and bronchoalveolar lavage fluid cytology in lung cancer. Asian Pac J Cancer Prev, 16(1), 201-204. Zhang, L., Wu, N., Li, M., Sun, W., Lyu, L., Hou, D. H., & Lin, D. M. (2017). The correlation study of ground glass opacity and lepidic growth pattern component in stage I lung invasive adenocarcinoma. Zhonghua zhong liu za zhi [Chinese journal of oncology], 39(4), 269-273. DOI: 10.3760/cma.j.issn.0253-3766.2017.04.006 Karmakar, S., Naorem, R., Ansari, M. H., Neyaz, Z., Lal, H., & Nath, A. (2019). Bronchioloalveolar Carcinoma: A Case Series. The Journal of Association of Chest Physicians, 7(2), 66.;year=2019;volume=7;issue=2;spage=66;epage=69;aulast=Karmakar Hackett, N. J., De Oliveira, G. S., Jain, U. K., & Kim, J. Y. (2015). ASA class is a reliable independent predictor of medical complications and mortality following surgery. International journal of surgery, 18, 184-190. Yang, D., Grant, M. C., Stone, A., Wu, C. L., & Wick, E. C. (2016). A meta-analysis of intraoperative ventilation strategies to prevent pulmonary complications. Annals of surgery, 263(5), 881-887. De la Torre, M., Fernández, R., Fieira, E., González, D., Delgado, M., Méndez, L., & Borro, J. M. (2015). Postoperative surgical complications after lung transplantation. Revista Portuguesa de Pneumologia (English Edition), 21(1), 36-40. Murakami, N., Motwani, S., & Riella, L. V. (2017). Renal complications of immune checkpoint blockade. Current problems in cancer, 41(2), 100-110. Strand, T. E., Rostad, H., Strøm, E. H., & Hasleton, P. (2015). The percentage of lepidic growth is an independent prognostic factor in invasive adenocarcinoma of the lung. Diagnostic pathology, 10(1), 94.

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