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A4157 - The Initial Evaluation of a Newly Diagnosed Malignancy: A Diagnostic Dilemma
Author Block: S. Sama1, L. Delasos2, C. Mosebach3; 1Internal Medicine Residency Program, University of Connecticut, Farmington, CT, United States, 2Internal Medicine, UConn Health, Farmington, CT, United States, 3University of Connecticut, Farmington, CT, United States.
Introduction:Experts estimate that unnecessary medical tests and treatments cost approximately $200 billion annually. With the cost of healthcare reaching record levels, physician-centered cost consciousness is vital to reducing the economic burden of healthcare in the United States. The initial evaluation of newly diagnosed malignancy raises a financial and ethical dilemma in this era of cost conscious healthcare organizations. Should physicians initiate an extensive costly workup on hospitalized patients with a newly diagnosed malignancy in order to provide definitive pathological and anatomical diagnosis prior to discharge?Case Report:A 63-year-old male with a past medical history of retinal vein hemorrhage and nephrolithiasis presented to the hospital with a two week history of constipation and abdominal pain. The patient endorsed 30 pounds of unintentional weight loss over the last year as well as a 45 pack year smoking history. He reported having a negative colonoscopy 12 years ago. Due to the severity of his abdominal pain a CTA of his abdomen was performed, which was negative for occlusive thrombus but did reveal multiple hepatic lesions along with diffuse osteolytic lesions in the spine and pelvis. The patient was admitted and underwent an iliac bone biopsy, which led to the diagnosis of a high-grade neuroendocrine tumor with an unknown primary source. He was subsequently discharged from the hospital with instructions to follow-up with an Oncologist. Ten days later he presented to the emergency department with acute onset shortness of breath, hemoptysis, and epistaxis. CTA of the thorax was negative for a pulmonary embolism; however, it did identify a large mass involving the left suprahilar region. The primary source for his neuroendocrine tumor had been identified and the patient was given a new diagnosis of extensive stage small cell lung cancer.Discussion:This case highlights the importance of early diagnosis with anatomic and pathologic staging in all patients with newly diagnosed malignancy. Unfortunately, during the patient’s initial hospital admission he only received a CT of the abdomen and pelvis without further imaging to identify a primary source.An initial extensive workup in this case would have led to an early in-hospital diagnosis and initiation of treatment which could have potentially prevented this patient’s second hospital admission. As the cost of healthcare continues to increase, physicians will have to deal with the financial dilemma of when to order expensive tests on hospitalized patients and when to defer further evaluation until after discharge.