Mr. Eberly follows up with his doctor, who explains these test results to him and that he recommends do a test today.
A blood sample is sent and returns with this value:
The doctor calls Mr. Eberly and tells him he needs to pick up a prescription for a medication that he will take at 11 pm and then get his blood drawn at 8 pm prior to taking the medication that night and again at 8 am the next morning. He emphasizes that the time to take the medication and to get the blood drawn are critically important and that the test will not be useful if there is a problem with taking the medication or getting the test done. Mr. Eberly assures the doctor he will follow directions and be at the lab in time in the evening and the morning. They plan for an office appointment on June 8th to discuss results and next steps.
The doctor shows Mr. Eberly the test results, below:
|8 pm prior to taking medication||Serum free cortisol||497 pg/mL|
|8 am after medication taken at 11:30 pm||Serum free cortisol||512 pg/mL|
He explains the significance of these results to Mr. Eberly and they talk about the possible causes of this problem given the information so far. The doctor discusses several options, including a referral to an endocrinologist for further workup of this problem. He also recommends an x-ray of the chest due to Mr. Eberly’s smoking history and a referral for a screening colonoscopy, since it is overdue. A chest x-ray ordered the same day shows:
When Mr. Eberly’s physician sees the chest x-ray result, he calls the patient and arranges for a CT of the chest, which demonstrates a 7x5 cm mass surrounding the aorta and pulmonary artery.
His biopsy is shown below, with immunohistochemistry staining on the right that is positive for ACTH production by the tumor. The pathologic diagnosis of the lung mass was small cell carcinoma. Mr. Eberly is started on a medication to decrease the symptoms and physiologic consequences of his hormonal disorder as he gets ready for definitive cancer treatment.