OS 213: Human Disease Treatment 3 (Circulation

and Respiration)
SGD 01: MALIGNANCY
Exam 3 | Med Onco Preceptors | August 23, 2012
OUTLINE
Case 1
Case 2
Case 3

Case 4
General Notes

CASE 1
R.S., 50, M
CC: Right lung nodule

o
o

HPI:
2 mo PTC
o CXR done for employment purposes revealed a
solitary pulmonary nodule measuring approx. 2 cm
o Px denied other symptoms except for an
occasional dry, non-productive cough
o diagnosed with PTB and was given anti-TB meds
regularly taken for 2 months
After 2 months
o repeat chest X-ray was done and revealed an
increase in the size of mass to 3cm
o chest CT scan revealed 3.5 x 2.8 cm enhancing
mass at SUPERIOR SEGMENT OF R UPPER LUNG.
o (-) enlarged peribronchial, hilar, mediastinal nodes
o still no other symptoms except for occasional dry
cough
PMHx: Unremarkable (U/R)
PSSx: (+) Smoking: 1 pack/day for 20 years (20 pack
years)
ROS: (-) anorexia, headache, weight loss, back pain,
hemoptysis
PE: (-) palpable lymph nodes, Clear lung fields, U/R
abdomen
Diagnosis
(Note from the transers: Case 1 contains all general data
applicable to lung malignancies. Italicized and underlined
phrases are applicable to Case 1.)

As with diagnosing any disease condition (in this case,

and in all other cases you will encounter), the most
crucial initial step is a thorough history and physical
examination.
By Hx:
Sx of lung cancer can arise from
1.Local mass effects and systemic effects

Symptoms related to tumor itself: hemoptysis and

chest pain

Constitutional non-specific symptoms such as:

anorexia, weight loss, fevers/night sweats

Tumor mass effects such as cough due to nerve

irritation, hoarseness due to compression of
recurrent laryngeal nerve, and facial/upper
extremity syndrome
2.Effects of metastatic disease

bone, pleura, brain, liver, and adrenal glands

3.Effects of products produced by the tumor
(paraneoplastic syndromes).
*Most lung cancers arise in patients with a long
smoking history; the symptoms of cough and dyspnea
are relatively non-specific.
However, an acute
change in previously stable symptoms can be a clue
to an underlying malignancy.
By PE:
Classic PE findings associated with lung CAs:

Horners syndrome (sympathetic ganglion

dysfunction with ptosis, miosis, enopthalmos and
anhydrosis)

CES, MIKKI, JOLO

A supraclavicular mass due to a Pancoast

tumor (apical tumor involving C8 and T1-2 nerves
causing shoulder pain radiating down to the arm)
SVC syndrome (upper extremity swelling with
or without facial swelling due to vascular obstruction)
Clubbing of fingers and adenopathy suggestive (but not pathognomonic) of an underlying
malignancy.
Table 1. Diagnostic Procedures
Chest X-Ray
tumor in the lungs
enlargement in the mediastinum
due to enlarged lymph node
opacity or white-out lung may
indicate presence of malignancy
or tuberculosis
other thoracic causes
Chest and
localizing tumors, especially
Abdominal CT
central masses not visualized in
Scan
chest X-ray
metastasis (if present)
commonly in the brain and
adrenal glands
determining the presence of fluid
assist in biopsy procedures (CT
GAB)
Positron Emission visualize tumors <1 cm in
Tomography
diameter, malignant lesions and
(PET) Scan
solitary pulmonary nodules
aid in staging mediastinal tumors
R/O active infection (also take up
glucose)
Expensive!
Usually
not
recommended
Bone Scan
detect bone metastasis/es
Magnetic
determine brain metastasis and
Resonance
spinal compression
Imaging (MRI)
rule out (R/O) Potts disease
Chest Ultrasound effusion
locate lung tumors
extent of tumor infiltration
guide needle during thoracentesis
or biopsy.
Histopathology detect cancer cells
special stains (acid fast) to R/O TB
Thoracentesis
drain fluid from pleural effusion
collect samples for histologic
exam,
presence
of
serosanguinous
fluid
is
indicative of malignancy and to
determine if the fluid is a
transudate or exudates
Fine Needle
To collect samples from the
Aspiration Biopsy
lesions that are too large to
(FNAB)
excise for cytologic evaluation
usually CT-guided
Bronchoscopy can also be used if
the lesion is centrally located.
Excision Biopsy if mass is not too large
Pleural Biopsy
samples from pleural tissue
Bronchoscopy
evaluate lung lesions (esp.
central)
investigate unexplained
hemoptysis or adventitious lung
sounds
obtain materials for microbiologic
studies

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OS 213: Human Disease Treatment 3 (Circulation

and Respiration)
SGD 01: MALIGNANCY
Exam 3 | Med Onco Preceptors | August 23, 2012
Mediastinoscopy Suprasternal approach to obtain
specimens from mediastinal
nodes
Thoracoscopy
visualizing and biopsy of pleural
and mediastinal nodes
Pulmonary
establish if dyspnea is cardiac or
Function Test
pulmonary in origin
(PFT)
R/O other differentials
CBC
establish if pallor is due to
anemia
determine the patients blood
type if transfusion is needed
(IMPORTANT Note: A patient who is male, >45 years old,
with history of smoking, presenting with a solitary pulmonary
nodule, should always be considered to have lung CA unless
proven otherwise.)

Staging
(Note: See the Lecture
Malignancies for this part.)

trans

on

Overview

of

Lung

Tumor tissue obtained:

By bronchial/transbronchial biopsy
during FOB
2.
By node biopsy during
mediastinoscopy
3.
From operative specimen at the time of
definitive surgical resection
4.
By percutaneous biopsy of enlarged
lymph node, soft tissue mass, lytic bone lesion, bone
marrow or pleural effusion
5.
By FNAB (CT Guided) Preferred for
this Px because of the peripheral location of the
lesion
6.
From adequate cell block from a
malignant pleural effusion
1.

TNM Classification: used in staging NSCLCs

Cancer Staging: Using the TNM guideline: T1 N0 M0
Stage IA
3.5x2.8 cm superior RUL, no note of enlarged
peribronchial, hilar or mediastinal nodes; But needs
other modalities to rule out possible metastasis
(Note: Patients usually come in late or advanced stages,
seldomly early)

Management
Counseling
together with the patients family
3Cs: Coping, Communicating, Connecting
ADVISE TO QUIT SMOKING!!!
Good balanced diet, exercise
Avoid cancer risks: asbestos, radiation
explaining his condition: natural history of the disease
(stage of his disease), prognosis, treatment options
Intervention Options
Surgery - considered if cancer is only small and
localized to one tumor nodule
o Pneumonectomy
o Lobectomy - preferred operation for SCLC
o Segmentectomy
Radiation Therapy - given in patient with SCLC in the
ff situations:

CES, MIKKI, JOLO

In combination with chemotherapy: treat the tumor

and lymph nodes in the chest; improve 3-year
survival rates, especially in patients less than 65
years old
o After chemotherapy: kill any small deposits of
cancer that may remain
Chemotherapy - main treatment for SCLC.
o

(Note: For more complete lists and details on the drugs

used by Lung Cancer patients, see the Lecture trans on
Overview of Lung Malignancies)

Targeted Therapy
Complementary Methods and Palliative Care
Given after chemotherapy sessions and throughout
treatment as an adjunct to therapy, or to reduce the
side effects.
Help the patient feel better and add to patient's
comfort
o Ex. meditation to reduce stress, acupuncture to
relieve
pain,
peppermint
tea
to
relieve
nausea, aromatherapy, massage therapy, yoga.
Pain medication, palliative care, symptomatic therapy
(for difficulty breathing, etc.) can also be given as
necessary.
Group Counseling/Therapy
Follow-Up
Check-up every 2mo post-treatment
CA patients should be educated about signs and
symptoms of recurrence and potential adverse
effects related to therapy
Monitoring with: CXR, Chest CTSc
Liver UTS every 6 months
Bone scan every year
Cranial CTSc if with frequent headache or signs of inc.
ICP
CASE 2
65, M, Filipino
CC: Cough, mild difficulty of breathing, and progressive
hip pain
HPI:
CXR revealed pulmonary mass at the R upper lung with
2 nodules on the L upper and mid-lung fields.
PMHx: U/R
PSSx: (+) smoking: 40 pack years
ROS: (+) facial swelling upon awakening, weight
loss, anorexia
(-) headache, abdominal pain, or hemoptysis
PE: 2x2 cm hard, fixed right supraclavicular node,
decreased breath sounds at the right upper lung field
with dullness to percussion, and occasional inspiratory
wheezing on all lung fields.
Diagnosis
Table 2. Differentials (Case 2)
Disease
Reason for R/I
SCLC
(+) Pulmonary
mass
(+) Cough
(+) Dyspnea
(+) Facial swelling
(plethora)
(+) Weight loss
Smoking hx: 95%

Reason for R/O

(-) ankle edema
(-) muscle
weakness
(-) polyuria,
polydipsia
Facial swelling
improves (in
small cell CA, it

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OS 213: Human Disease Treatment 3 (Circulation

and Respiration)
SGD 01: MALIGNANCY
Exam 3 | Med Onco Preceptors | August 23, 2012

NSCLC

(Squamous
cell)

Adenocarcino
ma

of CA associated
with a chronic
smoking Hx is
SCLC
Presence of
nodules at R and
mid-upper lung
field
Hard, fixed R
supraclavicular
node
(+) Pulmonary
mass
(+) Cough
(+) Dyspnea
(+) Facial swelling
(+) Weight loss
Smoking hx
Presence of
nodules at R and
mid-upper lung
field
Age, Sex
(+) Pulmonary

mass
(+) Cough
(+) Dyspnea
(+) Facial swelling
(plethora)

does not
improve due to
constant
hormone
production of
the tumor)

No reason to rule
out
yet
(histopathologic
examination
needed
for
differentiation)

Ancillary
Tests:
paraneoplasms

CES, MIKKI, JOLO

o
o

o
o
o

Adenocarcinoma,
although more
common than
squamous cell
CA, is more
prevalent in
women,
nonsmokers
Mass is central (vs.
Adenocarcinoma
which is more
peripheral)

mainly

Primary Working Impression: non small cell,

squamous cell lung CA
65 yo, M, Smoker, with Pulmonary Mass probably
malignancy!
Cough, dyspnea Common manifestation of
pulmonary disease; could be due to compression of
airway by a mass in this case
Facial swelling upon awakening Could be due to the
compression of the Superior Vena Cava (SVC
syndrome) by the mass on the right upper lung while
on supine position (sleeping)
Weight loss, anorexia Effect of cancer
Two nodules on L upper & mid lung field Metastasis
to the L lung
Hard, fixed R supraclavicular node Nodal metastasis
from R lung
Progressive hip pain Metastasis to the hip bone
Diagnostic Procedures
CXR and Chest CT Scan
Abdominal and Cranial CT Scan, Bone Scan:
detect metastasis
Biopsy: FNAB of the supraclavicular node,
Bronchoscopy of mediastinal lymph nodes (for
possible metastasis; the more specimens, the
better!)
PET scan: detects widespread metastases; but
again, expensive!
Sputum cytology: if (+), R/O head and neck
primary lesions

for

detection

Serum ACTH Cushingoid syndrome; R/O ACTHproducing small cell CA

Blood chemistry, ABG (to look for hypokalemic
alkalosis)
CBC
BUN-Creatinine Clearance: to check whether or
not the kidneys are competent to filter nephrotoxic
CA drugs (platinum waste)
Staging
T4N3M1 Stage IV Lung CA
T4 2 x 2 cm hard supraclavicular node
N3 involvement of mediastinal and contralateral
lymph nodes
M1 presence of metastasis to supraclavicular
node and hip
Very poor Prognosis
Median survival for untreated patients with Stage
IV bronchogenic CA:

4-6 months

5-year survival rate: 2%

Survival time impkroves with chemotherapy and
other targeted therapies
Management

Counseling
(see Case 1 > Management > Counseling)

Intervention Options
Symptomatic Management
o pain: give non-opioids first before moving on to
stronger drugs like morphine when the pain is
already unbearable
o cough (and hemoptysis): can be treated
pharmacologically
Palliative radiotherapy
o FOR: Bronchial obstruction with pneumonitis,
hemoptysis, upper airway or SVC obstruction brain
or spinal cord compression (important!), or
painful bony metastases.
o
It provides relief of intrathoracic symptoms:
o Hemoptysis (84%), SVC syndrome (80%), Dyspnea
(60%), Cough (60%), Atelectasis (23%), Vocal cord
paralysis (6%)
o Also for: cardiac tamponade, painful bony
metastasis, CNS compression, brachial plexus
involvement
Chemotherapy: Palliates symptoms, improves QOL, and
improves survival in newly-diagnosed patients
o First-line: Cisplatin or Carboplateine, Texane
(paclitaxel, docetaxel), Gemicitabine
o Second-line: Docetaxel or pemetrexed
Growth factor support is rarely needed
EGFR Targeted Therapy: Erlotinib (2nd or 3rd line)
o Prolong ssurvival, Second or Third line therapy
o Very expensive
Management for Bone Metastasis
o Radiotherapy
o Bisphosphonates: reduce secondary close, prevent
Complementary Methods and Palliative Care
(Note: In squamous cell lung CA, you will not give
Bevacizumab (which is an angiogenesis inhibitor) will
cause the patient to bleed out)

of

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OS 213: Human Disease Treatment 3 (Circulation

and Respiration)
SGD 01: MALIGNANCY
Exam 3 | Med Onco Preceptors | August 23, 2012
CASE 3
52, M
CC: non-productive, associated with back pain.

Pulmonary 10 pack-year
embolism
smoking
(+) unproductive
cough for 1 mo
(+) occasional
pleuritic chest
pain
(+) Hemoptysis
Pneumonia (+) unproductive
cough for 1 mo
(+) occasional
pleuritic chest
pain

HPI:
1 mo PTC
o Non-productive progressing cough, assoc. pleural
chest pain
10 days PTC
o (+) Hemoptysis, Fatigue, Anorexia
PMHx: U/R
PSSx: (+) smoking: 10 pack year
ROS: (+) 30 % weight loss; (-) headache, abdominal
pain, back pain
PE: Slightly cachexic, no palpable nodes, occasional
wheezing at all lung fields
CXR: Large bulky mass with hilar adenopathy
CT Scan:
3x5 cm tumor invading the R main bronchus, 3 cm
distal to carina
Atelectasis at hilar region
Enlarged ipsilateral hilar and mediastinal lymph nodes
Diagnosis
Table 3. Differentials (Case 3)
Disease
Reason for R/I
Reason for R/O
Bronchoge 10 pack-year
nic CA
smoking
(SCLC)
(+) unproductive
cough for 1 mo
(+) occasional
pleuritic chest
pain
(+) Hemoptysis
(+) Anorexia,
weight loss
(+) wheezing in all
lung areas on PE
Large bulky mass
with hilar
adenopathy on
CXR
3x5 tumor invading
R main bronchus
Enlarged ipsilateral
hilar and
mediastinal
lymph nodes
Atelectasis at hilar
region on CT
Pulmonary 10 pack-year
(-) night sweats,
Tuberculosi
smoking
fever
s
(+) unproductive
no tests done for
cough for 1 mo
AFB
smear/culture
(+) occasional
pleuritic chest
pain
(+) Hemoptysis
(+) Anorexia,
weight loss
Large bulky mass
with hilar
adenopathy on
CXR

CES, MIKKI, JOLO

(-) evidence of
effusion
(transudative or
exudative)
no reported
dyspnea

(-) no PE findings
of consolidation,
abnormal breath
sounds

Primary Working Impression: Small cell lung CA

Arises in peribronchial locations and infiltrate the
bronchial submucosa
Usually occurs in the big airways (hilar & central)
Very rapid progression and highly malignant
Smoking is a risk factor (as well as being male)
Common spread is to the mediastinal lymph nodes,
liver, bones, adrenal glands and brain
Diagnostic Procedures
CXR, CT Scan
Biopsy: Bronchoscopy with biopsy, CT scandirected needle biopsy, Endoscopic esophageal
ultrasound w/ biopsy, Mediastinoscopy w/ biopsy,
Open lung biopsy, Pleural biopsy

Ancillary Tests: CBC with platelet count,

Serum electrolytes, glucose, calcium, Liver Function
Tests (ALT, AST), Renal Function Test, ECG, Bone
Scan, PET Scan

Staging
TNM Classification is not used in staging SCLC. Instead,
we describe the malignancy as Limited or Extensive
Limited
o Limited to one side of the chest
o Can be treated with sufficient radiation therapy
o Prognosis: 20 months, 2-year survival rate of 25%,
5-year survival rate of 20%
Extensive
o Spread to other side and/or other distant organs
(including pleural/pericardial effusion or
hematogenous metastases)
o Prognosis: 12 months, 2-year survival rate of 4.6%
Confinement to one Hemithorax Limited-Stage
Disease
Management
Counseling
(see Case 1 > Management > Counseling)

Intervention Options
Chemotherapy:
o Etopside +cisplatin / carboplatin
o CRx doses may be adjusted on the basis of nadir
granulocyte counts
o Blood work +CBC is needed prior to each cycle of
chemotherapy to ensure marrow recovery before
the next dose of chemotherapy is administered.
o Serum LDH is a good marker for response and
should be monitored.
o Renal function should be monitored because of
nephrotoxicity from cisplatin.
o CT scans should be obtained after 2 cycles of
therapy to assess response (if afforded)

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OS 213: Human Disease Treatment 3 (Circulation

and Respiration)
SGD 01: MALIGNANCY
Exam 3 | Med Onco Preceptors | August 23, 2012
Radiotherapy
o In combination with Chemotherapy
o Main treatment for our case will consist of
combination Chemotherapy and chest irradiation
(etoposide plus cisplatin plus 45 Gy chest radiation
therapy).
o PROPHYLACTIC BRAIN RADIATION THERAPY
(PBRT)

Lung CA can metastasize to the brain around

60% of controlled lung CA

PBRT reduces the chance of metastasis to the

brain

Px should be advised of the possible cognitive

deficits as a result of PBRT
Supportive and Other Considerations: Antiemetics,
Fluid support with Cisplatin, Monitoring for blood
counts and blood chemistry, signs of bleeding and
infection, Possible Blood Transfusions for the
hemoptysis (if massive), Nutrition therapy for signs
of cachexia, Analgesics (for the pleuritic chest pain),
Cough
suppressants,
if
cough
becomes
uncomfortable, If required, use of hemopoietins
(treatment for anemia)
Complementary Methods and Palliative care
CASE 4
55, M
CC: Chronic cough and weight loss
HPI:
5 mo PTC: chronic cough and weight loss
PMHx:
Ischemic Heart Disease
diagnosed 2 years ago
Tx: isosorbide mononitrate and aspirin
No recent attacks of chest pain

PSSx: (+) smoking, alcohol (occasional)

ROS: (+) occasional hemoptysis, exertional dyspnea,

30% weight loss, anorexia, occasional right
sided pleuritic chest pain
(-) headache, back pain, facial swelling,
abdominal pain, orthopnea, and PND.

PE: pale palpebral conjunctivae, no palpable cervical

or supraclavicular nodes, decreased breath sounds at
the right upper lung fields with dullness to percussion
over said area, and an unremarkable abdomen.
CXR: (+) density at the right apex
Chest CT Scan: 5.5x6.8 cm mass with right perihilar
and subcarinal lymph node enlargement.
Diagnosis
Table 4. Differentials (Case 4)
Disease
Reasons for R/I
Reasons for R/O
NSCLC (+) chronic cough
No reason to rule
(squamous (+) worsening or
out yet
cell CA)
(histopathologic
new dyspnea
al examination
(+) weight loss
of biopsy
(+) hemoptysis
sample needed)
(+) pleuritic pain
(+) decreased
breath sounds;
dull on percussion

CES, MIKKI, JOLO

Cachexia and
weight loss
suggest systemic
spread
Subcarinal and
perihilar
lymphadenopathy
(bronchogenic
CA)
Small cell (+) chronic cough
Usually presents
lung
with central
(+) worsening or
carcinoma
endobronchial
new dyspnea
(SCLC) (+) weight loss
tumor
(-) headache upon
(+) hemoptysis
consult
(+) pleuritic pain
(+) decreased
breath sounds;
dull on percussion
Cachexia and
weight loss
suggest systemic
spread
Pulmonary Smoking hx
(-) night sweating
Tuberculosi (+) cough,
(-) orthopnea,
s
hemoptysis
PND
(+) chest pain
(+) weight loss,
anorexia
(+) perihilar and
subcarinal
lymphadenopathy
(remember
Rankes complex)
Primary Working Impression: Squamous Cell
Carcinoma
Presence of respiratory symptoms due to a possible
lung tumor (cough, dyspnea, hemoptysis - possible
rich blood supply of tumor)
decreased breath sounds at the right upper lung fields
with dullness to percussion
Signs suggesting the presence of a malignancy: weight
loss, anorexia, lymphadenopathy
Imaging studies reveal a mass at the right apex
History of smoking
To rule in: PTB (difficult to rule out unless patient is
asked to have sputum AFB and/or culture)

Diagnostic Procedures
CXR, CT Scan
PET Scan, Cranial and Abdominal CT or MRI,
Bone Scan, CT Scan for Adrenals
CBC with platelet count: check for hemodynamic
stability
o patient presented with pale conjunctive and
hemoptysis, which is not yet quantified.
o Px may present with a bleeding mass due to the
high vascularity of a carcinoma.
Biopsy
Sputum Cytology/Examination if its squamous
cell CA, it is likely that it will be detected using this
procedure
Ancillary tests
Staging
T2bN2M0 Stage IIA
o T2B: Tumor is >5 cm, does not directly involve
carina; invades visceral pleura

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OS 213: Human Disease Treatment 3 (Circulation

and Respiration)
SGD 01: MALIGNANCY
Exam 3 | Med Onco Preceptors | August 23, 2012
o
o

N2: metastasis to ipsilateral mediastinal and/or

subcarinal lymph nodes
M0: no distant metastasis (based on PE findings;
ideal = radiographic image of lymph nodes)
Management

Counseling
(see Case 1 > Management > Counseling)

Intervention Options
Surgical resection with lymph node dissection
o may have poor results because of node
involvement
o Some oncologist conclude that surgery should only
be conducted in patients who have clearing of the
mediastinal nodes after adjuvant therapy
Chemotherapy followed by Radiation Therapy (Tx
of choice)
o Cisplatin-based combination (with etoposide)
o Improved survival compared with sequential
therapy but more side effects such as fatigue,
esophagitis and neutropenia
Supportive Therapy: Pain relief, Emesis therapy,
Ondansetron, Prochloroperazine, Dexamethasone,
Nutritional intervention
Complementary Methods and Palliative Care
GENERAL NOTES
On History and PE:
Getting a good history and PE is important since
most CAs metastasize to the lungs. For women, usually
comes from breast cancer, and for men, rectal cancer.
Before doing treatment for Lung CA, always check for
CA in other locations.

On Doing a Biopsy
Do a biopsy to check for possible malignant cells
then classify what type of cancer; always opt for the
most accessible biopsy (e.g. lymph node)
FNAB
CT-guided biopsy (CT GAB): for peripheral masses
Bronchoscopy-guided biopsy: for central (hilar or
mediastinal) masses
VATS as a last resort if you're absolutely positive that
there's a malignancy but other the methods have
failed to give a positive result
On Staging and Treatment:
Stage dictates treatment
Stage 1: Surgery then chemo (Don't do radio)
Stage 2: Surgery
Stage 3A: Chemotherapy then surgery
Stage 4: Chemotherapy and Radiotherapy;
palliative

On Other diagnostics:
Do a brain CT scan for small cell carcinoma because it
is very malignant

CES, MIKKI, JOLO

Sputum cell cytology is seldom used as a diagnostic

measure; do biopsy instead
On Patient Workups:
Before doing biopsies, do PT, PTT test to see if there
are any bleeding disorders
Must have cardiopulmonary clearance (ECG, etc.)
before having a bronchoscopy
Platinum-containing anti-cancer drugs are nephrotoxic
(also hepatotoxic) - check kidney function via
BUN/Creatinine
CBC is done to see if the patient has recovered from
chemotherapy
On Other Treatment:
Chemotherapy and Radiotherapy requires good
performance status (i.e. children) otherwise the
patient might die from the treatment
Erythropoietin transfusion can increase the risk of
stroke and ischemia if given at the wrong dose.
Proper regimen is high dose erythropoietin once a
week.
Combine chemotherapy with other forms of therapy
like anti-angiogenesis drugs and radiotherapy, etc.
Leads to a better outcome
Others:
Sarcoidosis is rarely a viable differential in the
Philippines
Always get a good history; the lung malignancy might
only be secondary
END
Ces: Here it is, from 9 pages of pure redundancy,
tenen! Haay. Antoxic tuloy magreorganize. Tinoxic ko
rin yata ang sarili ko sa pag-aayos ng isang trans na
hindi naman babasahin ng mga tao. T___T Sana ganito
pa rin ung cases sa future, para purposeful naman ang
pagpapaka-OC ko sa trans na to. Haha. Kung hindi,
ohwell.
At dahil smileys na lang ang greetings nina Mikki at
Jolo, uubusin ko na lang ang space na to. Not. Kalahati
na lang siguro.
Hello Block B! Kumusta naman ang weekly transing
natin?
Hello 2016! 2nd place ang EPIMERS sa FATE! XVI:
Walang Kapantay!
Hello Medchoir 2016! Fun fun fun (and eat eat
EAAAAT!) in San Juan! Sana next time makapunta na
tayong lahat for more chikahan. Hahaha! Mag-ipon na
lang muna tayo ng mga ala-The Buzz na mga tanong
sa ngayon. ;)
Mikki, Jolo:

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