60 year old woman presents with acute shortness of breath. She also endorses hoarseness, chest discomfort, cough, and increasing sputum production over the past 6 months. She denies any chest pain, hemoptysis, fever, chills, night sweats, weight loss. She endorses significant secondhand smoke exposure for the past six years.
Chest x-ray performed one month ago did not reveal any abnormalities. She was diagnosed with a URI and treated with two courses of antibiotics at the time.
Vital Signs: BP 140/89, HR 93, RR 22, T 99.5
Gen: Alert and oriented female in no acute distress.
HEENT: Normal with no lymphadenopathy noted
Lungs: Clear to auscultation bilaterally. No wheezing, ronchi, rales
CV: Normal S1, S2. No murmurs, rubs, gallops.
Abd: Nontender, nondistended. Normal active bowel sounds.
Neuro: 5/5 strength, no sensory deficits
-WBC 13.9 (90.8% neut), Platelets 497
-Aspartate Aminotransferase (AST) 36
â€˘CXR: New bandlike area of opacification in the left upper lobe, not seen on previous exam.
â€˘CT chest w/ contrast: Large aggregation of mediastinal adenopathy involving left and right paratracheal, subcarinal, prevascular, aortic window, and left hilar nodes. There is partial obstruction of the left main stem bronchus and at the carina, likely representing peribronchial invasion. There is a significant mass effect on the left pulmonary artery and left subclavian vein, with possible invasion. In the left upper lobe there is a 2 cm spiculated focus of consolidation.
In the right hepatic lobe of the liver, near the dome, there is a 1.2 x 0.8 cm area of low attenuation. Within segment 2 of the liver a 2.2 x 3.5 cm hypoattenuating lesion demonstrates peripheral enhancement. A similar lesion is seen in segment 8 of the right lobe, measuring 1.2 x 2.4 cm.
There is a low-attenuating pericardial effusion.
â€˘Primary Lung Cancer
â€˘Metastatic cancer to the lung
The patient will need a PET or CT to complete her metastatic workup. Palliative external beam radiotherapy can be utilized for local tumor control, and to reduce her symptoms. Subsequent systemic chemotherapy will be required.
Based on the findings of the CXR there was a broad differential to consider. It appeared as if there were a single nodule, which could be caused by a number of benign processes as well as malignancy. However, when a CT scan was obtained it showed that the diagnosis was most likely not benign. Not only did it show additional tissue involvement, it revealed an invasive process with lymphadenopathy. While the AST elevation may not have been impressive, the presence of multiple nodules that appeared similar in density to the pulmonary process must bring to mind malignant metastases.
Given this patient's age and exposure to smoke, lung cancer should be at the top of the differential. Her new cough and SOB signaled the increasing amount of pulmonary invasion. The hoarseness she was experiencing could be explained by involvement of the recurrent laryngeal nerve as it hooks around the aortic arch. In addition leukocytosis and thrombocytosis can be seen with lung cancer. While the exposure to smoke and predominately central pulmonary involvement might make you favor small cell or squamous cell carcinoma, this patient actually had atypical adenocarcinoma. Adenocarcinoma of the lung is the most common histologic type of lung cancer.
Lung cancer has surpassed breast cancer in becoming the leading cause of cancer death in women. Adenocarcinoma accounts for 30-40% of lung cancers and is the most common histologic type. It is also the most common type of lung cancer in non-smokers (an estimated 10-15% of patients diagnosed with lung cancer are non-smokers). The most common sites of distant metastases are the brain, bones (most commonly vertebrae), liver, adrenals, and skin. The American Thoracic Society recommends measurement of a CBC, serum electrolytes, calcium, alkaline phosphatase, albumin, AST, ALT, total bilirubin, and creatinine in all patients with lung cancer. Abnormal LFTs should be followed up with a contrast-enhanced CT of the liver, and an elevated alkaline phosphatase or calcium level should be followed up with a bone or PET scan to detect metastases (there is conflicting evidence as to which imaging modality has greater sensitivity). With regard to monitoring response to therapy, one study reported that changes in FDG uptake on PET scan rather than changes in lesion size on CT more accurately correlates with response to therapy. Stage IV disease is primarily managed with chemotherapy or with palliative measures for symptomatic relief, and the five year survival rate is less than 5%.
Systematic screening for lung cancer is not currently recommended by any major medical organizations. The USPSTF concluded that there is currently insufficient evidence to argue for or against screening asymptomatic individuals for lung cancer with either chest x-ray, low dose computerized tomography, sputum cytology, or a combination of these tests. Studies evaluating the benefits of screening have shown increased detection of early stage lung cancer in asymptomatic individuals but have not shown a reduction in mortality. The Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial is an ongoing trial evaluating the use of a single posterior-anterior CXR, and the Early Lung Cancer Action Project is currently evaluating the use of low-dose spiral CT for screening.
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