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Abstract

Case Reports: Tension pneumothorax is a rare complication of lung cancer. We describe a geriatric patient who was diagnosed with non-small cell lung carcinoma (NSCLC) after initially presenting with an acute spontaneous tension pneumothorax. A 70-year-old male presented with progressive dyspnea over a four hour time span. His past medical history was significant for asthma, chronic obstructive pulmonary disease (COPD) and a 55-pack-year smoking history. Physical examination revealed an elderly male in severe respiratory distress. He was tachycardic, hypotensive with a respiratory rate of 28 per minute and oxygen saturation of 82% on room air. Lung examination was consistent with right sided pneumothorax. Immediate needle decompression was performed with improvement in vital signs. Chest radiograph showed right upper lobe (RUL) collapse and ipsilateral pneumothorax. Chest computerized tomography (CT) scan revealed a 4 cm mass in the RUL with perihilar lymphadenopathy. Bronchoscopy-guided biopsy confirmed the diagnosis of NSCLC. Bone scan showed metastatic spread to the sternum and ribs. Chemotherapy with palliative radiation resulted in partial re-expansion of the right lung. He was discharged with an indwelling pleural catheter after 31 days of hospitalization. Spontaneous tension pneumothorax as an initial presentation of lung cancer is rare and carries a poor prognosis due to advanced tumor spread. Approximately 2% of all spontaneous pneumothoraces are associated with lung cancer. This complication ought to be considered in older patients. Proposed theories for malignancy causing pneumothorax include formation of a bronchopleural fistula due to tissue necrosis, rupture of a subpleural malignant nodule, direct pleural invasion, rupture of bulla from chronic lung disease, post radiotherapy or cytotoxic chemotherapy and a check valve phenomenon where tumor obstructs bronchioles and cause alveolar overdistension and rupture. In conclusion, spontaneous pneumothorax can be encountered in the setting of chronic lung disease. However, in the absence of obvious clues, occult lung cancer should be considered as a possible etiology, especially in heavy smokers and the elderly.