An Unusual Presentation of Adenocarcinoma of the Lung

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SESSION TITLE: Global Case Report Poster - Lung Cancer SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Lung cancer is the most common type of cancer. Adenocarcinoma occupies approximately %50 in all lung cancer. Adenocarcinomas present as peripheral nodules or masses often with pleural involment. They can present radiologically as a single mass or a diffuse, multi-nodular lesion. It is rare for the non-small cell carcinoma (adenocarcinoma) of the lung to present as miliary mottling (1). Miliary tuberculosis, sarcoidosis, silicosis, pneumoconiosis, varicella infection, histoplasmosis, hemosiderosis demonstrate miliary mottling on chest radiography (2,3). Milliary mottling is seen most frequently in adenocarcinoma (4). CASE PRESENTATION: A 80-year-old female patient, with diabetes mellitus, hypertension, cholelithiasis, coronary artery disease, presented with a history of cough, sputum, weight of-loss, dyspnea, weakness of 1 month duration. Physical examination and laboratory tests were normal. Her chest radiograph demonstrated miliary mottling. In the preliminary diagnosis, miliary tuberculosis was thaught, because tuberculosis incidence is very high in Turkey. Three samples of sputum for AFB and PPD test showed negative results,3 cm nodular lesion at left lower lobe and bilateral multipl nodules were seen in thorax CT. There was no endobronchial lesion in fiberoptic bronchoscopy. Transthoracic biopsy was performed and the histopathological examination revealed Adenocarcinoma. PET/CT was done for disease staging. In PET/CT, multiple intracranial metastases, 20x18mm nodule with high FDG uptake (SUVmax:6.53) at the lower lobe of left lung and multiple nodular lesions maximum size of 1 cm (SUVmax:3.04) in both lungs were seen. Then the patients was considered as T1N3M1B stage 4 disease. 6MV photon cranial radiotherapy was applied for intracranial metastasis. Test for EGFR-ALK mutation was performed; EGFR mutation gene sequencing identified a deletion in exon 19 and ALK was negative. Erlotinib treatment was given. Total survey of the patient was 6 months. DISCUSSION: Milier nodules are oval or round shaped 0.1-1cm nodules and are seen in chest rediography when they reach to the size of 2-3mm (3,4). Miliary mottling on chest radiography is seen in miliary tuberculosis, sarcoidodosis, silicosis, pneumoconiosis, varicella infection, histoplasmosis and hemosiderosis. Adenocarcinomas with miliary mottling consists of %1 of all lung cancers and are seen mostly in non smoking patients (3). In differential diagnosis, sputum AFB should be done as tuberculosis is highly seen in our country. TTFNAB and FOB tests are used in the diagnosis. Chemotherapy and radiotherapy are used in the treatment and EGRF-ALK mutation tests are done for evaluation of treatment choice in such patients(5). CONCLUSIONS: Miliary mottling in lung can be a sign of many diseases and differential diagnosis is very important for treatment decision. Reference #1: 1. Rabia Ergelen, Nuri Cagatay Cimsit Akciğer Tümörleri Marmara Universitesi Pendik Eğitim ve Arastirma Hastanesi, Radyoloji Anabilim Dali, Istanbul, Türkiye 2. Jayaram Subhashchandra B1, Ismailkhan M, Chikkaveeraiah Shashidhar K, Gopalakrishna Narahari M. A rare case of non-small cell carcinoma of lung presenting as military mottling Iran J Med Sci. 2013 Mar;38(1):65-8 Reference #2: 3. Nay Min Tun, MD* and Vijay Mattoo, MD Miliary Mottling on Chest X-ray: An Unusual Presentation of Adenocarcinoma of the Lung The American Journal of medical sciences Volume 34, Issue 4, April 2015, pages e4 4. Saleem A1, Thomas EC, Wilkinson A, Azher M, Saleem N Bilateral miliary shadowing on chest X-ray J Coll Physicians Surg Pak. 2013 Dec;23(12):902-3. doi: 12.2013/JCPSP.902903 Reference #3: 5. Schaller A1, Beau-Faller M2, Mennecier B1, Renaud-Picard B1, Weingertner N3, Massard G4, Quoix E1 Lung Adenocarcinoma with Pulmonary Miliary Metastases and Complex Somatic Heterozygous EGFR Mutation Case Rep Oncol. 2014 Nov 19;7(3):769-73. doi: 10.1159/000369526 DISCLOSURE: The following authors have nothing to disclose: Filiz Cimen No Product/Research Disclosure Information