METASTATIC CAVITARY ADENOCARCINOMA OF THE LUNG IN A PATIENT WITH RECENT AGGRESSIVE SQUAMOUS CELL CARCINOMA OF THE CHEST WALL

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Simultaneous existence of two histologically different primary malignancies, although rare, has been reported in literature1. This represents a diagnostic dilemma especially when the first detected primary malignancy is aggressive, therefore, the second primary is often deemed to be a metastatic lesion, until proven otherwise on biopsy. We present a case of a 62 year old male, with a recent aggressive squamous cell carcinoma (SCC) of the chest wall, who developed metastatic cavitary adenocarcinoma of the lungs. CASE PRESENTATION: A 62-year old gentleman, with past medical history significant for basal cell carcinoma of the nose and a recent aggressive SCC of the chest wall, status post Mohs surgery, was referred to the outpatient pulmonology clinic after a CT scan of the chest showed persistent dense consolidation of the left upper lobe, multiple bilateral lung nodules with central necrosis and cavitation, and left sided hilar and mediastinal lymphadenopathy. He presented with low-grade fever and a productive cough, unresponsive to antibiotics, for the past three weeks prompting the CT scan of the chest. Diagnostic work-up, for infection (including fungal studies), vasculitis or any other autoimmune disorder, was started and urgent bronchoscopy was arranged. PET/CT scan showed a hyper-metabolic left upper lung mass, multiple hypermetabolic cavitary lung lesions. Bronchoscopy with endobronchial ultrasound revealed a reversible external compression of the right middle lobe bronchus with mediastinal lymphadenopathy. Bronchoalveolar lavage from the left upper lobe showed atypical cells, suspicious for malignancy while negative for fungal organisms. Fine needle aspiration of lymph nodes, station 7 and 4L, revealed non-small cell carcinoma with tumor cells being positive for CK-7 and TTF-1 and negative for CK20, CDX-2 and NKX3.1. With the recent aggressive SCC history and multiple cavitary lung lesions, biopsy of one of the cavitary lesions was recommended by the tumor board, to determine if they were SCC vs adenocarcinoma. Results of the biopsy were consistent with an invasive lung adenocarcinoma. DISCUSSION: Cavitary lesions shown on chest imaging can have several etiologies. Although various radiological features of these cavitations, including wall thickness, have been studied to differentiate benign from non-benign etiologies2, the final diagnosis in many instances is made on serological investigations or biopsy. 22% of primary lung cancers can cause cavitation with squamous cell carcinoma being the most common type of lung cancer associated with cavitary lesions followed by adenocarcinoma and large cell carcinoma3. CONCLUSIONS: Our case emphasizes that cavitary lesions on imaging, in patients with a prior history of malignancy, should prompt investigation for possible malignancy. Early biopsy, in such cases, becomes crucial for a timely and accurate diagnosis, and appropriate management. Reference #1: Jena A, Patnayak R, Lakshmi AY, Manilal B, Reddy MK. Multiple primary cancers: An enigma. South Asian J Cancer. 2016;5(1):29-32. Reference #2: Parkar AP, Kandiah P. Differential Diagnosis of Cavitary Lung Lesions. Journal of the Belgian Society of Radiology. 2016;100(1):100. DOI: http://doi.org/10.5334/jbr-btr.1202. Reference #3: Gill, R. R., Matsusoka, S. & Hatabu, H. Cavities in the lung in oncology patients: imaging overview and differential diagnoses. Applied Radiology 39, 10 (2010). DISCLOSURES: No relevant relationships by Huthayfa Ateeli, source=Web Response No relevant relationships by Mahum Shahid, source=Web Response