Non-small Cell Carcinoma Of The Lung Research Articles

A rare case of pulmonary endobronchial spindle cell carcinoma with liver metastasis along with concurrent cutaneous neurofibroma

Spindle cell carcinoma is one of the histological variants of pulmonary sarcomatoid carcinoma. It is a rare, poorly differentiated, highly malignant, and rapidly growing non-small cell carcinoma of the lung. Information about pulmonary spindle carcinoma incidence, clinical features, and immunohistochemical markers are not well known compared to other variants of sarcomatoid carcinoma. Most sarcomatoid carcinoma features mimic non-small cell carcinoma, so it is easily misdiagnosed. Cutaneous neurofibroma with primary lung spindle cell carcinoma has not been reported in any previous literature. Here we report a rare endobronchial sarcoma with liver metastasis and concurrent skin neurofibroma.

Pathologic Nodal Staging Before SBRT for Early-stage NSCLC Does Not Impact Overall Survival: A Propensity Score-matched NCDB Analysis.

Stereotactic body radiation therapy (SBRT) for early-stage non-small cell carcinoma of the lung (NSCLC) is increasingly utilized. We sought to assess overall survival (OS) for early-stage NSCLC patients receiving SBRT depending on staging method. Early-stage NSCLC patients treated with definitive SBRT were identified in the National Cancer Database (NCDB), and OS was determined based on method of staging. Patient, disease, and treatment characteristics were also analyzed. A total of 12,106 patients were included; 865 (7%) received invasive staging (nodal sampling, NS) and 11,241 (93%) had no nodal sampling (NNS). From this larger dataset, a propensity score matching (1:1 without replacement) was performed, which yielded 839 patients for each group (NNS and NS). With a median follow-up time of 3.12 years, median survival for all patients included in the matched dataset was 2.75 years (95% CI: 2.55-2.93y), with 2- and 5-year OS estimated at 63.9% and 25.7%, respectively. In a multivariable analysis on matched data, there was no difference in mortality risk between the NNS and NS groups (hazard ratio=1.08, 95% CI: 0.94-1.24, P =0.25). Negative prognostic factors identified in the multivariable analysis of the matched data included: age more than 65, male sex, Charlson-Deyo Score ≥1, and tumor size ≥3cm. SBRT use in early-stage NSCLC steadily increased over the study period. Most patients proceeded to SBRT without nodal staging, conflicting with National Comprehensive Cancer Network (NCCN) guidelines which recommend pathologic mediastinal lymph node evaluation for all early-stage NSCLC cases, except stage IA. Our findings suggest similar OS in patients with early-stage NSCLC treated with SBRT irrespective of nodal staging. Furthermore, we highlight patient-related, disease-related, and treatment-related prognostic factors to consider when planning therapy for these patients.

SDPS-42 METASTATIC NON-SMALL CELL LUNG CANCER (NSCLC) AND BRAIN EDEMA: A TOPOGRAPHICAL AND CLINICOPATHOLOGIC INVESTIGATION

Abstract Tumor-associated vasogenic brain edema is a well-known contributor of morbidity and mortality in patients with metastatic disease to the brain. It is widely accepted that metastatic disease to the brain is associated with extensive edema and can cause increased symptomatology such as pain, neurologic deficit, and elevated intracranial pressure depending on extent and location. We present a retrospective artificial intelligence (AI) mediated analysis of radiological and clinicopathologic data including specific molecular markers, presenting symptoms, and tumor location of 86 patients with non-small cell carcinoma of the lung (NSCLC) and brain metastases who underwent surgical resection and were not previously on steroids. We found that overall, tumors in all locations demonstrated a mean 10:1 edema to tumor ratio (ETR) and an occipital tumor location was associated with a significantly elevated ETR. Within our cohort there were no other factors that were significantly associated with ETR. This study demonstrates a proof of concept that NSCLC is associated with significant peritumoral edema and that topographical factors may be associated with increased extent of edema.

Multiplying Brown Spots.

Bilateral diffuse uveal melanocytic proliferation (BDUMP) is a paraneoplastic syndrome affecting the eye that is a sign of poor prognosis of underlying malignancy.This is the first documented case to show serial and sustained improvement of BDUMP following immunotherapy in the setting of primary non-small cell carcinoma of the lung. A 65-year-old man reported a gradual decrease in vision and floaters in the right eye after cataract surgery. Fundus examination demonstrated diffuse multiple brown subretinal lesions bilaterally. Next generation sequencing of melanocytic tissue of the patient described in this case revealed a specific RB1 c.411A>T (p.Glu137Asp) variant with an allele frequency of 44.8%, consistent with heterozygosity. Plasma samples from the patient and a control patient with no history of cancer and/or paraneoplastic syndrome were cultured with neonatal melanocytes, which revealed a greater than 180% increase in proliferation of normal neonatal melanocytes compared to the control. Pembrolizumab therapy was initiated which resulted in shrinkage and stabilization of the lesions documented in serial diagnostic testing. In conclusion, we report a cytologically and serologically confirmed case of BDUMP in a patient with a primary non-small cell carcinoma of the lung. Next generation sequencing of melanocytic tissue of the patient described in this case revealed a specific RB1c.411A>T (p.Glu137Asp) variant with an allele frequency of 44.8%, consistent with heterozygosity. Furthermore, we show documented serial improvement in the patient's ocular and systemic disease with treatment. This case as one of the longest surviving confirmed cases of a patient with BDUMP.

Two Cases of Anti-PD1 Antibody Associated Neurological Immune-Related Adverse Effects (P5-4.001)

<h3>Objective:</h3> We present two cases of neurological immune-related adverse events (irAEs) indefinitely triggered by pembrolizumab. <h3>Background:</h3> Recently, immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy. Programmed cell death protein 1 (PD-1) is a key immune checkpoint receptor expressed by activated T cells. PD-1/PD-L1 antibody therapy is used to treat multiple malignancies; however, it has been associated with an increasing number of irAEs. Neurological irAEs are highly significant complications of ICI therapy that can cause long-term disability and death. Most commonly, neurological irAEs are neuromuscular complications and occur within 4 months after immunotherapy initiation. The anti-PD-1 agent pembrolizumab is currently approved for treatment of several tumors and has been used increasingly due to its more favorable toxicity profile. <h3>Design/Methods:</h3> NA <h3>Results:</h3> NA <h3>Conclusions:</h3> <h3>Case 1:</h3> Our first case is an 84-year-old man with a history of metastatic colon cancer that was treated with pembrolizumab. This is thought to have elicited myositis with elevated CK as well as acetylcholine receptor antibody-positive myasthenia gravis, causing him diffuse and debilitating weakness and functional limitation. He had multiple exacerbations of these symptoms temporally associated with pembrolizumab administration. With the initiation of maintenance treatment and the cessation of pembrolizumab, he required no further admissions for neurologic irAEs, but ultimately he was transitioned to hospice care for cancer progression. <h3>Case 2:</h3> A 65-year-old man with a history of non-small cell carcinoma of the lung on pembrolizumab and zoledronic acid presented with altered mental status and agitation. He had mild pleocytosis on CSF, MRI brain with left mesial temporal T2 FLAIR hyperintensity and nonspecific encephalopathy markers on continuous EEG. He subsequently had complete recovery with IV high-dose steroids followed by plasmapheresis. His symptoms were therefore suspected to be secondary to autoimmune encephalitis elicited by pembrolizumab administration. His oncologist elected to transition to another treatment regimen, and he has had no relapses to date. <b>Disclosure:</b> Ms. Vitek has nothing to disclose. Dr. Hansra has nothing to disclose.

ODP170 Check Point Inhibitor Associated Multi-Endocrine Dysfunction Presenting With Euglycemic Ketoacidosis

Abstract Introduction Immune check point inhibitors have become breakthrough therapy for many types of cancers. They inhibit one of two immune regulatory pathways, the cytotoxic T-lymphocyte antigen 4 (CTLA-4), and 'programmed death-1' (PD-1) and (PD-L1) pathways. Removing immune regulation allows for anti-cancer immune responses. They also cause immune related endocrine dysfunction such as hypophysitis, thyroiditis, diabetes mellitus (DM) and primary adrenal insufficiency (AI). We describe a patient on Pembrolizumab (PEM) (an anti-PD-1 inhibitor) who presented with new onset DM, euglycemic diabetic ketoacidosis (DKA) with simultaneous secondary AI. Case report 54-year-old woman with stage 4 non-small cell carcinoma of the lung (NSCLC) with known brain metastasis, was under therapy with carboplastin, paclitaxel and PEM, presented with headache, blurry vision and altered mental status. She had past history of Graves’ disease s/p radioactive iodine therapy, currently on levothyroxine. For two weeks, she had decreased oral intake, and generalized weakness. Upon presentation, she was cachectic, BP 152/65, pulse 117 and confabulating. Laboratory evaluation showed: serum glucose 72 mg/dL, Na 139 mmol/L, K 3.2 mmol/L, Cl 113 mmol/L, HCO3 11 mmol/L, anion gap 15 mmol/L, beta-hydroxybutyrate 4.8 mmol/L, lactic acid 0.7 mmol/L, venous pH 7.2 and base excess -16.6 mmol/L. The delta-delta gap was 10 mmol/L, compatible with a mixed anion-gap and hyperchloremic acidosis (HCA). Antibodies to GAD-65, and Zinc transporter-8 were negative. To evaluate euglycemia despite DKA, levels were obtained for serum cortisol 1 mcg/dL, and ACTH &amp;lt;1 pg/mL confirming secondary AI. MRI neuroimaging showed several metastatic brain lesions, a small pituitary gland without stalk enhancement or thickening. Management of euglycemic ketoacidosis required high dose glucose infusion (&amp;gt;10 g/hour), stress doses of hydrocortisone (HC), and infusion of low chloride solute for HCA. Conclusion Awareness of the potential for multi-endocrine dysfunction, directed us towards the urgent institution of therapy for DKA with supplementation of stress dose HC for presumed AI, the latter as a cause of relative "hypoglycemia". Central AI was confirmed with undetectable levels of cortisol and ACTH. Although less frequent than with CTLA-4 inhibitors, PD-1 inhibitors are associated with hypophysitis even without abnormalities on pituitary MRI. The DM (associated with PD-1 inhibitors) although autoimmune is nature, is "antibody" positive approximately 50% of the time. Further therapy for both euglycemic DKA and HCA required adjustment of the conventional management for DKA. To our knowledge this is the first reported case of Euglycemic DKA and secondary AI due to PD-1 inhibitors per literature review. Reference: Walters AGB, BraatvedtG G. Endocrine adverse effects of immune check point inhibitors . Intern Med J. 2021Jul;51(7): 1016-1020. doi: 10.111/imj . 14992. PMID: 34278695. Hattersley R, Nana M,Lansdown AJ. Endocrine complications of immunopathies: a review . ClinMed(Lond).2021 Mar;21(2): e212-e222. doi: 10.7861/clinmed.2020-0827. PMID: 33762389;PMCID: PMC8002767 Presentation: No date and time listed

Lung Cancer: Solitary Pulmonary Nodule

A 55-year old, middle-aged man, known for hypertension and dyslipidemia, presented to the OPD with complaints of fever along with a mild dry cough. There was no shortness of breath or chest pain associated with the patient’s complaints. Therefore, as a seemingly obvious diagnosis, he was suspected of having a COVID-19 infection. &#x0D; The man has a positive smoking history of approximately 20 cigarettes per day for 25 years. However, his COVID-19 PCR tests provided two negative results. His chest X-ray was also unremarkable. Apart from some abnormalities in his laboratory analyses, which have been discussed in detail in the coming sections, there seemed to be nothing unusual or out of place with the patient.&#x0D; However, when a CT scan without contrast was ordered for the patient, the report showed a mass that was approximately 23 x 21 x 16 mm in size. The mass had a soft, tissue-like consistency. It also appeared to have irregular, lobulated margins. This entire mass was seen to be present in the anterior segment of the upper lobe of the left lung.&#x0D; Apart from this mass, no COVID-19-related consolidations or signs of respiratory distress were seen in this patient.&#x0D; When the mass was confirmed, a needle-core biopsy was done to find out the nature of it. The biopsy report confirmed that the mass was indeed a moderate-to-poorly differentiated non-small cell carcinoma of the lung, which was consistent with adenocarcinoma with sarcomatoid features. All these aspects of the tumor, with radiological evidence, have been discussed below.&#x0D; The patient is being supportively managed as of now and is also being kept on a follow-up schedule.&#x0D; What's worth mentioning, however, is that despite such minor symptoms, the underlying problem could still be serious. If the patient had not gone for an X-ray or CT for their suspected COVID-19 abnormalities, then their case would not have come to a diagnosis and it would have eventually taken a turn for the worse. The whole case, along with the findings and the patient response has been discussed throughout this paper.

Abstract #1183604: Check point inhibitor associated multi-endocrine dysfunction presenting with euglycemic ketoacidosis

Immune check point inhibitors have become breakthrough therapy for many types of cancers. They inhibit one of two immune regulatory pathways, the cytotoxic T-lymphocyte antigen 4 (CTLA-4), and ‘programmed death-1’ (PD-1) and (PD-L1) pathways. Removing immune regulation allows for anti-cancer immune responses. They also cause immune related endocrine dysfunction such as hypophysitis, thyroiditis, diabetes mellitus (DM) and primary adrenal insufficiency (AI). We describe a patient on Pembrolizumab (PEM) (an anti-PD-1 inhibitor) who presented with new onset DM, euglycemic diabetic ketoacidosis (DKA) with simultaneous secondary AI. 54-year-old woman with stage 4 non-small cell carcinoma of the lung (NSCLC) with known brain metastasis, was under therapy with carboplastin, paclitaxel and PEM, presented with headache, blurry vision and altered mental status. She had past history of Grave's disease s/p radioactive iodine therapy, currently on levothyroxine. For two weeks, she had decreased oral intake, and generalized weakness. Upon presentation, she was cachectic, BP 152/65, pulse 117 and confabulating. Laboratory evaluation showed: serum glucose 72 mg/dL, Na 139 mmol/L, K 3.2 mmol/L, Cl 113 mmol/L, HCO3 11 mmol/L, anion gap 15 mmol/L, beta-hydroxybutyrate 4.8 mmol/L, lactic acid 0.7 mmol/L, venous pH 7.2 and base excess -16.6 mmol/L. The delta-delta gap was 10 mmol/L, compatible with a mixed anion-gap and hyperchloremic acidosis (HCA). Antibodies to GAD-65, and Zinc transporter-8 were negative. To evaluate euglycemia despite DKA, levels were obtained for serum cortisol 1 mcg/dL, and ACTH < 1 pg/mL confirming secondary AI. MRI neuroimaging showed several metastatic brain lesions, a small pituitary gland without stalk enhancement or thickening. Management of euglycemic ketoacidosis required high dose glucose infusion ( >10 g/hour), stress doses of hydrocortisone (HC), and infusion of low chloride solute for HCA. Awareness of the potential multi-endocrine dysfunction, directed us towards the urgent institution of therapy for DKA with supplementation of stress dose HC for presumed AI, the latter as a cause of relative “hypoglycemia”. Central AI was confirmed with undetectable levels of cortisol and ACTH. Although less frequent than with CTLA-4 inhibitors, PD-1 inhibitors are associated with hypophysitis even without abnormalities on pituitary MRI. The DM (associated with PD-1 inhibitors) although autoimmune is nature, is “antibody” positive approximately 50% of the time. Further therapy for both euglycemic DKA and HCA required adjustment of the conventional management for DKA.

Afatinib-induced acneiform eruptions

Epidermal growth factor receptor (EGFR) inhibitors are being increasingly used in the treatment of non-small cell carcinoma of the lung. Cutaneous toxicity of various EGFR inhibitors is being increasingly noticed by dermatologists. We hereby report a case of papulopustular eruption in a male patient who had received oral afatinib for well-differentiated squamous cell carcinoma of the lower lip. The offending drug was continued and the papulopustular eruption was treated with oral doxycycline and local care.

184 - Hypereosinophilia as a paraneoplastic syndrome in non-small cell carcinoma of the lung

184 - Hypereosinophilia as a paraneoplastic syndrome in non-small cell carcinoma of the lung

175P Incidence and treatment outcomes of brain metastasis in advanced non-small cell lung cancer at presentation: An experience from south India

Background: Brain metastasis is one of the significant problems in patients with lung cancer. Most of the patients are asymptomatic at presentation. Prognosis and survival in these patients are lacking. Many studies that looked upon the incidence of brain metastasis at the presentation of NSCLC are retrospective. In India, brain metastasis frequency in patients with NSCLC at the presentation has not been well studied. This study has been planned to evaluate the incidence of brain metastasis in NSCLC patients treated in our center. Methods: It is a prospective observational study conducted in medical oncology at our tertiary care center from Sep 2019- Sep 2020. A total of 150 patients with lung cancer were registered in the department. Among them, 112 patients had advanced non-small cell carcinoma of the lung (NSCLC), and they were enrolled in the study. MRI brain was taken at the time of diagnosis. Results: The mean age at presentation was 60 years. The Median follow-up was 15 months. Median overall survival in the study was 11 months. Patients with brain metastasis had a median survival of 7 months, whereas patients without brain metastasis had 13 months. Clinical profile, performance status, demographic characteristics, and imaging findings were noted at the presentation time and the results were analyzed as follows. Table 175PBaseline characteristicsNo of Patients (%)Mean age60 years<6044 (39%)>6068 (61%)SexMale69 (62%)Female43 (38%)Adenocarcinoma86 (77%)Squamous cell carcinoma26 (23%)Brain metastasis39 (35%)Male19 (49%)Female20 (51%)Adenocarcinoma32 (82%)Squamous cell carcinoma7 (18%)Asymptomatic12 (30%)Symptomatic27 (70%)Synchronous metastasis21 (19%)Contralateral lung metastasis12 (57%)Bone metastasis5 (23%) Open table in a new tab Conclusions: The study period is short, so that data on molecular abnormalities in patients with brain metastasis was not included in the data. Our study found that female patients were at higher risk for brain metastasis. Other risk factors were adenocarcinoma histology and age less than 60 years. There are no biomarkers to predict brain metastasis in NSCLC due to its molecular heterogeneity. The study will serve as a baseline platform of clinical predictors of brain metastasis in NSCLC. Our future direction and research will be clinical predictors along with molecular driver mutations in NSCLC in detecting brain metastasis. Legal entity responsible for the study: Rajiv Gandhi Government General Hospital, Madras Medical College. Funding: Has not received any funding. Disclosure: The author has declared no conflicts of interest.

Acute kidney Injury due to Alectinib, an Anaplastic Lymphoma Kinase inhibitor

Introduction: The array of unintended effects of targeted oncological treatments is still being elucidated. Cognizance of these effects is important since they allow early identification and intervention. Methods: We report a case of progressive reduction in kidney function following the introduction of the oral second generation Anaplastic Lymphoma Kinase (ALK) Inhibitor: Alectinib for the treatment of metastatic non-small cell carcinoma of the lung (NSCLC). Kidney biopsy findings suggested that the predominant manifestation was acute tubular injury, which resolved with cessation of Alectinib therapy and did not recur with the introduction of the third generation ALK inhibitor Lorlatinib. Conclusions: This case report adds to the Onco-Nephrology literature in relation to the potential nephrotoxic effects of ALK inhibitors.

Treatment at Integrated Centers Might Bridge the Academic-Community Survival Gap in Patients With Metastatic Non-Small Cell Carcinoma of the Lung

BackgroundNon-small cell lung cancer (NSCLC) is responsible for the most cancer-related deaths in the United States. A better understanding of treatment-related disparities and ways to address them are important to improving survival for patients with metastatic NSCLC. Materials and MethodsWe performed a retrospective analysis using the National Cancer Database. Included in this analysis were 107,116 patients with metastatic NSCLC who were treated at academic centers (AC), community-based centers (CC), and integrated centers (IC) between 2004 and 2015. The primary end point was overall survival, with comparisons of AC, CC, and IC. ResultsThe survival disparity between AC and CC continued to grow over the study period, from a 5.7% difference in 2-year survival to a 7.5% difference. Treatment at IC was initially associated with survival similar to CC (hazard ratio [HR], 0.93), however, later in the study period treatment at IC improved (HR, 0.74) outpacing the improvement in survival in CC (HR, 0.82) but not to the same degree as the improvement in AC (HR, 0.64). The improvement in survival at IC was noted predominantly in patients with adenocarcinoma (HR, 0.72; P < .001) but not in squamous-cell carcinoma (HR, 0.89; P value not significant). ConclusionTreatment of metastatic NSCLC at IC was associated with improved survival during our study period compared with treatment at CC. This appeared to be histology-dependent, suggesting a treatment-related improvement in survival because over this period newer therapies were preferentially available for adenocarcinoma. Integrating care across treatment facilities might be one way to bridge the growing gap in survival between AC and CC.

PRIMARY MEDIASTINAL CHORIOCARCINOMA (PMC) IN A YOUNG WOMAN WITH HEMOPTYSIS AND A LUNG MASS

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Primary mediastinal choriocarcinoma (PMC) is an extra gonadal, non-gestational, angioinvasive rare germ cell neoplasm that mostly arises along the midline structures. PMC contains syncytiotrophoblastic cells which secrete human chorionic gonadotropin hormone (hCG). An elevated hCG is considered an important serologic tumor marker in the diagnosis of mediastinal germ cell tumor, in the absence of gestation and with no previous gynecologic malignancy. CASE PRESENTATION: A 39 year-old woman with no past medical history was admitted to the hospital with severe right sided chest pain associated with hemoptysis that started 2 weeks prior to admission. Physical exam revealed decreased breath sounds on the right hemithorax with dullness to percussion. Bloodwork was significant for β-HCG of 6,566 mlU/ml with negative alpha fetoprotein, and normal lactate dehydrogenase. A CT scan of the chest revealed a large necrotic solid mass with numerus enlarged vessels located in the anterior mediastinum (Figure 1). PET scan was negative for any metastatic lesions. Transvaginal ultrasound was negative for intrauterine or ectopic pregnancy. Transthoracic core biopsy showed poorly differentiated choriocarcinoma. Immunohistochemistry staining was positive for β-HCG, placental alkaline phosphatase, and pancytokeratin AE1/AE3 (Figure 2). The tumor was not amenable to surgical resection due to its large size and high vascularity. The patient was started on cisplatin and etoposide followed by etoposide, MTX, Act-D, cyclophosphamide, and vincristine (EMA-CO). After the first course of chemotherapy, the levels of β-HCG markedly decreased. DISCUSSION: PMC is a rare malignancy in both genders, more prevalent in men than in women. The natural process of PMC has been poorly understood. Possible theories include: (1) trophoblastic embolus related to a gestational event after a long period of latency; (2) metastases from a primary gonadal choriocarcinoma; (3) retained primordial germ cells that migrated during embryogenesis. An extensive workup is required to exclude other β-HCG-positive tumors from PMC, such as primary poorly differentiated non-small cell carcinoma of the lung, and gestational metastatic choriocarcinoma. Our patient was found to have a large highly vascular mass in the presence of elevated β-HCG, and absence of primary genital tumor. The histological features showed extensive areas of hemorrhage and necrosis and biphasic cellular population including cytotrophoblastic and syncytiotrophoblastic cells. In contrast to gestational choriocarcinoma, PMC is rapidly progressive and fatal in the great majority of cases with a dismal 5 years survival of less than 5%. CONCLUSIONS: Due to the rarity of PMC, currently there is no consensus regarding treatment guidelines. Thus, case reports such as this contribute to the scant literature to raise the profile of this rare and devastating disease. Reference #1: Ruan Z, Wang S, Wang Z, Jing Y. A rare case of bilateral massive hemothorax from spontaneous rupture of a primary mediastinal mixed germ cell tumor. Ann Thorac Surg. 2012;93:664–666 Reference #2: Bachmann J, Ernestus K, Werner T, et al. Detection of primary choriocarcinoma in the mediastinum by F-18 FDG positron emission tomography. Clin Nucl Med. 2007;32:663–665. Reference #3: Serno J, Zeppernick F, Jakel J, Primary pulmonary choriocarcinoma; cas report and the review of the literature, Gynecologic nad obstetric investigation, vol. 74, no. 2, pp. 171-176,2012 DISCLOSURES: No relevant relationships by Marwah Abduljabbar, source=Web Response No relevant relationships by Sara Mehrsefat, source=Web Response No relevant relationships by jorge otoya, source=Web Response No relevant relationships by Noman Subhani, source=Web Response no disclosure on file for Maria Wallis-Crespo

44. Dual expression of p40 AND TTF-1 In non-small cell carcinoma of the lung – A case series

44. Dual expression of p40 AND TTF-1 In non-small cell carcinoma of the lung – A case series

1802 A Hard Truth to Swallow

INTRODUCTION: Pseudoachalasia is a condition typically caused by lower esophageal sphincter (LES) obstruction in the setting of invasive neoplasm. In rare cases, a syndrome known as paraneoplastic achalasia can present similarly, but is not associated with tumor invasion into the esophageal mucosa. CASE DESCRIPTION/METHODS: 76-year-old female with history of breast cancer status post mastectomy and radiation presented to her oncologist with one month of progressive dysphagia. She was referred to gastroenterology and scheduled for an outpatient EGD, but presented to the ED with weakness, fatigue and weight loss prior to completion of the EGD. CT scan in the ED showed two right lung masses, mediastinal adenopathy and esophageal wall thickening. Patient was admitted for further workup. Day 1 of admission, patient underwent EGD that was pertinent for severe Candida esophagitis, but was aborted after progressing only 1/3 of the way into the esophagus. Patient was started on fluconazole for esophagitis with improvement in dysphagia. On day 2, patient underwent bronchoscopy with biopsy and was discharged home with oncology follow up. Five days later, she was directly readmitted from the oncology office for worsened dysphagia and continued weight loss. Esophagram showed distal esophageal obstruction presumably secondary to post-inflammatory stricture. EGD the following day showed dilated and poorly contractile esophagus with a spastic LES concerning for achalasia. Manometry revealed absence of esophageal body contractility, but was unable to assess the LES due to intolerance of the procedure by the patient. Further workup including pathology showed that patient had metastatic non-small cell carcinoma (NSCC), lung primary. It was determined that patient had pseudoachalasia due to paraneoplastic syndrome in setting of non-small cell carcinoma of the lung without invasion of the tumor into the LES. Patient ultimately underwent palliative botox injection at the LES with improvement in symptoms. DISCUSSION: Paraneoplastic syndromes are considered rare disorders triggered by an altered immune response in the setting of malignancy. Paraneoplastic achalasia is a type of paraneoplastic syndrome that presents as a rapidly progressive dysphagia. Though it has been reported in the setting different malignancies, this is one of the very few case reports of paraneoplastic achalasia due to NSCC. This case also emphasizes the importance of considering other causes of achalasia when evaluating patients with abnormal presentations.

Role of immunohistochemistry in cell block sections for categorization of non-small cell carcinoma of lung

Background: Computed tomography (CT) guided fine needle aspiration and cytology (FNAC) is a useful modality which aids in early and fairly accurate diagnosis of mass lesions of lungs specially the malignant ones. Previously in patients with primary lung cancer the most important consideration was to discriminate between small cell and non-small cell carcinoma (NSCC) of the lung. With advancement of cancer therapy, sub-typing of NSCC has become very important. The aims of the study were to evaluate the pathological spectrum of the pulmonary diseases in CT guided FNAC of lung mass lesions and utility of limited immunohistochemistry (IHC) in cell block sections to subcategorize NSCC.&#x0D; Methods: The study was carried out at Department of Histopathology in Armed Forces Institute of Pathology from 1st January 2018 to 31st December 2018. It involved total 140 patients who underwent CT guided FNAC in Combined Military Hospital, Dhaka for lung mass lesions. Aspiration was done by pathologist and obtained material was used to make slide smears and cell blocks. Both FNAC smears and cell block sections were examined by histopathologists. The entities diagnosed as NSCC and poorly differentiated carcinomas in FNAC were treated with limited IHC panel in cell block sections.&#x0D; Results: Out of 140 cases 110 were male and 30 were female patients. Age range was from 18 to 85 years, (mean age 60±13.5). Total 83(59%) malignant neoplasms and 57(41%) benign lesions were diagnosed. Among the benign lesions, 28 were diagnosed as granulomatous lesion suggestive of tuberculosis and rests were nonspecific inflammatory lesion. In FNAC smear, small cell carcinoma was diagnosed in 16.9% (14/83) of all malignant lesions, squamous cell carcinoma (SCC) in 26.5% (22/83) patients and adenocarcinoma in 22.9% (19/83) patients. Twenty-five patients were categorized as NSCC as they could not be further subcategorized in FNAC as SCC/adenocarcinoma. Three patients were categorized as poorly differentiated carcinoma as their cytological features could not rule in/out small cell carcinoma. NSCC and poorly differentiated carcinoma diagnosed by FNAC were33.7% (28/83). Cell blocks of all of them were examined, three of NSCC cell blocks were found inadequate for evaluation. All of the rest cases underwent limited IHC panel in cell block sections and were further subcategorized; 13 as SCC and 12 as adenocarcinoma. Total cases of SCC diagnosed in the study after IHC on cell block sections were 35/83(42%) followed by adenocarcinoma 31/83, (33.35%).&#x0D; Conclusion: CT guided FNAC is an effective tool and can be used for fairly accurate and early diagnosis of lung mass lesions. Immunohistochemistry on cell block sections can be used as an effective tool for categorization of NSCC.&#x0D; Birdem Med J 2019; 9(3): 223-228

Severe and Fatal Multilobar Nonclassic Radiation Pneumonitis following Stereotactic Body Radiation Therapy (SBRT) for Treatment of Inoperable Non-Small-Cell Lung Cancer: A Report of Two Cases and Possible Enhancement by Concurrent Amiodarone

Stereotactic body radiation therapy (SBRT) is considered the standard of care for treatment of inoperable early stage non-small cell carcinoma of the lung. SBRT delivers a very high dose of ionizing radiation to a relatively small region encompassing the tumor and spares a significant portion of the remaining lung from high doses. However, the conformal high dose comes at the expense of treating a larger volume of normal lung to lower doses. In general, this has been deemed to be acceptable with an overall lower risk of radiation pneumonitis. However, in the face of predisposing factors, the higher doses delivered by this technique may lead to an increase in radiation pneumonitis. We report on two patients being treated with SBRT in which severe radiation pneumonitis developed in spite of our radiation dosimetry being significantly below the acceptable limit for lung toxicity. Both patients developed a “fulminant” form of radiation pneumonitis with radiographic abnormalities well beyond the treated volume. In one patient, the disease proved fatal. Both patients were on amiodarone at the time SBRT was administered. Given the rarity of fulminant radiation pneumonitis, especially with the relatively small fields treated by SBRT, we suspect that amiodarone enhanced the pulmonary toxicity.

“PRIDE” Complex: A Report of Two Cases

Epidermal growth factor receptor inhibitors are currently widely used for the treatment of nonsmall cell lung cancer and head-and-neck malignancy. These are associated with constellation of cutaneous reactions termed as PRIDE complex which comprises papulopustules and/or paronychia, regulatory abnormalities of hair growth, itching, and dryness. We report two cases of PRIDE complex, diagnosed clinically and histopathologically in patients of nonsmall cell carcinoma of the lung being treated with erlotinib and gefitinib.

Prognostic Role of S100A8 and S100A9 Protein Expressions in Non-small Cell Carcinoma of the Lung.

BackgroundS100A8 and S100A9 have been gaining recognition for modulating tumor growthand metastasis. This study aimed at evaluating the clinical significance of S100A8 and S100A9 innon-small cell lung cancer (NSCLC).MethodsWe analyzed the relationship between S100A8and S100A9 expressions, clinicopathological characteristics, and prognostic significance in tumorcells and peritumoral inflammatory cells.ResultsThe positive staining of S100A8 in tumorcells was significantly increased in male (p < .001), smoker (p = .034), surgical method other thanlobectomy (p = .024), squamous cell carcinoma (SQCC) (p < .001) and higher TNM stage (p = .022)compared with female, non-smoker, lobectomy, adenocarcinoma (ADC), and lower stage. Theproportion of tumor cells stained for S100A8 was related to histologic type (p < .001) and patientsex (p = .027). The proportion of inflammatory cells stained for S100A8 was correlated with patientage (p = .022), whereas the proportion of inflammatory cells stained for S100A9 was correlatedwith patient sex (p < .001) and smoking history (p = .031). Moreover, positive staining in tumorcells, more than 50% of the tumor cells stained and less than 30% of the inflammatory cellsstained for S100A8 and S100A9 suggested a tendency towards increased survivability in SQCCbut towards decreased survivability in ADC.ConclusionsS100A8 and S100A9 expressions might be potential prognostic markers in patients with NSCLC.