Right Pulmonary Collapse from Squamous Cell Carcinoma of the Lung
Ghosn Y, Kamareddine M, Walid Alam W, Metri M and Chamseddine N
Published on: 2020-04-07
This is a case of a 72-year-old Caucasian male, heavy smoker known to have coronary artery disease treated with angioplasty , hypertension and recent acute limb ischemia 18 days ago s/p thrombectomy and currently on dabigatran admitted to our institution for investigations of dysphagia to solids and liquids along with odynophagia. Additionally, patient has cough with whitish sputum but recently reports presence of a blood tinged sputum since one week.
KeywordsThrombectomy; Coronary artery disease
This is a case of a 72-year-old Caucasian male, heavy smoker known to have coronary artery disease treated with angioplasty , hypertension and recent acute limb ischemia 18 days ago s/p thrombectomy and currently on dabigatran admitted to our institution for investigations of dysphagia to solids and liquids along with odynophagia. Additionally, patient has cough with whitish sputum but recently reports presence of a blood tinged sputum since one week. Patient also reports progressive dyspnea over the course of the last two weeks that is currently present on minimal exertion, weight loss of 6 kilograms with decrease in appetite. There is no previous exposure to tuberculosis, no significant family history of malignancy and no recent travel to endemic countries.
Patient had lost significant weight in the last two weeks, he is not able to tolerate per os medications or food. On day of admission a total body injected CT Scan with po contrast was done to search for an underlying malignancy. It revealed presence of 2.5cm subpleural airspace opacity abutting the right major fissure surrounded by spiculations and minimal ground glass opacities. There is also a 6*5*9 cm enlarged heterogenous necrotic adenopathy in the infracarinal space, showing multiple necrotic centers and extending to the right hilum. It surrounds the main pulmonary artery and the right pulmonary veins with subsequent filling defects at the left atrium suggestive of invasion. In addition, these cuts showed significant mass effect and compression of the right mainstem bronchus with approximate 50% narrowing. It also shows compression of the esophagus with subsequent proximal dilatation and stasis in its proximal aspect. Finally there was also bilateral nodular enlargement of the adrenals. All these findings were in favor of a right upper lobe primary lung tumor with metastatic disease. The next day patient was scheduled for bronchoscopy and was found to have an endocronchial necrotic lesion in right mainstem bronchus without complete obstruction, biopsies were taken and so significant bleed happened. To note that since admission patient was switched from dagitarna to enoxaparin and it was appropriately held before biopsies as per protocol. Bronchoalveolar lavage was also done and sent for cytology.
Results And Treatment
Preliminary results of the pathology were in favor of a squamous cell carcinoma in the right main bronchus invading the esophagus and right atrium. Awaiting final pathology patient was treated for post obstructive pneumonia with antibiotics. (piperaccilin/tazobactom) 3 days later, patient had severe respiratory distress. He had absent air entry at the right lung on physical exam along with dullness to percussion in addition to severe hypoxemia refractory to high flow oxygen. Patient was diagnosed with hypoxemic respiratory failure and underwent urgent endotracheal (ET) intubation. Chest X-ray post intubation showed complete right side white-out lung compatible with pulmonary collapse despite proper position of the ET Tube 3 cm above the carina (Figure 1). Urgent Chest CT confirmed the right white lung with possible alveolar bleed etiology. Urgent bronchoscopy done showed blood obstructing the orifice of the right main bronchus (Figure 2), the blood was aspirated showing at that time a complete obstruction of the right mainstem orifice by a necrotic mass that is friable and bleeds upon minimal manipulation. This tumor has significantly increased in size compared to the initial bronchoscopy. The procedure was complicated by severe desaturation hence selective intubation of the left was done under direct bronchoscopic vision. Patient was started on high dose steroids as a trial to decrease the airway edema and reduce the size of the endobronchial tumor. Antibiotics were continued.
Figure 1: AP chest X-ray showing Total opacification of the right lung field with marked shift of the heart and mediastinum to the right with an endotracheal tube in good position 3 cm above the carina.
Figure 2: Bronchoscopic image showing a endobronchial lesion occluding the right main bronchus with mucosal damage. Patent left main bronchus is also noted.
Conclusion and Points for Discussion
The best explanation is that the endobronchial tumor is the initial source of hemoptysis and it has rapidly progressed over few days along with bleed to cause complete occlusion of the right mainstem bronchus causing the acute deterioration and the need for intubation and mechanical ventilation Later on, pathology from the right endobronchial lesion and the BAL confirmed the diagnosis of a poorly differentiated squamous cell carcinoma CK7+ , CK20- , p63+ , TTF1- along with high expression of 34BE12. In fact, NSCLC is a heterogeneous group of disease but it is usually slow growing. Some cases in the literature described adenocarcinoma as a tumor that has a rapid growth in tumor volume, but this was mainly within several weeks. To our knowledge that are no, or few reported cases where lung adenocarcinoma progressed that rapidly like in our case- over days. In the last decade, it was confirmed that the doubling time of a tumor is an independent factor in the prognosis of lung cancer patients. Hence, this aggressive adenocarcinoma tumor is a “rapid killer “.