Antibiotic-Resistant Cough and Back Pain in a 63-Year-Old

Discussion

Lung cancer is often insidious, failing to produce clear symptoms until advanced disease. A high index of suspicion is required to properly identify this disease in most patients. In this case, weight loss, hemoptysis, and a history of secondhand smoke exposure, along with a low-grade fever and irregularities upon lung evaluation, warranted an investigation for lung cancer. Subsequently, CT revealed a 1.3-cm left upper lobe complex nodule (Figure 1).

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Figure 1.

The patient underwent a left upper lobectomy with mediastinal lymph node dissection for a 1.5-cm poorly differentiated squamous cancer of lung, with 1 (station 5) of 18 lymph nodes positive with a microscopic focus of cancer. She was subsequently treated with adjuvant chemoradiation therapy, consisting of cisplatin and docetaxel concurrent with radiation. However, chemotherapy was stopped after a few doses owing to complications.

The patient later developed a seizure and was hospitalized; MRI of the brain was negative for metastatic disease but suggested possible temporal lobe inflammation. Her cerebrospinal fluid was positive for herpes. She was started on phenytoin and valacyclovir.

She completed radiation therapy to 6120 cGy. Additional planned chemotherapy was delayed owing to the patient's debility. She also experienced an outbreak of shingles. Serial follow-up every 4 months showed that disease was in complete remission, with a stable postradiation residual scar in the left lung.

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Figure 2.

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Figure 3.

Six years later, CT revealed a new enhancing mass in the medial right upper lobe (adjacent to the mediastinum) that was suspicious for metastatic or new primary lung cancer (Figure 2). A brain scan was negative for metastases. PET revealed uptake in the expected area and indeterminate uptake in a right hilar node (Figure 3), but was otherwise negative. Pulmonary function tests revealed showed an FEV₁ of 1.45 L, or 65% of predicted. The diffusing capacity of the lung for carbon monoxide (DLCO) was 42%. Saturation was normal at rest but decreased to 92% with exercise.

Endobronchial ultrasonography did not reveal any specific abnormality. The mucosa was friable. A right hilar lymph node was sampled, but no lymphoid elements were obtained. Nothing specific for the tumor area was seen.

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Figure 4.

A CT-guided biopsy was nondiagnostic. Surgical exploration yielded a small cell carcinoma that was unresectable owing to mediastinal invasion and bleeding (Figure 4). The patient started palliative chemotherapy with carboplatin/etoposide, with etoposide given orally on days 2 and 3. She completed four cycles of this chemotherapy and tolerated chemotherapy well overall.

Follow-up CT showed minimal residual density in the area of the prior lesion. As a result of excellent response, she was referred for proton therapy, because standard radiation was not feasible owing to prior dosing.

Induction chemotherapy was followed by consolidation radiation. The patient subsequently underwent proton radiation to the residual chest mass. She experienced a seizure; she was dehydrated, and was started on anticonvulsant and became stable. MRI of the brain revealed an area of right anterior temporal encephalomalacia. She is doing well currently and is under active surveillance for her cancer.

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