Skill Checkup: A 50-Year-Old Man With Cough, Sputum, Left Chest Pain, and a Lung Lesion

John C. Leighton Jr, MD, FACP


September 01, 2022

The Skill Checkup series provides a quick, case-style interactive quiz highlighting key guidelines- and evidence-based information to inform clinical practice.

A 50-year-old man in the United States who is a never-smoker presented with a cough, sputum, and left chest pain that had persisted for 20 days. A chest PET-CT showed a lesion measuring approximately 2.5  ×  2.0 cm in the left lung and the absence of enlarged lymph nodes in the mediastinum. No metastases were found in other areas of the body, which supported an initial clinical diagnosis of left lung upper lobe cancer (cT1bN0M0 stage IA).

The physician ordered an endobronchial ultrasound with biopsy. Pathology showed a left lung upper lobe moderately differentiated adenocarcinoma measuring 2.5  ×  2  ×  1.8  cm. Para-aortic lymph nodes in the mediastinum and multiple visceral pleural metastases were found. Immunohistochemistry analyses of the tumor showed TTF1+, Syn-, Ki-67 (20%), CD31+, CK+, EGFR- and ALK-.

A new diagnosis was made of left lung upper lobe adenocarcinoma (pT1N2M1, stage IV, EGFR-, ALK-). Subsequently, the patient received four cycles of pemetrexed-carboplatin and pembrolizumab. Unfortunately, thereafter, chest CT revealed disease progression. Chemotherapy was discontinued.

Genomic testing via next-generation sequencing (NGS) was performed on the patient's resected tumor tissue and identified the presence of the CCDC6-RET fusion gene; mutations in EGFR, KRAS, ALK, and MET were all negative.

At 6 months, MRI revealed metastasis to the brain.


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