Lung Cancer Presenting with Shortness of Breath for 2 Months and Hemoptysis

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

A 56-year-old African American male (AAM) with a past medical history (PMH) of COPD, alcohol abuse, and smoking is admitted to the hospital with a chief complaint of shortness of breath (SOB) for 2 months. SOB is so severe that he is not able to prepare his dinner. He also reports a 18-kg weight loss during the last 6 months. The patient is legally blind but he says that he has seen blood in his sputum. PPD was negative 2 years ago and he has a 60 pck-yrs h/o smoking.

He was admitted to the hospitals 2 months ago for a weight loss work-up. A CT of the abdomen showed a 1.5 cm-pancreatic mass which did not look cancerous on ERCP. He had evidence of chronic pancreatitis. A CXR was reported as COPD changes.

Physical examination

VSS.
Thin male in NAD.
Chest: Markedly decreased air entry on the right, with an area of dullness.
CVS: Clear S1S2.
Abdomen: Soft, NT, ND.
Extremities: no c/c/e.

What is the most likely diagnosis?

Is it a pleural effusion? This is less likely with audible air entry and normal percussion tone at the base.
Atelectasis?
Infiltrate vs. lung mass?
Pneumonia or TB?
Lung cancer? But how did it grow so fast? The CXR was reportedly only with COPD changes only 2 months ago.

What will be the next step in the diagnostic workup?

Let's start with a CXR.

PA CXR, close-up view (left); lateral CXR, close-up view(right) (click to enlarge the images).

Dow you see anything else than COPD changes on the CXR?

The film is overpenetrated but you can see a perihilar mass on the right. It is even clearer on the lateral film.


The CXR report (click to enlarge the image).

The labwork showed a mild hyponatremia (sodium 129 mEq/L ), a hemoglobin (Hgb) of 15 mg/dL, and a corrected calcium level of 10.4 mg/dL.


Laboratory results (click to enlarge the image).

What do you think is the most likely diagnosis now?

Is it SIADH?
The uric acid level is typically low in SIADH because of dilution and increased excretion of uric acid due to ADH.

The CT chest showed a mass in the right lung:


Lung cancer on CT of the chest (click to enlarge the images).


CT report (click to enlarge the image).

What is the next step?

Bronchoscopy and biopsy.

Final diagnosis

The biopsy showed a squamous cell lung cancer. The patient was not a surgical candidate due to the advanced stage of the tumor. SIADH was not confirmed by the follow-up laboratory results.

Related reading

Sir Richard Doll Dies at 92; Linked Smoking to Illnesses - NYTimes, 7/2005.

Published: 01/12/2004
Updated: 10/22/2009

5 comments:

  1. What about metastasic work up? Alkp, bone scan, lft, ct abdomen, mri brain?

    ReplyDelete
  2. The metastatic work-up is essential but was not the focus of this initial presentation. It is the next step in the evaluation of this patient.

    The same applies to oncology consult.

    ReplyDelete
  3. Very significant H/o smoking & alcoholism with wt.loss & SOB favors- Lung CA no doubt. Alcoholism could be the reason for Chronic pancreatitis & low Na (only relative & would have been corrected later)

    Qs= ? H/o says legally blind & sputum showed blood as per the pt?
    - Why was not sputum analysed for cytology?
    - CXR should not relied upon for diagnosis ! CT Abdomen should be repeated as a met work up + Bone scan & ALP

    ReplyDelete
  4. "H/o says legally blind & sputum showed blood as per the pt?"

    "Legally blind" does not mean "blind, cannot see color":

    "In North America and most of Europe, legal blindness is defined as visual acuity (vision) of 20/200 (6/60) or less in the better eye with best correction possible. This means that a legally blind individual would have to stand 20 feet (6.1 m) from an object to see it—with corrective lenses—with the same degree of clarity as a normally sighted person could from 200 feet (61 m)."

    http://en.wikipedia.org/wiki/Blindness

    ReplyDelete
  5. "- Why was not sputum analysed for cytology?
    - CXR should not relied upon for diagnosis ! CT Abdomen should be repeated as a met work up + Bone scan & ALP"

    Good questions. This is the initial presentation of the case and the tests suggested above were likely ordered during the subsequent workup during the hospital stay.

    ReplyDelete