Diffuse Lung Disease-A Case of Rapid Decompensation

Abstract

Introduction: Diffuse pulmonary nodular opacification has a wide differential diagnosis, including malignant (metastases, primary lung cancers, lymphoma) and benign (embolic, autoimmune, infectious) etiologies. Case description: A 62-year old man with end stage renal disease and hypertension presented with worsening dry cough and exertional dyspnea for four weeks. Physical examination revealed bilateral crackles. Vital signs were normal. Chest X ray revealed bilateral nodular and interstitial infiltrates. CT angiography revealed diffuse nodular opacification of the lungs, mediastinal and hilar lymphadenopathy, small bilateral pleural effusions, vague areas of hypoattenuation within the liver(Image 1). Bronchoscopy showed normal airways with enlarged lymph node station 7 & 11. FNA of lymph node station 7 showed metastatic adenocarcinoma. Needle biopsy pointed towards adenocarcinoma. Immunohistochemistry (IHC) stained cytokeratin 20+ (CK20+), CK7-, thyroid transcription factor 1 (TTF 1) (Image 2 & 3). Tumor markers carcinoembryonic antigen (CEA) and Beta-HCG were elevated. Investigations such as CT abdomen, colonoscopy & esophagogastroduodenoscopy (EGD) were unremarkable. Patient scheduled for initiation of chemotherapy with FOLFOX regimen. Three days later patient had worsening shortness of breath. New CT PE showed small thromboembolism and worsening opacification from previous CT (Image 4).Patient was started on heparin drip. His respiratory status continued to decline .He was DNR, started on comfort measures and died six days later. Discussion: Carcinoma of unknown primary (CUP) comprises 3-5% of all cancer patients (1). Autopsy on patients who died with CUP have found primaries in lung, pancreas, hepatobiliary tree, kidneys, and bowel in that order. Our case with lung biopsy showing adenocarcinoma and IHC CK20 +/ CK7-with negative endoscopy of the gastrointestinal tract falls under category CUP with colon cancer profile (CCP-CUP). This profile is rare with incidence about 6-8 % among CUP cancers and unlike other disseminated CUP, CCP-CUP is thought to be a favourable subset (2). CUP has traditionally been managed with broad-spectrum chemotherapy; however, CCP-CUP is an example of an emerging, specific CUP subset that seems to benefit from a tailored approach with FOLFOX/bevacizumab similar to metastatic colon carcinoma. Our case is an example of this rare entity which presented as an aggressive variant (3). We suspected lymphangitic metastasis in our case given CT findings which is a rare (6-8%) form of hematogenous dissemination of metastasis in lung(4). Conclusion:This case of diffuse lung nodules with rapid decompensation without treatment initiation will add on to literature as an aggressive variant to CCP-CUP

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TP141 THORACIC ONCOL OGY: RARE THORACIC MALIGNANCIES / Themat ic Po ster Ses sion
Diffuse Lung Disease-A Case of Rapid De compensation
K. N. Parmar1, J. Crane2, C. Morataya1, G. Del Rio-Pertuz1, M. M. Abohelwa1, K. M. Nugent2; 1Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, United
States, 2Pulmonary and Critical Care, Texas Tech University Health Sciences Center, Lubbock, TX, United States.
Corresponding author's email: kanak.parmar@ttuhsc.edu
Introduction: Diffuse pulmonary nodular opacification has a wide differential diagnosis, including malignant (metastases, primary lung cancers, lymphoma) and benign (embolic,
autoimmune, infectious) etiologies. Case description: A 62-year old man with end stage renal disease and hypertension presented with worsening dry cough and exertional dyspnea
for four weeks. Physical examination revealed bilateral crackles. Vital signs were normal. Chest X ray revealed bilateral nodular and interstitial infiltrates. CT angiography revealed
diffuse nodular opacification of the lungs, mediastinal and hilar lymphadenopathy, small bilateral pleural effusions, vague areas of hypoattenuation within the liver(Image 1).
Bronchos copy showed normal airways with enlarged lymph node station 7 & 11 . FNA of lymph node station 7 showed metastatic adenocarcinoma. Needle biopsy pointed towards
adenocarcinoma. Immunohistochemistry (IHC) stained cytokeratin 20+ (CK20+), CK7-, thyroid transcription factor 1 (TTF 1) (Image 2 & 3). Tumor markers carcinoembryonic antigen
(CEA) and Beta-HCG were elevated. Investigations such as CT abdomen, colonoscopy & esophagogastroduodenoscopy (EGD) were unremarkable. Patient scheduled for initiation of
chemotherapy with FOLFOX regimen. Three days later patient had worsening shortness of breath. New CT PE showed small thromboembolism and worsening opacification from
previous CT (Image 4).Patient was started on heparin drip. His respiratory status continued to decline .He was DNR, started on comfort measures and died six days later. Discussion:
Carcinoma of unknown primary (CUP) comprises 3-5% of all cancer patients (1). Autopsy on patients who died with CUP have found primaries in lung, pancreas, hepatobiliary tree,
kidneys, and bowel in that order. Our case with lung biopsy showing adenocarcinoma and IHC CK20 +/ CK7- with negative endoscopy of the gastrointestinal tract falls under
category CUP with colon cancer profile (CCP-CUP). This profile is rare with incidence about 6–8 % among CUP cancers and unlike other disseminated CUP, CCP-CUP is thought to be a
favourable subset (2). CUP has traditionally been managed with broad-spectrum chemotherapy; however, CCP-CUP is an example of an emerging, specific CUP subset that seems to
benefit from a tailored approach with FOLFOX/bevacizumab similar to metastatic colon carcinoma. Our case is an example of this rare entity which presented as an aggressive variant
(3). We suspected lymphangitic metastasis in our case given CT findings which is a rare (6-8%) form of hematogenous dissemination of metastasis in lung(4). Conclusion:This case of
diffuse lung nodules with rapid decompensation without treatment initiation will add on to literature as an aggressive variant to CCP-CUP

This abstract is funded by: None
Am J Respir Crit Ca re Med 2021;203:A4909
Interne t addres s: www .atsjo urna ls.o rg Online Abstracts Issue