Presentation
Chest pain.
Patient Data
Large well-defined rounded mass lesion measuring up to 7 cm and projected within the right lung mid to upper zones. The lungs and pleural spaces are otherwise clear. Cardiomediastinal contours are unremarkable allowing the limitations of this AP projection. No pneumothorax or subphrenic free gas. No destructive bone lesions.
Large (up to 9.0 cm) right upper lobe pulmonary mass. Small right pleural fluid collection.
Patchy ground glass in the dependent right upper lobe. Bibasal atelectasis. The left lung is otherwise clear.
Enlarged subcarinal node measuring 15mm short axis. Multiple prominent right paratracheal and right hilar lymph nodes.
Severe atherosclerotic disease of the descending thoracic aorta.
Heterogeneous opacification of the thyroid with multiple foci of calcification.
No suspicious osseous abnormality.
Macroscopy: Right lung biopsy - 6 pale tan needle core fragments 3-11 mm.
Microscopy: Sections core biopsy shows of fibrous tissue infiltrated by nests of atypical epithelial cells interspersed with areas of necrosis. Keratinization or gland formation are not seen. Lymphovascular or perineural invasion are not identified. The tumor cells are immunoreactive with p40, no reactivity is seen in the tumor cells with TTF-1 or CD45.
Conclusion: Non-small cell carcinoma, favor squamous cell carcinoma.
Addendum: No variant was detected in exon 18 - 21 of EGFR gene. Absence of an EGFR variant is associated with decreased sensitivity to EGFR tyrosine kinase inhibitors such as erlotinib and gefitinib (Mok et al NEJM 2010; 361:947-57)
No mutation detected, EGFRWT.
Case Discussion
Peripheral pulmonary mass involving the right upper lobe with relatively well-defined margins, only surrounded by a few foci of distal atelectasis. On CT it shows heterogenous attenuation with poor enhancement, no air bronchograms. These features are those of a neoplastic process, most likely malignant. There are no specific features in this case to suggest adenocarcinoma over SCC or vice-versa, in particular no cavitation.
Imaging staging, further complemented by PET-CT was: T4N2M0.