What's The Take Home?

A 72-Year-Old Man With Recently Diagnosed Lung Cancer

Ronald N. Rubin, MD1,2 Series Editor

  • Introduction. A 72-year-old man presented to the hospital for an apparent thrombotic stroke.

    Patient history. Regarding the present illness, the patient’s history began about 3 months prior, when a friend noticed that the patient’s left eye was unusually fixed to the lateral and downward direction. Despite this, he denied headache or double vision. Prompt consultation to ophthalmology, neurology, and neurosurgery resulted in the diagnosis of an orbital mass of the left orbit, emerging through the canal of Schlemm, with major differentials being metastatic orbital neoplasm, orbital lymphoma, or sarcoidosis.

    The patient’s medical history was significant and positive for at least 50 pack years and the known presence of moderate chronic obstructive pulmonary disease. There was no known coronary artery disease, diabetes, or hypertension. Four years prior, he experienced thoracic-level spinal stenosis requiring laminectomy. The patient is also a Vietnam War veteran, with heavy exposure to Agent Orange during his time in the war.

    Physical examination. There was consideration for orbital biopsy to obtain tissue diagnosis, and further preoperative studies revealed an alarming and markedly nonstandard chest x-ray, demonstrating a large mass of the left lower lobe with contiguous bilateral hilar and mediastinal adenopathy. Upon seeing the irregular chest radiology, a full evaluation was performed.

    Diagnostic examination. There was a 5 cm mass-like consolidation in the left lower lobe with irregular borders, contiguous multifocal left hilar, and mediastinal adenopathy consistent with metastases measuring more than 2 cm. A small unilateral left pleural effusion and reticulonodular right lower lobe opacity suspicious for lymphangitic carcinomatosis was also found.

    Transbronchial needle biopsy was performed and confirmed the presence of poorly differentiated adenocarcinoma of the lung with lymphangitic spread. Immuno-histochemical stains and genetics showed the tumor cells positive for PD-L1 greater than 50% and negative for estimated glomerular filtration rate and anaplastic lymphoma kinase genes, suggestive for sensitivity to the immunotherapeutic pembrolizumab.

    The patient was scheduled to begin that therapy as an outpatient in 1 week. However, 3 days prior to his therapy date, his daughter found him at home obtunded, incoherent, and disoriented. He was hospitalized and an emergency computed tomography (CT) and magnetic resonance imaging (MRI) of his brain revealed the presence of multiple bilateral acute to subacute cerebral infarctions with flow findings consistent with multiple thrombi. He had not manifest pain or fever throughout this period of evaluation.

    (Answer and Discussion on next page)