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Suspicion of Lung Cancer with Nodal Metastases in an Immunocompromised Patient

Reviewed By Clinical Problems Assembly

Submitted by

William A. Bulman, MD

Senior Pulmonary and Critical Care Fellow

Columbia University Medical Center

New York, NY

Charles Powell, MD

Division of Pulmonary, Allergy and Critical Care

Columbia University Medical Center

New York, NY

Roger Maxfield, MD

Director of Interventional Bronchoscopy

Columbia University Medical Center

New York, NY

Submit your comments to the author(s).

History

The patient is a 67-year-old man with a 30 pack-year smoking history and a recently identified lung nodule. Systemic lupus erythematosis had been diagnosed in 1972. One year ago he presented with proteinuria and was found to have membranous glomerulonephritis by renal biopsy. He was started on mycophenolate and prednisone, with subsequent improvement in his renal function. Three months into therapy he developed night sweats, low-grade fevers and malaise. He was admitted to an outside hospital, where a CT scan of the chest revealed a left upper lobe pulmonary nodule with solid and ground glass components and mediastinal lymphadenopathy highly suspicious for primary lung cancer. Flexible bronchoscopy was performed for bronchoalveolar lavage and brushings; cytology was negative for malignancy; and cultures were negative for bacterial, viral and fungal pathogens. He left against medical advice without a diagnosis. Mycophenolate and prednisone were continued. The patient presented to our institution 2 months later with continued complaints of malaise, unproductive cough, bilateral hand tremor and intermittent low-grade fevers. He also reported significant, progressive memory loss; a vocalist in an amateur singing group, he found he was no longer able to remember words to songs.

Physical Exam

On physical examination, the patient was afebrile at 36.9° C, with a normal heart rate and normal blood pressure. His respiratory rate was 14 breaths per minute and SaO2 was 100% while breathing room air. His physical exam was normal except for mild wasting, dysdiadochokinesia of the left upper extremity, and difficulty with attention and short-term recall. He was unable to remember three objects after 1 minute.

Lab

A lumbar puncture showed a mild lymphocyte predominant leukocytosis with no red cells; gram stain and fungal stains were negative. A CT scan of the chest revealed a left upper lobe nodule (Figure 1). Left paratracheal and left hilar adenopathy was noted (Figure 2). A PET scan showed FDG avidity in the left paratracheal and left hilar nodes and fainter avidity in the left upper lobe lesion (Figure 3). Comparison films were not available. An MRI of the brain showed mild atrophy and compensatory ventricular enlargement and multiple small lacunar infarcts in the basal ganglia, thalamus and periventricular white matter; no evidence of lupus cerebritis was noted. The patient underwent a bronchoscopy with endobronchial ultrasound-guided transbronchial needle aspiration of the left paratracheal node. Results of Diff-Quik staining and mucicarmine staining of the specimen are shown in Figures 4 and 5.

Laboratory:   Leukocytes    3.0 x103/mm3
Hemoglobin    9.7 g/dL
Platelets
    251 x103/mm3

Differential    Neutrophils 58%, Lymphocytes 36%, Monocytes 5%, Basophils 1%

Sodium  135 mM/L

Potassium  4.5 mM/L

Chloride  105 mM/L

Bicarb  22 mM/L

BUN  20 mg/dL

Creatinine  1.3 mg/dL

Glucose  85 mg/dL

ESR  80 mm/hr

 

Lumbar Puncture:    56 White Cells (Neutrophils 23%, Lymphocytes 70%, Monocytes 6%, Basophils 1%);   LDH  24 U/L, Protein 48 mg/dL, Glucose 35 mg/dL;  Gram Stain:  negative;  KOH Stain:  negative.  Cryptococcal Antigen:  negative; VDRL:  nonreactive.  

Chest CT:    A nodule with mixed solid and ground glass elements was identified in the left upper lobe, measuring approximately 2.3 cm x 1.8 cm.    Left lower paratracheal lymphadenopathy was noted measuring approximately 2.0 cm in the largest diameter.  No other pulmonary nodules were identified. There was no pleural effusion, pneumothorax, or congestion  (Figures 1 and 2).

PET Scan:   Faintly FDG avid (SUV mean 0.9/ max 1.1 ) focus in the LUL;  small FDG avid (SUV mean 3.1/max 4.3) focus in left hilar region and an FDG avid focus (SUV mean 4.4/max 5.5) in the left lower paratracheal region  (Figure 3).

Figures


Figure 1. Axial view of CT scan of the chest (lung windows) showing a left upper lobe lesion with surrounding ground glass opacification.

Figure 2. Axial view of CT scan of the chest (mediastinal windows) showing an enlarged left paratracheal lymph node in the aortopulmonary window (arrow).

Figure 3. Coronal section of PET scan showing FDG-avidity in the left paratracheal area (white arrow) and left hilum (black arrow). The left upper lobe lesion was weakly positive (not shown).

Figure 4. EBUS view of the left paratracheal lymph node (outlined by dark arrows) during needle aspiration (white arrow at needle tip). Centimeter markings are in white at right of frame.

Figure 5. Diff-Quik stained EBUS-TBNA specimen.

Figure 6. Mucicarmine stained EBUS-TBNA specimen.

Question 1

What is the diagnosis?

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