INTRODUCTION: Presence of foreign body simultaneouly with lung cancer is a very rare entity. We report a unique case of presence of foreign body concomitant with adeonocarcinoma of the lung.
CASE PRESENTATION: 60-year-old caucasian male with extensive smoking history and chronic obstructive lung disease with FEV1 of 0.9 L and Dlco of 53% of predicted presented with fever, dyspnea, wheezing, coughing and sputum production. Chest imaging showed right upper lobe consolidation and multiple subcentimeter pulmonary nodules. Patient was treated for COPD exacerbation and pneumonia with steroids, bronchodilators and antibiotics. Barium swallow was consistent with aspiration. On day number 4 of hospitalization, patient underwent bronchoscopy for concern of foreign body in the airway. Inspection of the airway with flexible bronchoscope showed presence of tan colored foreign body in the right mainstem. Several fragments of the foreign body along with surrounding mucosa were removed using cryotherapy. Pathological review of the removed material showed structures consistent with vegetable material and infiltrating moderately differentiated non-small cell adenocarcinoma of the lung, with lymphovascular invasion. The tumoral cells stained positive for CK 7 and TTF-1 and negative for CK 20 most consistent with primary lung cancer.
DISCUSSION: Post obstructive pneumonia is a common complication of foreign body aspiration. Foreign bodies are usually noted in the right lower lobe because of the bronchial anatomy. Intact swallowing mechanism is required to prevent aspiration. Our patient is a chronic alcoholic and was noted to be aspirating intermittently on swallow evaluation by the speech therapist. There are case reports described in literature about foreign body mimicking as lung tumors. Concomitant presence of tumor and foreign body has not been frequently described in literature. Our case is unique as there is a synchronous presence of tumor and foreign body in the bronchial tree. Radiographically foreign body in the tracheobronchial tree is obvious if the aspirated material is radioopaque, otherwise atelactasis and post obstructive pneumonia can be the manifestations. Pathologically inflammation and granulation tissue surrounding the aspirated material has been reported. Early complications of tracheobronchial foreign body aspiration may include acute dyspnea, asphyxia, cardiac arrest, laryngeal edema, and pneumothorax. Late complications include bronchiectasis, hemoptysis, bronchial stricture, development of inflammatory polyps at the site of lodgment, and diminished perfusion to the lung on the side of lodgment. Rigid and flexible bronchoscope has been used to remove foreign bodies. Minority of patients require thoracotomy for the removal of distal foreign bodies.
CONCLUSIONS: Our case underscores the importance of use of flexible bronchoscopy with cryotherapy for the removal of foreign bodies. To our knowledge there has been only one case report of synchronous foreign body with primary lung cancer.
Reference #1 Yoruk etal "Synchronous foreign body and non-small cell carcinoma of the main bronchi" Eur J Cardiothorac Surg. 2004 Sep;26(3):648
Reference #2 Chung-Hua etal "Airway in Chinese Adults Foreign Body Aspiration Into the Lower" Chest 1997;112;129-133
Reference #3 Montserrat Blanco Ramos etal "Extraction of airway foreign bodies in adults: experience from 1987-2008"Interact CardioVasc Thorac Surg 2009;9:402-405
DISCLOSURE: The following authors have nothing to disclose: Riffat Meraj, Virgilius Cornea, Sadia Benzaquen
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