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Simultaneous Presentation of Small Cell Lung Cancer and Coccidioidomycosis: Diagnostic and Management Challenges FREE TO VIEW

Aida Venado, MD; Francisco Robert, MD
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University of Alabama at Birmingham, Birmingham, AL

Chest. 2013;144(4_MeetingAbstracts):610A. doi:10.1378/chest.1703575
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SESSION TITLE: Cancer Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Small cell lung cancer (SCLC) carries a poor prognosis with a median survival of 15-20 months and 8-13 months for limited and extensive stage, respectively. Two thirds of the cases present with extensive disease.

CASE PRESENTATION: Our patient is a 59 year old man living in Mexico who presented with a six week history of progressive dyspnea accompanied by productive cough, occasional hemoptysis and low grade fever. He had an 84 pack-year smoking history. Computed tomography (CT) of the chest revealed multiple cavitary lesions in the left upper lobe, the largest measuring 52.4 x 52.4 mm containing an air fluid level and multiple adjacent nodules. There was extensive mediastinal adenopathy involving the lateral aortic, left hilar and AP window forming a confluent mass measuring 60 x 68 mm compressing the pulmonary artery. Bronchoscopy was initially unrevealing. A right paratracheal mass was identified by mediastinoscopy and biopsied. Immunostains were positive for TTF1, synaptophysin and CD56 and negative for chromogranin consistent with SCLC. Two weeks later cultures from bronchial washings revealed coccidioidomycosis and fluconazole was started. SCLC stage was uncertain as it could not be determined which lesions were infectious versus malignant. He was staged as extensive disease and received combination chemotherapy with bendamustine and irinotecan every three weeks for 3 cycles followed by 3 cycles of carboplatin and etoposide. CT scan after cycle 2 showed decrease in mediastinal adenopathy but also enlargement of the cavitary lesion. The patient developed worsening cough, dyspnea, fatigue and weight loss. Bronchoscopy showed persistent coccidioidomycosis and he was switched to itraconazole with good response. He completed chemotherapy and underwent prophylactic brain radiation. Nine months later, he had radiographic improvement of mediastinal adenopathy with AP window mass measuring 19 x 12 mm and left apical lesion measuring 24 x 15 mm. One year after diagnosis his Karnofsky Performance Status is 80%.

DISCUSSION: Degree of extension is the most important prognostic factor in SCLC survival. Our patient’s concurrent coccidioidomycosis likely accounted for an earlier diagnosis. The resolution of multiple infectious lesions raised uncertainty about limited versus extensive stage. Concern for worsening fungal infection precluded pursuing consolidation radiotherapy.

CONCLUSIONS: Staging and treatment of SCLC in the setting of severe infection are challenging. The risk of worsening or persistent infection due to immunosuppression should be balanced against the benefit of timely chemoradiation. The outcome of consolidation radiotherapy once infection is controlled warrants further investigation.

Reference #1: Van Meerbeeck JP, Fennell DA, de Ruysscher KDM. Small-cell lung cancer. Lancet vol 378 Nov 12,2011

DISCLOSURE: Francisco Robert: Employee: University of Alabama at Birmingham The following authors have nothing to disclose: Aida Venado

I will be presenting a case of small cell lung cancer which was specially challenging to diagnose and manage due to a concomitant severe infection. The patient was treated with a combination chemotherapy regimen which is under investigation. I have no relationship with the clinical trial.




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