Lung Cancer |

Not All Fever Is Infections, Not All Small Cell Is Pulmonary FREE TO VIEW

Pamela Hoof, MD; Ginger Tsai-Nguyen, MD; Adan Mora, MD
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Baylor University Medical Center, Dallas, TX

Chest. 2015;148(4_MeetingAbstracts):581A. doi:10.1378/chest.2250328
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SESSION TITLE: Lung Cancer Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: The etiology of fever of unknown origin can include malignancy. Presented is a case of a lung nodule found to be an extra-pulmonary high grade neuroendocrine carcinoma with likely prostatic origin.

CASE PRESENTATION: A 78-year-old male with COPD presented with a 6-month history of a low-grade fever. He had weight loss and a cough with dyspnea not relieved despite repeated treatment for pneumonia and an otherwise negative work up. His physical exam was notable for mild crackles in the left base. Notable labs were a WBC of 12.7 K/uL, C-reactive protein of 13.5 mg/L, ESR of 40 mm/hr and CEA of 46.5 mcg/L. Computed tomography images revealed pulmonary and pleural metastatic lesions and a large necrotic mass in the liver. He underwent lung nodule biopsy. Pathology revealed staining positive for prostate specific antigen phosphatase and neuroendocrine markers synaptophysin & chromogranin. An extra-pulmonary high-grade neuroendocrine carcinoma of the lung with likely prostatic origin was diagnosed.

DISCUSSION: This form of prostate cancer is characterized by an aggressive clinical course. It accounts for less than 1-2% of all small cell cancers. It is reported to occur in 0.5-2% of men with prostate cancer. Initial presentation varies with approximately 50% of patients having pure small cell carcinoma, 25-50% are mixed with prostatic adenocarcinoma and 25-40% are initially diagnosed as adenocarcinoma and recur as small cell after hormonal therapy. Distant metastases are present in 25% of patients at initial presentation as seen with our patient. These tumors have short or no response to androgen deprivation therapy. They have a high prevalence of lytic bone metastases. Symptomatic patients have locally advanced or metastatic disease at time of presentation. Serum prostate specific antigen does not correlate with burden of disease. Paraneoplastic syndrome occurs in about 10%of patients. This patient experienced low grade fevers prior to and over the course of admission which were ultimately attributed to underlying malignancy. Metastatic disease therapy is platinum based therapy plus etoposide with adjuvant radiation. Neuroendocrine markers are not predictive of survival which has a median of 9 to13 months and a 5 year survival of <1%.

CONCLUSIONS: One must remain ever mindful of the metastatic malignancies encountered in the lungs especially in patients with fever of unknown origin.

Reference #1: Rubenstein JH, Katin MJ, Mangano MM, et al. Small cell anaplastic carcinoma of the prostate: seven new cases, review of the literature, and discussion of a therapeutic strategy. Am J Clin Oncol. Aug 1997;20(4):376-80.

Reference #2: Tetu B, Ro JY, Ayala AG, Johnson DE, Logothetis CJ, Ordonez NG. Small cell carcinoma of the prostate. Part I. A clinicopathologic study of 20 cases. Cancer. May 15 1987;59(10):1803-9

DISCLOSURE: The following authors have nothing to disclose: Pamela Hoof, Ginger Tsai-Nguyen, Adan Mora

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