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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 37-40

Unusual presentation of adenocarcinoma of lung with metastasis in a young female


Swapn Multispeciality Hospital, Vastral, Ahmedabad, Gujarat, India

Date of Submission01-Jun-2020
Date of Decision08-Jul-2020
Date of Acceptance19-Jul-2020
Date of Web Publication15-Feb-2021

Correspondence Address:
Dr. Hiren P Pandya
Swapn Multispeciality Hospital, Shivsagar Complex, Mahadev Nagar Tekra, Vastral, Ahmedabad, 382418
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacp.jacp_33_20

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  Abstract 


Adenocarcinoma of lung remains the commonest subtype of lung cancer. Despite of recent advances, the presentation of carcinoma of lung is delayed many of the times until later stages. Here is a case of a young pregnant female with adenocarcinoma of lung with brain metastasis with unusual presentation.

Keywords: Adenocarcinoma of lung, brain metastasis, young female


How to cite this article:
Pandya HV, Pandya HP. Unusual presentation of adenocarcinoma of lung with metastasis in a young female. J Assoc Chest Physicians 2021;9:37-40

How to cite this URL:
Pandya HV, Pandya HP. Unusual presentation of adenocarcinoma of lung with metastasis in a young female. J Assoc Chest Physicians [serial online] 2021 [cited 2021 Jun 13];9:37-40. Available from: https://www.jacpjournal.org/text.asp?2021/9/1/37/309473




  Introduction Top


Lung cancer is the commonest cause of cancer-related deaths worldwide.[1] In India, lung cancer is the most common cancer in men and the fourth most common cancer in the overall population.[2] In both smokers and nonsmokers, adenocarcinoma is the most common histological subtype. Despite the recent advances, lung cancer remain undiagnosed until later stages. It is estimated that 40% of patients with newly diagnosed Non-small-cell lung carcinoma (NSCLC) have incurable stage IV disease.[3] Here is a case report of Adenocarcinoma of lung with unusual presentation.


  Case report Top


A 29 year old pregnant female with 34 weeks of gestation presented to OPD with complaints of severe headache with nausea since last 10 days, not subsiding with NSAIDS. There were no complaints of giddiness, fever, altered mental status, seizures or any weakness in any of the limbs. There were no similar episodes in past. Vitals were within normal limits. Neurological, Cardiac and Respiratory examinations were unremarkable. Patient was following regular check-up to gynaecologist during pregnancy.

MRI Brain with venography was done to rule out cerebral venous thrombosis. But to our surprise, it suggested well-circumscribed lesion in left frontal cortex with perilesional edema [Figure 1]. Possibility of metastasis was suggested rather than tuberculoma. MRI spectroscopy was done which showed similar findings but also showed two small nodular enhancing lesions, one in right occipital cortex and other in left inferior cerebellar hemisphere. All findings favouring the possibility of metastasis.
Figure 1 Intra-axial lesion in left frontal cortex with perilesional edema showing extension, mass effect & midline shift

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Because it was critical to look for primary source of malignancy, patient was advised for X-ray chest (with abdominal shield) and USG breast. X-ray chest showed suspected lesion in left lower zone adjacent to heart border [Figure 2]. CT thorax was followed providing abdominal shield which revealed mass lesion in anterior basal segment of left lower lobe [Figure 3]. Bronchoscopy was done which revealed no intrabronchial lesion. So CT guided biopsy from mass was taken and sent for histopathology which revealed adenocarcinoma of lung [Figure 4].
Figure 2 Suspected mass lesion in left paracardiac region

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Figure 3 Mass lesion in anterior basal segment of left lower lobe

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Figure 4 Acinar and papillary clusters of malignant epithelial cells. Suggestive of adenocarcinoma of lung

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Elective Caesarean section was performed which delivered a healthy fetus. Following the delivery of fetus, patient was advised PET CT which showed no lesion elsewhere other than brain and lung. Palliative care has been provided from Radiotherapy and tissue has been sent for immune-histo chemistry (IHC) panel.


  Discussion Top


The published literature on lung cancer in young adult population is scanty; the available studies are small, retrospective case series conducted in one medical institute.[4],[5],[6],[7],[8],[9]

Retrospective studies have confirmed the low rate of early stage disease detection in the young adult group.[6],[9],[10],[11] Lara et al.[12] (The California Registry) reported that 80% of their cohort of adults <50 years of age with NSCLC had advanced stage 3 or 4 disease. Late stage diagnosis could be attributed to the usual behaviour of young patient as well as consultants’ bias towards young adults. Young adult patients are less likely to consider cancer and thus they delay being seen by consultants. Similarly, the consultant may place cancer at the bottom of the differential and therefore may delay in evaluating the patient for possible presence of cancer. Hence, it is not unusual that younger patients are more likely to be asymptomatic at the time of presentation.[13],[14]

Adenocarcinoma accounts for 40% of all types of lung cancer. As seen in current case report of ours, more than 70% of patients are diagnosed in advanced stage (Stage IIIb and IV) where the disease is incurable and associated with poor outcomes.[15]

Historically, lung cancer has been found to be more prevalent in men than in women.[16],[17] Because the incidence of lung cancer in women has risen in recent past, there is increased concern with female lung cancer.[16],[18],[19],[20],[21] Compared with male counterparts, female patients with NSCLC have distinct clinical features.[16],[18],[19],[20],[21] The proportion of never smokers and adenocarcinomas is higher in females than males, result consisting with our case report.[20],[21]

Usually, patients with Lung cancer present with variety of symptoms. However, chest pain is definitively the most frequently reported symptom in younger patients according to comparative analysis.[22],[23] A large study from Korea showed that in most cases, lung cancer was detected with subjective symptoms, but 6.5% of cases had no symptoms indicative of lung cancer at the time of diagnosis.[24] Our patient presented with no symptoms suggestive of lung cancer, in fact patient was incidentally diagnosed to have Adenocarcinoma of lung.

At the time of diagnosis, approximately 50% of the cases of lung carcinoma have distant metastasis.[25] Although exact data are unavailable, the incidence of brain metastases in NSCLC patients is reportedly 24‑44% and it is considered to be increasing with the advances in diagnostic techniques, such as magnetic resonance imaging.[26] Although intention to do MRI in our patient was different, it must be said that our patient would have remained undiagnosed.

Financial Support and Sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Pantel K, Izbicki J, Passlick B, Angstwurm M, Häussinger K, Thetter O et al. Frequency and prognostic significance of isolated tumour cells in bone marrow of patients with non-small-cell lung cancer without overt metastases. Lancet 1996;347:649-53.  Back to cited text no. 1
    
2.
Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C et al. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 11. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://www.globocan.iarc.fr.(Accessed March 21, 2014).  Back to cited text no. 2
    
3.
Socinski MA, Crowell R, Hensing TE et al. Treatment of non‑small cell lung cancer, stage IV: ACCP evidence‑based clinical practice guidelines (2nd edition). Chest 132:S277-S289, 2007.  Back to cited text no. 3
    
4.
Minami H, Yoshimura M, Miyamoto Y et al. Lung cancer in women: sex-associated differences in survival of patients undergoing resection for lung cancer. Chest 2000;118:1603-1609.  Back to cited text no. 4
    
5.
Icard P, Regnard JF, de Napoli S, Rojas-Miranda A, Dartevelle P, Levasseur P. Primary lung cancer in young patients: a study of 82 surgically treated patients. Ann Thorac Surg 1992;54:99-103.  Back to cited text no. 5
    
6.
Antkowiak JG, Regal AM, Takita H. Bronchogenic carcinoma in patients under age 40. Ann Thorac Surg 1989;47:391-3.  Back to cited text no. 6
    
7.
Mauri D, Pentheroudakis G, Bafaloukos D, Pectasides D, Samantas E, Efstathiou E et al. Non-small cell lung cancer in the young: a retrospective analysis of diagnosis, management and outcome data. Anticancer Res 2006;26:3175-81.  Back to cited text no. 7
    
8.
Sugio K, Ishida T, Kaneko S, Yokoyama H, Sugimachi K. Surgically resected lung cancer in young adults. Ann Thorac Surg 1992;53:127-31.  Back to cited text no. 8
    
9.
Green LS, Fortoul TI, Ponciano G, Robles C, Rivero O. Bronchogenic cancer in patients under 40 years old. The experience of a Latin American country. Chest 1993;104:1477-81.  Back to cited text no. 9
    
10.
Bourke W, Milstein D, Giura R, Donghi M, Luisetti M, Rubin AH et al. Lung cancer in young adults. Chest 1992;102:1723-9.  Back to cited text no. 10
    
11.
Liu NS, Spitz MR, Kemp BL, Cooksley C, Fossella FV, Lee JS et al. Adenocarcinoma of the lung in young patients: the M. D. Anderson experience. Cancer 2000;88:1837-41.  Back to cited text no. 11
    
12.
Lara MS, Brunson A, Wun T, Tomlinson B, Qi L, Cress R et al. Predictors of survival for younger patients less than 50 years of age with non-small cell lung cancer (NSCLC): a California Cancer Registry analysis. Lung Cancer 2014;85:264-9.  Back to cited text no. 12
    
13.
Bryant AS, Cerfolio RJ. Differences in outcomes between younger and older patients with non-small cell lung cancer. Ann Thorac Surg 2008;85:1735-9; discussion 9.  Back to cited text no. 13
    
14.
Dell’Amore A, Monteverde M, Martucci N, Davoli F, Caroli G, Pipitone E et al. Surgery for non-small cell lung cancer in younger patients: what are the differences? Heart Lung Circ 2015;24:62-8.  Back to cited text no. 14
    
15.
Travis WD, Brambilla E, Muller‑Hermelink HK, Harris CC, editors. World Health Organization Classification of Tumours, Pathology and Genetics of Tumours of the Lung, Pleura, Thymus and Heart. Lyon: IARC Press 2004. p. 12-5  Back to cited text no. 15
    
16.
Fu JB, Kau TY, Severson RK et al. Lung cancer in women: analysis of the national Surveillance, Epidemiology, and End Results database. Chest 2005;127:768-77.  Back to cited text no. 16
    
17.
Won Y, Sung J, Jung K et al. Nationwide cancer incidence in Korea, 2003–2005. Cancer Res Treat 2009;41:122-31.  Back to cited text no. 17
    
18.
Matsuo K, Ito H, Yatabe Y et al. Risk factors differ for non-small-cell lung cancers with and without EGFR mutation: assessment of smoking and sex by a case-control study in Japanese. Cancer Sci 2007;98:96-101.  Back to cited text no. 18
    
19.
Planchard D, Loriot Y, Goubar A et al. Differential expression of biomarkers in men and women. Semin Oncol 2009;36:553-65.  Back to cited text no. 19
    
20.
Chen K, Chang C, Yu C et al. Distribution according to histologic type and outcome by gender and age group in Taiwanese patients with lung carcinoma. Cancer 2005;103:2566-74.  Back to cited text no. 20
    
21.
Visbal AL, Williams BA, Nichols FC et al. Gender differences in non-small-cell lung cancer survival: an analysis of 4, 618 patients diagnosed between1997 and 2002. Ann Thorac Surg 2004;78:209-15; discussion 215.  Back to cited text no. 21
    
22.
Kuo CW, Chen YM, Chao JY et al. Non-small cell lung cancer in very young and very old patients. Chest 2000;117:354-57. [PubMed]  Back to cited text no. 22
    
23.
Radzikowska E, Roszkowski K, Glaz P. Lung cancer in patients under 50 years old. Lung Cancer 2001;33:203-11.  Back to cited text no. 23
    
24.
In KH, Kwon YS, Oh IJ, Kim KS, Jung MH, Lee KH, Kim SY, Ryu JS, Lee SY, Jeong ET, Lee SY. Lung cancer patients who are asymptomatic at diagnosis show favorable prognosis: a Korean Lung Cancer Registry Study. Lung Cancer 2009;64:232-7.  Back to cited text no. 24
    
25.
Fısher ER, Gıngrıch RM, Gruhn J, Laıng P. Ossifying metastatic carcinoma; report of a case with comments relative to histogenesis of ectopic ossification. Cancer 1959;12:257-62.  Back to cited text no. 25
    
26.
Nayak L, Lee EQ, Wen PY. Epidemiology of brain metastases. Curr Oncol Rep 2012;14:48-54.  Back to cited text no. 26
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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