A 74-year-old male with 37-pack year smoking history presented to the clinic with complaints of intermittent hemoptysis, wheezing cough, and 35-pound weight loss. He has a past medical history of pulmonary embolism on anticoagulation, bullous emphysema, asbestos exposure and diagnosis of limited small cell lung cancer (2 cm in greatest dimension, Stage IB high grade neuroendocrine carcinoma, T2a, N0 M0, positive visceral pleural invasion, negative margins with 0/26 lymph node showing no metastasis) 3 years ago treated with left thoracotomy and left upper lobectomy along with adjuvant chemotherapy (Cisplatin and Etoposide) and prophylactic cranial irradiation (PCI).
He responded well and was symptom free for 3 years. He had surveillance CT scan of the chest 1 year back which showed stable multiple lung nodules and new 1.5 cm stellate nodule in the right upper lobe and a slight enlargement of 8 mm nodule in the posterior right lower lobe. He also had a follow up positron emission tomography (PET) scan that showed an area in the right upper lobe with standardized uptake value (SUV) of 2.2 which might harbor multiple dysplastic nodules but were not large enough for biopsy. Patient underwent Navigational bronchoscopy and pathology was inconclusive. Patient presented to the primary care physician 6 months later with 3-week history of new onset cough, wheezing and 10 lb weight loss. The cough was productive with intermittent bloody sputum associated with nasal congestion and postnasal drip. He denied chest pain, chills, fever, headaches, heartburn, myalgias, rash, rhinorrhea, sore throat, shortness of breath and night sweats. Patient was on anticoagulation with rivaroxaban, which was continued since he had history of pulmonary embolism. He was treated for upper respiratory infection with oral antibiotics. Patient had 2 admissions to the hospital in 1-month duration for exacerbation of chronic obstructive pulmonary disease and had another CT scan of Chest on his second admission. It revealed a polypoid mass in the anterior wall of upper trachea suspicious for malignant lesion with a 2nd mass also arising from anterior wall suspicious for malignancy vs. adherent debris (Fig. 1). It also revealed new mild adenopathy on the right side, 6 mm nodule in the left lower lobe, prominent peribronchial thickening in the left lower lobe (Fig. 1). Patient underwent bronchoscopy (Fig. 2) that showed two tracheal polyps/lesions causing up to 50% tracheal obstruction. Biopsies were taken and pathology was consistent with small-cell lung cancer (Fig. 3, Fig. 4, Fig. 5). Patient was referred to Interventional Pulmonology and he underwent rigid bronchoscopy with tumor debulking along with cauterization of the two-polypoid lesions. Patient's clinical symptoms including cough and wheezing improved with plans to proceed with definitive treatment, including chemo-radiotherapy.