The patient was a 55-year-old man current smoker. He underwent a left pneumonectomy with lymph node resection in 2007 for a huge tumor of the left lower lobe. The pathological examination found a typical carcinoid tumor of 8 cm long axis of the left lower lobe with minimal infiltration of the upper lobe, pulmonary and lymph node caseo-follicular tuberculosis. Hilar and mediastinal lymph node examination had shown no metastasis.
A histological diagnosis of bronchial carcinoid tumor was made. No adjuvant chemotherapy was undergone. Pulmonary tuberculosis was treated using a six-months-lasting oral quadritherapy including Isoniazid, Rifampicin, Pyrazinamide, and Ethambutol. Clinical and radiological follow-up for ten years had shown no recurrence sign. The patient presented in 2019 an intense lumbar squeezing pain progressively worsened, not relieved after using Paracetamol or Ibuprofen. Our patient noted also crural electrical discharges when he walked.
On examination, there were new obvious signs detected on sight: protruding lower jaw and brow, an enlarged nose, thickened lips, coarse fingers and toes (Fig. 1). Acromegaly was recognized and we suspected a paraneoplastic mechanism. We detected on examination also, the presence of a left paravertebral swelling at the level of T 12, quite painful on palpation.
A whole-body scanner was requested. It has shown a left pneumonectomy with a free right bronchial stump, diffuse dense right pulmonary nodules of different sizes. The largest nodule sits at the ventral segment of the right upper lobe and measures 13mm. We spotted multiple osseous lesions concerning the posterior arch of the 12th left rib with extension to the soft parts, the right side of the third lumbar vertebra, and into the medullary canal (Fig. 2).
CT scan had shown also multiple hypodense liver nodules, the greatest of which sized 21 mm in diameter, osteocondensing lesions of the skull, which sit at the frontal bone and the left parietal bone.
A biopsy of the hepatic nodule by echo-guided route was performed, concluding with a secondary localization of a typical carcinoid tumor (Fig. 3).
Oral route morphine was prescribed to get sufficient spinal analgesia. Palliative chemotherapy based on Cisplatin and Etoposide was started. After having received four cycles of chemotherapy, a body CT scan compared to the first imaging findings concluded to stability of the tumor volume. There was no regression of the paraneoplastic signs after chemotherapy. The patient is alive nowadays after a follow-up of 14 months.