The patient, a 68-year-old male, was admitted to our hospital because of "cough and sputum with breathlessness for 3 months". The patient presented with cough and sputum 3 months ago. Specifically, the patient had a paroxysmal cough with white mucous sputum, accompanied by chest distress, shortness of breath, and numbness of both lower limbs. He had a previous history of smoking for 50 years (20 cigarettes/day) but had quit smoking for 5 months. The rest of his past medical history was negative.
Physical examination: general condition was acceptable, superficial lymph nodes were not palpably enlarged, and the breath sounds of both lungs were rough without rhonchus and moist rales. No abnormalities were found on cardiac or abdominal examination.
The examinations undertaken are listed in Table 1. All images were taken by contrast-enhanced CT.
1. Chest CT plain scan and enhanced scan: (Figures 1A, B, 05 March 2022): a mixed-density mass measuring approximately 12.6 x 7.6 cm was found on the left upper lobe of the lung, with truncated bronchi in the upper lobe of the left lung, localized thinning of the left pulmonary artery, and multiple small patchy and nodular high-density shadows in the surrounding lung; multiple small nodules and small patchy high-density shadows were found in the lower lobe of the left lung.
2. Cranial MRI plain scan and enhanced scan (06 March 2022): abnormal lesion signal shadow was found in the anterior horn of the left lateral ventricle, which was presumed to be a cavernous hemangioma.
3. Tracheoscopy (09 March 2022): cauliflower-like neoplasm was found to block the orifice in the upper lobe of the left lung, and the opening of the lower lobe was slightly compressed and narrowed; no abnormalities were found in the bronchial tubes of the bilateral lobes.
4. Tumor markers (03 March 2022): carcinoembryonic antigen (CEA) was 6mg/ml, CA125 was 88.18U/ml, section 19 of cytokeratin was 12.91ng/ml, and neuron-specific enolase (NSE) was 33.72ng/ml.
There were no abnormalities in the routine blood test, whole-body bone imaging, biochemistry analysis, blood clotting, echocardiography, and electrocardiogram.
Pathological findings: the moderately differentiated squamous cell carcinoma was revealed (through bronchoscopy biopsy of left upper lobe lung). Immunohistochemical findings: CK5/6 (+), CK7 (-), Ki-67 (+, 50%-60%), NapsinA (-), P40 (+), TTF-1 (-), and P63 (+). No abnormalities were found in etiological examinations for bacteria, fungus, M. tuberculosis, Pneumocystis carinii, Actinomyces, nocardiosis, and cytomegalovirus.
Final diagnosis: there was a malignant tumor (squamous cell carcinoma, cT4N3M0 IIIC) with obstructive pneumonia in the upper lobe of the left lung. Since the patient had no surgical indications, he was suggested for chemotherapy combined with radiotherapy and PD-L1 testing. Genetic testing showed negative results for EGFR, ALK, ROS1, and PD-L1 expression.
Treatment:
Treatment course: a brief description of the treatment course is shown in Figure 2. After excluding contraindications, the first cycle of DP chemotherapy (docetaxel 120mg d1 + cisplatin 40mg d1-d3) was administered on 15 March 2022. Here, the chemotherapy went smoothly and the patient did not have any complaints. Then, the second cycle of chemotherapy was administered on 05 April 2022 with the same regimen as the first cycle. During chemotherapy, the patient had a severe gastrointestinal reaction and bone marrow suppression, with white blood cells falling to 1.3 x 109/L and neutrophils dropping to 0.23 x 109/L. Also, the patient was given symptomatic treatment such as leuke-raising injections but refused to accept another cycle of chemotherapy. After excluding contraindications, he was treated with 200 mg of camrelizumab for immunotherapy on 25 April 2022. On 21 May 2022, the patient began to cough up blood in phlegm with a volume of about 20 ml and he was reviewed using a chest CT on 22 May 2022 (Figures 3A, B), which showed that the lung cancer in the upper lobe of the left lung was less extensive than before, while multiple small nodules and small patchy high-density shadows in both lungs were more extensive than before, which could not exclude pneumonia or infection associated with ICIs. The patient was diagnosed with a tracheoscopy and a 13-item nucleic acid test for respiratory pathogens in the lavage fluid, which was positive for MTB. Moreover, the acid-fast bacillus stain test was positive. Therefore, the patient was considered to have active TB. Multidisciplinary oncology consultation suggested that the patient should stop immunotherapy and be treated with a four-drug anti-TB regimen of isoniazide, rifampicin, ethambutol, and pyrazinamide. After 3 months of anti-TB treatment, the patient was reviewed using an enhanced CT scan on 19 August 2022, which showed that the primary focus of cancer in the right lung was stable and the nodular and small patchy high-density shadows in both lungs were less extensive than before (Figures 4A, B). Finally, the lung was stable, and no further ICIs were administered.The patient is currently in a relatively stable condition and is being followed up.
Chest CT on 22 May 2022. (A) The lung cancer in the upper lobe of the left lung was less extensive than before.