A 72 years old normotensive, non-diabetic male smoker presented with dull aching pain in the upper anterior chest wall adjacent to sternum, along with cough with scanty, white, mucoid expectoration for one month. His night sleep was disturbed due to severe chest pain which was not relieved by non-narcotic analgesic. He also complained of a gradually progressive hoarseness of voice for fifteen days. He had a history of anorexia and a significant weight loss, but there was no history of hemoptysis or dyspnoea. No past history of pulmonary tuberculosis was present either.
On general survey, he had pallor, clubbing, and left sided supraclavicular lymphadenopathy. His axillary temperature, respiratory rate, pulse rate and blood pressure were 36 C, 16 breaths/minute, 100 beats/minute and 110/80 mmHg respectively. On examination of respiratory process, the chest was acutely tendered in the left infraclavicular area and in sternal region, but no mass was palpable. Percussion note over left second and third intercostal spaces near parasternal area and over sternum was dull. Complete hemogram, blood biochemistry and urinalysis proved normal. Sputum smear for acid fast bacilli and malignant cells was negative. Chest X-ray (posteroanterior view) showed left sided para-hilar mass with irregular margin. Contrast enhanced computed tomography (CECT) of the thorax showed a soft tissue mass in the left upper lobe with variegated appearance and irregular margin without any calcification, associated with left sided mediastinal lymphadenopathy and osteolytic erosion of left half of the manubrium sterni (Figure 1). Radioisotope bone scan using Technetium -99m (99mTc) labeled methylene diphosphonate (MDP) showed sternal deposit without the involvement of other bones. Ultrasound of abdomen was also normal. Fibreoptic bronchoscopy (FOB) showed no endobronchial lesion and bronchoalveolar (BAL) lavage fluid revealed no acid fast bacillus or malignant cell. Fine needle aspiration cytology (FNAC) of left supraclavicular lymphadenopathy showed metastatic squamous cell carcinoma. CT-guided FNAC of the left lung mass showed dispersed clusters of malignant epithelial cells with squamous differentiation and cytoplasmic keratinization in the background of inflammatory cells (Figure 2). CT-guided FNAC of sternal lesion yielded a similar cytology. Hence, final diagnosis was squamous cell carcinoma of left lung with sternum and mediastinal plus cervical lymph node metastases. The patient was advised for cytotoxic chemotherapy comprising of cisplatin and etoposide, but unfortunately, he succumbed to his illness before initiation of first cycle of chemotherapy.
CECT thorax showing left upper lobe mass with erosion of manubrium sterni.