A 64-year-old male, a current smoker with a wet cough and fever lasting for one week followed by the spontaneous resolution of symptoms, presented to the outpatient clinic for an evaluation of an abnormal shadow on a chest X-ray. The chest X-ray showed an area of consolidation in the apex of the right lung (Figure 1A). In addition, laboratory tests revealed an elevated CRP level(3.86 mg/L) and white blood cell count (8,980 ml), although the levels of serum tumor markers such as CEA, CYFLA, and ProGRP were within the normal range. Contrast-enhanced CT showed a low-density lesion with thick ring-enhanced irregular walls in the right upper lobe. The mass measured 53x43 mm, and had poorly defined margins. The interface between the lesion and surrounding organs was not clear. No gas collection or calcification was indicated. Enlarged lymph nodes were not detected in the mediastinum(Figure 1B). A PET/CT scan demonstrated a high uptake in the lesion, with a maximum SUV of 8.7, and the mediastinal lymph node, with a maximum SUV of 3.7, suspicious for both lung cancer and lung abscess formation (Figure 1C). An abscess was initially suspected based on the patient's symptoms, CT image findings and laboratory test results. Both a transbronchial lung biopsy (TBLB) and CT-guided fine-needle biopsy of the lesion showed inflammatory cells compatible with active inflammation, No malignant cells were seen, and all bacterial cultures were negative.
The patient was referred to our institution for management of the mass one month later. We suspected that the lesion indicated malignancy, as a follow-up CT scan showed an increase in the lesion in size to 59x49 mm (Figure 2) despite the absence of symptoms, such as fever. Therefore, we planned to perform surgery because there were no other signs of distant metastasis based on a CT scan of the chest, abdomen and pelvis, brain MRI and PET/CT.
Based on the intraoperative findings, the right middle lobe was found to be involved with the mass in the upper lobe. A pathological diagnosis of lung cancer was confirmed according to the results of a rapid frozen section biopsy of the lesion. Consequently, we performed the right upper and middle lobectomy. There were no intraoperative complications, and the patient had an uneventful recovery. The final results of the pathologic examination showed a pleomorphic carcinoma of pT2N0M0, stage A.