Case Presentation
This patient was a 56-year-old female who presented to a local urgent care due to persistent cough that she had had for about a week. The cough was dry in nature (no hemoptysis) and her only other complaints at the time were severe joint pain, requiring NSAID use, and swelling of her fingers. While she was there, she was tested for COVID, which was negative, and had a CXR which was read after the patient left the urgent care. Of note, this patient had minimal past medical history but did have a 55-pack year smoking history with cessation of tobacco products 2 years prior. Patient does vape daily. After the urgent care visit, she was sent home with azithromycin for suspected community acquired pneumonia but was later called for a suspicious lesion found on the CXR located near the right lateral pleural space. This lesion was not seen on CXR that she had 5 years prior, for an unrelated issue.
She was then referred to a pulmonologist for evaluation of the persistent cough and CXR finding. The pulmonologist did a thorough work up for the right lower lobe lung mass, which included a CT of the abdomen/pelvis, pulmonary function tests, and a PET scan of her body, with plans to biopsy the mass (Figure 1). A CT guided biopsy of the mass was diagnostic for invasive poorly differentiated squamous cell carcinoma. PET CT scan and MRI of the spine revealed the mass to be without metastases. However, the imaging did reveal right posterolateral chest wall involvement.
At this time, she was sent to thoracic surgery for pre-operative evaluation. Upon presentation to our clinic, patient states she was taking ibuprofen for left knee pain that started about a year ago and a few months after the onset the pain migrated to other sites, including her right knee, right ankle, and left foot. She had also noticed progressive swelling in her phalanges and metacarpal bones bilaterally at the time she developed the nonproductive cough.
After appropriate clearances patient underwent a flexible bronchoscopy, right posterolateral thoracotomy with a right lower lobectomy with en bloc chest wall resection of posterior ribs 7-8, and a mediastinal lymph node dissection. Patient was discharged on post op day 4 without complications and was seen again in the clinic for a 1 week follow. The final pathology demonstrated an 11 cm, T4 N0 M0 Stage IIIB squamous cell carcinoma. During the visit she noted that her joint pain and swelling had significantly improved. She then continued on to her post operative adjuvant chemotherapy and her follow up surveillance appointments, according to the NCCN guidelines; 6 month follow up PET-CT showed no evidence of active neoplastic disease (Figure 2).