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An official publication of the Middle-Eastern Association for Cancer Research
Clinical Cancer Investigation Journal
ISSN Print: 2278-1668, Online: 2278-0513
ARTICLE
Year: 2022   |   Volume: 11   |   Issue: 2   |   Page: 21-25     View issue

Adenocarcinoma Lung Diagnosed as a ‘Synchronous Primary Double Malignancy’ in Treated Case of Carcinoma of Breast: Case Report

Shital Patil1*, Deepak Patil2, Gajanan Gondhali2

1Pulmonary Medicine, MIMSR Medical College, Latur, Maharashtra, India. 2Internal Medicine, MIMSR Medical College, Latur, Maharashtra, India.


Abstract

Double primary malignancies are rarely observed in breast malignancy, and frequently documented in hematological and gynecological malignancies due to genetic mutations. In present case report, 48-year female presented with left breast carcinoma undergone surgical treatment and received first chemotherapy cycle. Her general health deteriorated and present in our center due to worsened dyspnea. Her radiological workup shown possible metastatic lung process from on treatment carcinoma left breast as classically described ‘bilateral cannon ball’ opacities with middle lobe lung mass. Bronchoscopy was done in critical care unit with oxygen supplementation in sick health after clinical stability. Bronchoscopy workup documented Lung adenocarcinoma. Immunohistochemistry confirmed as Primary lung adenocarcinoma with EGFR positivity. Palliative care was offered due to poor performance status and EGFR targeted therapy was initiated. In this case report we have documented concurrent occurrence of carcinoma breast and adenocarcinoma lung as double primary malignancy.

Keywords: Double primary malignancy, Carcinoma breast, Adenocarcinoma lung, Bronchoscopy, Targeted therapy


Introduction

Double primary malignancies are occurrence malignant process in two different anatomically defined organ sites with different histology concurrently or sequentially. Double primary malignancies have been described since last century and more frequently documented in visceral, gynecological and endocrine malignancies. Rationale for more reporting of double primary malignancies would be increased survival of general population, increased awareness regarding cancer detection and advancement in cancer screening and diagnosis.[1] Depending on the time between tumor diagnoses, there are two categories of double primary malignancies.[2] Synchronous malignancies are those in which a secondary tumor develops at the same time as the primary tumor or within six months of it, whereas metachronous malignancies are those in which the secondary tumor develops more than six months after the primary tumor.[2]

Case summary

48-year-old female, farmer by occupation, no addiction history, normotensive, non-diabetic, referred to our center by family physician for-shortness of breath in recently diagnosed carcinoma of breast. 

Clinical details documented as-

  1. Cough-for 2 months dry, intermittent, with minimal white sputum production.
  2. Shortness of breath on exertion in the last 2 months, initially grade 1 and progressed to grade IV and associated with drastically change in quality of life leading to inability to perform routine activities due to shortness of breath. Loss of appetite and weight loss over period of 4months
  3. Weakness and myalgia with fatigability for 4 months

 

Clinical Examination Documented as-

Restless, dry oral mucosa, cyanosis

Heart rate-130/min Respiratory rate: 46/bpm, BP-160/90 mmhg

PsO2: 71@ room air resting & 89-91% @ 14 litres/minute oxygen with reservoir bag

Respiratory system examination revealed- bilateral breath sounds normal, bilateral crepitation’s heard on both lung fields

Nervous system examination- higher functions normal, no neurological

abnormality

 

Cardiovascular and gastrointestinal systems were normal

Her husband disclosed that she was diagnosed as case of infiltrating ductal carcinoma of left breast 6 months back. She undergone mastectomy left side with one follow up chemotherapy cycle. After first chemotherapy cycle, she developed loss of appetite, weakness and myalgia and they decided for prolongation of chemotherapy cycle to avoid further worsening of general health condition. Subsequently, she developed dry cough and breathlessness which was progressive and worsened over 2 months of initial symptoms to bedridden stage. She has consulted to local family physician and took chest x-rays. We have reassessed chest imaging and observed normal chest x-ray taken at one month (Figure 1) and two month (Figure 2) interval, and mammography reports showing micro lobulated irregular mass lesion in inner quadrant with left breast with rest of the parenchyma showing micro calcifications (Figure 3). She was referred by family physician to our centre for worsening of dyspnoea. Her chest x-ray done by family physician shown right middle zone lobulated mass and left paracradiac nodular opacity (Figure 4). As patients’ general health is deteriorating and underestimation of bilateral lung pathology in previous hospital visits by general physicians, we have repeated chest X-ray and documented more advanced and predominant parenchymal abnormalities in bilateral middle and lower lung in bilateral lung in all zones (Figure 5).

Figure 1. chest x-ray posteroanterior view showing normal lung parenchyma

 

Figure 2. chest x-ray posteroanterior view showing normal lung parenchyma

 

Figure 3. Mammography- microlobulated irregular mass lesion in inner quadrant with left breast with rest of the parenchyma showing microcalcifications (BIRADS-V)

 

Figure 4. chest x-ray posteroanterior view showing right middle zone lobulated mass and left paracradiac nodular opacity

 

Figure 5. chest x-ray posteroanterior view showing predominant parenchymal abnormalities in bilateral middle and lower lung

Laboratory Examination Documented as-

Hemoglobin-10.3 gm% total white blood cells- 3000/mm3 Polymorphs-70%, Platelet count-190000/uL

CRP- 45 mg/L (0-6 mg/L), random blood sugar level-144 mg% HbA1C-5.70 %

LDH-1080 IU/L (70-470 IU/L), Uric acid-3.4 mg (3.5-7.5 mg/dL)

Serum electrolytes: Sodium-131 meq/L (135-145 meq/L) Potassium-3.8 meq/L (3.5-5.5 meq/L) Ionic calcium-1.32 meq/L (1.09-1.36 meq/L)

D-dimer- 568 ng/ml (<500 ng/ml)

IL-6-4.75 pg/ml (0.00-7.00 pg/ml)

Thyroid functions-normal

Liver and kidney functions- normal

Induced Sputum examination for acid fast bacilli was negative and TB Gene Xpert MTB/RIF were negative for MTB genome.

As patient’s tropical workup is negative and showing leucopoenia with raised CRP titre, we have started her on oxygen supplementation with target oxygen saturation above 90 % and intravenous methylprednisolone, Injection meropenem and moxifloxacin and supportive care with intravenous saline. Her general health improved on day 3 of hospitalization and we have done HRCT thorax to rule out opportunistic infection or pneumonia after chemotherapy.

HRCT Thorax suggestive of

  1. bilateral, peripheral and central multifocal nodular masses and cannon ball opacities
  2. central right lung mass with narrowing of right main stem bronchus
  3. right middle lobe mass with narrowing of intermediate bronchus
  4. right lower lobe parenchymal mass with collapse of bronchial luminal opening
  5. left hilar mass

 

 

Figure 6. HRCT thorax showing bilateral cannon ball opacities with central parenchymal opacities suggestive of metastatic lung disease

 

As HRCT thorax was showing possible malignant lesions in lung, we have performed portable bronchoscopy in intensive care unit with oxygen supplementation and documented growth in intermediate bronchus. Bronchoscope could not negotiate distal to mucosal narrowing and fragile nature of growth. We have taken four bronchial biopsy specimens and sent for histopathology. Local minor bleeding documented after biopsy and vital parameters were normal after bronchoscopy.             

We have sent 40 ml of bronchial aspirate collected after instillation of 60 ml saline during procedure and biopsy specimens to onomatologist.

BAL AFB-Negative, Gene Xpert MTB/RIF- Negative

BAL Bacterial culture- no growth,

Bronchial aspirate was showing malignant cells positive with possible adenocarcinoma type. Histopathology of bronchial biopsy were showing papillary adenocarcinoma (Figure 7).