PRIMARY PULMONARY CAVITATING ADENOCARCINOMA IN A PATIENT PRESENTING WITH COVID-19 PNEUMONIA: A CASE REPORT

ABSTRACT

SESSION TITLE Lung Cancer Imaging Case Report Posters 2 SESSION TYPE Case Report Posters PRESENTED ON 10/19/2022 1245 pm - 0145 pm INTRODUCTION: SARS-CoV-2 pneumonia typically presents with ground-glass and consolidative pulmonary opacities, atypically small cavities may be seen in severe cases. In patients with cavities persisting beyond 12 weeks, an underlying malignancy is a worrisome concern. We present a case of a 39-year old female without significant risk factors for pulmonary malignancy who was found, surprisingly, to have a cavitating adenocarcinoma in the setting of COVID-19 Pneumonia. CASE PRESENTATION A 39 year old obese African American female, never smoker, with co-existing metabolic syndrome presented to our institution with a four day history of productive cough (without hemoptysis), body aches, fever and fatigue. She denied weight loss or loss of appetite. No known family history of malignancy. She tested positive for SARS-CoV-2. She was clinically stable, hence discharged home with recommendations for quarantine and supportive care. She returned the following day with worsening dyspnea. Her chest radiograph noted a supra-hilar opacity with central lucency, Chest CT revealed wedge-shaped ground-glass and consolidative density in the right lower lobe and a 3.8 x 4.1 cm cavitary right upper lobe mass with mediastinal lymphadenopathy. She received parenteral antibiotic therapy and underwent infectious and autoimmune workup, which was negative. Repeat CT imaging, approximately three months post discharge, revealed persisting cavitary lesion and enlarging mediastinal lymphadenopathy. She underwent Electromagnetic Navigational Bronchoscopy with biopsy and fine needle aspiration of mediastinal lymph nodes (stations 7 and 4R) via endobronchial ultrasound. Biopsy results and fine needle aspiration of lymph nodes revealed adenocarcinoma with tumor cells being positive for TTF-1 and negative for CK20, CDX2, GATA3, PAX8 and Synaptophysin. Next generation sequencing reported several variants including EGFR and Tp53, there was also noted amplification of CDK4 and MDM2. PDL-1 was negative. DISCUSSION: A cavity is a gas-filled space, seen as a lucency or low-attenuation area, within a nodule, mass, or area of parenchymal consolidation. Underlying etiologies are typically classified as infectious, autoimmune and malignant. Cavities are atypical findings on CT imaging in patients with viral pneumonias, including SARS-CoV-2. Those cavities persisting beyond 12 weeks are typically classified as being chronic, with malignancy a key concern in these patients. The most common type of primary cavitary lung cancer is squamous cell carcinoma, in fact Primary Pulmonary Adenocarcinomas are unlikely to cavitate. Treatment options, depending on the presence of targetable mutations, include concurrent chemoradiation, chemoimmunotherapy or oral targeted agent. CONCLUSIONS: Though an atypical presentation, Pulmonary Adenocarcinoma may present as a cavitary lesion, particularly in the presence of persisting or enlarging lymphadenopathy. Reference #1 Gafoor K, Patel S, Girvin F, Gupta N, Naidich D, Machnicki S, Brown KK, Mehta A, Husta B, Ryu JH, Sarosi GA, Franquet T, Verschakelen J, Johkoh T, Travis W, Raoof S. Cavitary Lung Diseases A Clinical-Radiologic Algorithmic Approach. Chest. 2018 Jun;153(6)1443-1465. doi 10.1016/j.chest.2018.02.026. Epub 2018 Mar 6. PMID 29518379. Reference #2 Radiological Society of North America Expert Consensus Document on Reporting Chest CT Findings Related to COVID-19 Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA Scott Simpson, Fernando U. Kay, Suhny Abbara, Sanjeev Bhalla, Jonathan H. Chung, Michael Chung, Travis S. Henry, Jeffrey P. Kanne, Seth Kligerman, Jane P. Ko, and Harold Litt Radiology Cardiothoracic Imaging 2020 22 DISCLOSURES No relevant relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No relevant relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No releva t relationships by Mark Bowling, value=Consulting fee Removed 04/02/2022 by Mark Bowling No relevant relationships by Sulaiman Tijani