The diagnostic challenge in a patient with metachronous malignancies

Abstract

Introduction. Metachronous malignancies are a rare entity in clinical practice. This case report reveals interconnection between a malignant adrenal tumor diagnosed 6 years ago and a rare central bronchial carcinoid tumor that developed later. This case also illustrates the differential diagnosis with the pathology of fungal etiology. Case statement. A 64-year-old woman, never a smoker, with a history of malignant adrenal tumor diagnosed in 2017, presented with complaints of dry cough, chest discomfort and fatigue. Despite previous treatments with minimal improvement, suspicion of malignancy led to referral to the Oncology Institute. Bronchoscopy revealed a complete bronchial obstruction of the upper lobar bronchus. Pathological examination of the biopsy specimen showed fragments of necrotic masses, with positive Grocott staining revealing Aspergillus hyphae. Being suspected of pulmonary aspergillosis the patient was referred to the tertiary level pulmonology clinic for diagnosis and treatment. A repeated biopsy from the bronchial mass obstructing the bronchus identified a carcinoid tumor in the upper lobe of the right lung, while the contrast chest CT showed evidence of pulmonary metastasis on the contralateral lung. Discussions. Metachronous malignant tumors are a rare phenomenon, with an incidence ranging between 1.33% and 5.8%. Moreover, carcinoid tumors are rare malignancies of the neuroendocrine system which account for 2% of all lung cancer cases. The present case illustrates the unique coexistence of these rare medical entities. Conclusion. This case report demonstrates the need for a comprehensive approach to patients with a history of malignant tumors in view of the possibility of metachronous cancers. reveals interconnection between a malignant adrenal tumo r diagnosed 6 years ago and a rare central bronchial carcinoid tumor that developed later. T his case also illustrates the differential diagnosis with the pathology of fungal etiology. Case statement. A 64-year-old woman, never a smoker, with a history of m alignant adrenal tumor diagnosed in 2017, presented with complaints of dry cough, che st discomfort and fatigue. Despite previous treatments with minimal improvement, suspicion of malignancy led to referral to the Oncology Institute. Bronchoscopy revealed a complete br onchial obstruction of the upper lobar bronchus. Pathological examination of the biopsy specimen showed fragments of necrotic masses, with positive Grocott staining revealing Aspergillus hyphae. Being sus pected of pulmonary aspergillosis the patient was referred to the tertiary lev el pulmonology clinic for diagnosis and treatment. A repeated biopsy from the bronchial mass ob structing the bronchus identified a carcinoid tumor in the upper lobe of the right lung, while the contrast chest CT showed evidence of pulmonary metastasis on the contralateral lung. Discussions. Metachronous malignant tumors are a rare phenomenon, w ith an incidence ranging between 1.33% and 5.8%. Moreover, carcinoid tumors are rare malignancies of the neuroendocrine system which account for 2% of all lung cancer cases. The present case illustrates the unique coexistence of these rare medical entities. Conclusion. This case report demonstrates the need for a comprehensive approach to patients with a history of malignant tumors in view of the possibility of metachronous cancers.