3 Aug 2021

4/22/21: Metastatic Lung Adenocarcinoma in Pregnancy

PGY2 Alexander Klonoff presented a case of a 27 year old female G4P1021 in 27w4d gestation with reported history of pericardial effusion s/p pericardiocentesis 2 months ago at outside hospital who presents with back pain 3 months and acute on chronic cough x9 months.  Patient states she has had a unproductive dry cough for the pat 9 months, associated with dry mouth and development of dental cavities during her pregnancy.  The cough has worsened over the past 3 months with increase in frequency and duration for each episode of cough, and is associated with sharp left sided chest pain.  Around 3 months ago, she also started experiencing intermittent localized 6/10 dull achy pain over bilateral scapular region that is worse with laying supine and improved with sitting up and NSAIDs.

ROS: + alopecia, dry mouth and L arm pain

Home Meds: None

FH: No family history of autoimmune disease, asthma, or malignancy

SH: denies tobacco, ETOH or drug use

OBGYN Hx: 2 spontaneous abortions at 4weeks (3 years ago and 4 years ago), 1 termed birth 2 years ago

Vitals: T 36.6, HR 99, RR 21, BP 85/51, O2 sat 100% on RA

Physical Exam: +mobile, tender L supraclavicular LAD, +pericardial friction rub over LLSB, diminished breath soundo n the L mid and lower lung field with dullness to percussion

CBC: WBC 8.6> Hb 9.9/Hct 31 <Plt 293(MCV 84.5, RDW 18.5%)

CMP:

Na 136/K 4.7/Cl 103/HCO3 20/BUN 4/Cr 0.37<Glucose 82

ALP 117>T.protein 6.1/Albumin 3.2/AST 19/ALT 8/Tbili 0.2/Dbili <0.2

Ca 8.3, Mg 2.0 Phos 3.6

Coags: PT 13.9, INR 1.08, PTT 33.2

CXR with opacity in the LLL.

Infectious workup including BCx, UCx, procal, RPR, HIV, hepatitis panel, fungal and TB all negative.

APLS labs: all negative

LDH within normal limits

Rheum workup completed with the following findings:

  • ANA 1:80, positive, speckled
  • ANCA, dsDNA, RF, Scl-70 all negative
  • C3 and C4 normal limits
  • SSA Ab: 4.5 (high), SSB Ab <1 (normal)

US Head and neck: abnormally enlarged L supraclavicular LN.

CT Thorax/Abdomen/Pelvis with contrast: 3cm LLL mass.  L upper and lower lobe nodular interlobular septal thickening and peri-lymphatic nodules.  Extensive mediastinal, supraclavicular, hilar, retroperitoneal and pelvic LN enlargement.  Nodular pericardial thickening.

L supraclavicular LN core biopsy: Metastatic adenocarcinoma, immunostain pattern consistent with lung primary

Treatment: Patient was started on broad spectrum antibiotics while awaiting results from fungal/bacterial/viral workup.  Core needle biopsy showed metastatic adenocarcinoma of the lung, and she was started on crizotinib given positive for ALK rearrangement.  Delivery was induced at 34 weeks given crizotinib is a category D for pregnancy and thus cannot be initiated until patient delivered.  Patient was found to have brain mets and transitions to alectinib s/p WBRT.  Most recent imaging with no evidence of progression.

Teaching points:

1. Fewer than 70 cases of lung cancer in pregnancy have been published.  Poor prognosis; median survivial approximately 4.5 months (range 1-42 months).  Lung cancer in setting of pregnancy likely due in part to increase in hormone levels during pregnancy, continuation of tobacco consumption in young women even during gestation and delaying of pregnancies into the third or fourth decades of life.

2. Advanced disease of lung cancer is treated with combination of surgery, chemotherapy and radiation.  Crizotinib (oral ALK inhibitor) is demonstrated to provide dramatic clinical benefit with little toxicity in patients having advance NSCLC.

3. New UPSTF guidelines updated 3/9/2021: Annual low dose CT scan for adults who have a 20 pack year smoking history and currently smoke or have quit within the past 15 years.

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