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A 25 year old unmarried lady was admitted to our department with complaints of abdominal swelling for one month, anorexia, occasional pain abdomen & vomiting. She had chest pain and haemoptysis 9 months back. Chest X-ray done at that time showed homogeneous opacity in lower zone of the left lung and CT scan showed irregular mass in left lower zone, right lung field normal and few mediastinal lymph nodes (Figure 1 and Figure 2).
Figure 1. Chest X-ray of the patient at initial presentation showing left sided homogeneous opacity in the lower zone with collapse of the lung
Figure 2. Histopathological slide of lung tumour showing moderately differentiated squamous cell carcinoma of bronchus
At this point of time author SD posted the case in a web based discussion forum and following is the conversation he had:
Pleural aspirate revealed malignant cells. The patient then underwent bronchoscopy and a polypoidal structure is seen in Left lower bronchus, from which biopsy was taken and the histopathology revealed moderately differentiated infiltrating squamous cell carcinoma bronchus. It is to be noted that she was a nonsmoker and there was no family history of smoking or lung cancer. CT scan of brain and abdomen done at that time showed no evidence of metastasis. One month later, patient underwent left sided thoracotomy which revealed 10 cm x 8 cm x 5 cm growth in left lower lobe, a large (6 cm x 7 cm) hilar lymph node and another large hard lymph node (8 cm x 8 cm) over the aorta. Further procedure was abandoned, declaring it as inoperable carcinoma left lung. Biopsy taken from the growth and lymph nodes also confirmed squamous cell carcinoma. Unfortunately the patient then did not follow medical advice and for next 6 months she consulted alternate medicine specialists and as per her version, she was symptomatically better at that time (Figure 3 and Figure 4).
Figure 3. CT scan of thorax before chemotherapy showing left sided tumour, right sided pulmonary nodule, pleural effusion, mediastinal lymph nodes
Figure 4. USG abdomen before laparotomy showing cystic SOL, probably left ovarian mass
After 6 months, suddenly she developed acute onset respiratory distress with chest pain for which she consulted department of Medicine from where she was referred to department of Radiotherapy. After initial stabilization and supportive measures including blood transfusion and pleural fluid drainage, further investigations were done. The CT scan of thorax showed irregular mass with collapse of left lower zone, a pulmonary nodule (8 mm x 10 mm) in right lung and extensive medistinal lymph nodes with bilateral pleural effusion. The radiotherapists initially questioned the diagnosis of squamous cell carcinoma lung due to its rare occurrence in young female non-smoker and they suspected it as lymphoma. But review of previous biopsy slides revealed squamous cell carcinoma. As the patient’s general condition improved, chemotherapy was planned for primary lung carcinoma. After basic investigations, she received one cycle of carboplatin (450 mg) & paclitaxel (260 mg) therapy.