71-Year-old woman, never smoker, with no significant medical or family history. She presented with asthenia and progressive dyspnea of subacute onset to modified Medical Research Council grade 3. She had bilateral pulmonary pseudo-nodular pattern on chest X-ray (Fig. 1A and B), not present two years before. No relevant exposures or autoimmunity symptoms were identified. Room air oxygen saturation was 95%, without clubbing or crackles on chest exam. High-resolution chest computed tomography (CT) scan showed a left subpleural lung mass in the left lower lobe (Fig. 1C and E) with multiple bilateral ground-glass nodular opacities (Fig. 1D), without enlarged mediastinal lymph nodes. A fluorine-18 fluorodeoxyglucose positron emission tomography/CT revealed pathological increased uptake in the mass and unspecific low generalized activity, ruling out distant metastatic activity (Fig. 1F). A CT-guided transthoracic biopsy was diagnostic of adenocarcinoma with acinar growth pattern according to 2021 World Health Organization classification.1 Next sequencing generation found epidermal growth factor exon 19 deletion, without PDL-1 expression on immunohistochemistry. She was referred to Oncology to consider systemic treatment. This is an uncommon presentation of metastatic lung adenocarcinoma, given the broad differential diagnosis of multiple nodular images in the absence of clear identifiable lung mass in the X-ray.
Clinical case images: chest X-ray, computed tomography scan and positron emission tomography/computed tomography. Posteroanterior (A) and lateral (B) chest X-ray with bilateral nodular pattern. Chest computed tomography showing the lung mass (asterisk) in left lower lobe (coronal (C) and axial (E) views) with multiple bilateral ground-glass nodules, with a tendency to cavitation better defined in lower lobes (lateral view (D)). Fluorine-18 fluorodeoxyglucose positron emission tomography (E) with pathologic increased uptake in the mass, with unspecific low generalized metabolic activity.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interestThe authors declare not to have any conflicts of interest that may be considered to influence directly or indirectly the content of the manuscript.
Artificial intelligence involvementNot used.
