Clinical summary: A 60-year-old man consulted his physician in 7/98 for a painless mass next to the right side of his jaw. He was a 70-pack-year smoker. A fine needle aspirate of the mass showed necrotic cancer, but the primary site was unknown. Small pieces (biopsies) of tissue from the tongue, throat, and tonsils showed no tumor under the microscope. A chest X-ray was normal. Imaging of the brain showed a right frontal mass, and a brain biopsy showed small cell cancer. Later, a computed tomogram (CT) of the chest showed a right medial lung mass, 2.5 x 3 cm in diameter, and associated enlarged lymph nodes. The lung was believed to be the site of origin. He was treated with chemotherapy and radiation, during which he lost weight and generally felt bad. The size of the lung tumor decreased temporarily, but then increased, and he received more chemotherapy in 4/99. A bone scan in 10/99 showed no tumor despite the presence of back pain. CT of the head performed because the patient developed difficulty walking showed multiple tumors. Whole brain radiation was given. Weakness progressed, and he died in February, 2000.
Postmortem examination showed a tumor, 6 cm in extent, surrounding the main bronchi of the right lower lobe. Adjacent lymph nodes were enlarged by tumor. Metastases were present in bone, brain, liver, and adrenal glands. The tumor was classified as a small cell cancer.
Comment: This story illustrates the multiple diagnostic tests and treatment measures that patients with lung cancer undergo. Patients with this particular type of tumor, which constitutes about 25% of all lung cancers, have the lowest survival rate of any type of lung cancer: median survival is about 10 mo. There has been no significant improvement in survival over the past 25 years.