Case-based discussion: a case of misdiagnosis of primary lung malignancy

A 69-year-old man was initially referred to urology outpatient clinic for investigation of frank haematuria. His medical history included transurethral resection of prostate in 2008, autoimmune hepatitis, hyperlipidaemia and hypertension. He was an active smoker with a 52 pack-year history and drinks 12 units of alcohol per week. He worked as a librarian with no history of chemical or asbestos exposure. His regular prescription included azathioprine and ursodeoxycholic acid, amlodipine, alfuzosin and finasteride. He underwent a cystoscopy which was normal. Subsequently, a CT urogram was performed which demonstrated a 48 mm mass within the left adrenal gland, suspected of malignancy; however, no primary site had been identified. A subsequent CT of the thorax and abdomen displayed a 6.5 cm diameter mass within the base of the right upper lobe on the background of emphysema, with precarinal and right hilar lymph nodes, and multiple nodules in the middle lobe and left lower lobe (figure 1A). A large left adrenal mass was again identified. On further questioning, the patient described symptoms of breathlessness and lethargy but denied any chest pain or cough. There was no history of sputum production or haemoptysis. He did, however, report loss of appetite and had lost 3 kg of weight over the previous 4 weeks. Figure 1 (A) Initial CT thorax demonstrating a 6.5 cm diameter mass within the base of the right upper lobe, small precarinal and right hilar nodes and evidence of multiple intrapulmonary nodules; (B) PET CT demonstrating large necrotic mass at right upper lobe; (C) FDG avid intrapulmonary metastasis; (D) histopathological features of lymphomatoid granulomatosis under high power microscopy (40× objective, NIKON eclipse 80i). With the symptoms of breathlessness and unintentional weight loss, in combination with a significant smoking history and suspicious radiological findings, metastatic bronchogenic carcinoma with a left adrenal metastasis was the most …