Brief description of the disease
The patient is female, 40 years old, from Hainan. Six months after right breast cancer surgery, after multiple courses of chemotherapy, chest tightness, shortness of breath and cough for 3 months, aggravated for 1 month. The patient’s right breast cancer was discovered in early 2012 and was treated with 6 cycles of chemotherapy (cyclophosphamide ＼epiampicillin ＼ docetaxel) using the CET regimen at an unknown dose. modified radical breast cancer surgery was performed in May 2012. Postoperative pathology: invasive ductal carcinoma in the right breast, cancer thrombus in the veins, 3/12 metastases in the ipsilateral axillary lymph nodes. Immunohistochemistry: ER(-), PR(-), HER-2(-). Postoperative chemotherapy was repeated for one cycle with the same regimen. After chemotherapy, a generalized skin rash appeared, mainly on the face and extremities. Drug dermatitis was considered in dermatology and treated with poor results and no remission. He developed chest tightness and shortness of breath, coughing, and coughing up a small amount of white foamy sputum. In the past 1 month, chest tightness, shortness of breath and cough were aggravated. Non-invasive positive pressure oxygen administration, anti-inflammatory and antifungal treatment were given, but the condition did not improve, and a consultation was requested. Lu Yanda, Department of Radiotherapy, Affiliated Hospital of Hainan Medical College
Physical examination
Clear, seated breathing, oxygen administration under pressure. There was a rash with bran-like flaking all over the body, mainly on the face and extremities. Superficial lymph nodes were not enlarged. The chest wall was changed by modified radical surgery for breast cancer, the incision was healed, and no nodes were palpable. The breath sounds in both lungs were coarse, and dry rales and a few wet rales could be heard.
Auxiliary examination
Chest X-ray and CT showed: hairy glass-like changes, multiple lamellar and nodular shadows were seen in both lungs, a small amount of pleural effusion bilaterally, see Figure 1-7, considering:1. pulmonary infection, mycobacterial is not excluded; 2. bilateral lung metastases are not excluded. Multiple cultures of blood and sputum did not show bacterial and mycobacterial growth. Blood picture and liver and kidney function were approximately normal range. No clear metastases were seen in other organs. Tumor marker examination was negative. Fibrinoscopy and percutaneous lung puncture and pleural effusion puncture were not tolerated not examined.
My opinion
1. Double lung metastases are unlikely. Although it is a triple-negative breast cancer, with cancer emboli seen in the pathological vasculature and a young patient with high malignancy and easy metastasis, it seems uncommon to see such a large area of metastasis in a short period of chemotherapy with high intensity. The pulmonary lesions were not consistent with metastatic manifestations, but rather with interstitial changes. The slow growth of pleural effusion without antitumor therapy was also not consistent with metastatic manifestations. No clear metastatic foci were seen in other organs and negative tumor marker tests did not support the presence of tumor spread. At present, it is impossible to obtain pathological examination for confirmation. After the condition improves, fibrinoscopy and percutaneous pulmonary puncture and pleural effusion aspiration examination can be clarified.
2. Mycobacterial infection in the lung is suspicious. Blood, sputum repeated culture did not see mycobacterial growth, the regular full amount, full course of anti-mycotic treatment is ineffective.
3.Severe lung injury due to chemotherapy is likely. Lung imaging manifestations consistent with interstitial injury changes, a history of chemotherapy, it is important to have a rash in chemotherapy and has not been controlled, which is a clue of great significance. In addition, multiple negative cultures of blood and sputum and ineffective anti-inflammatory and antifungal therapy did not support infection.
Is this the truth of the matter? It remains to be observed and followed up further by the patient, and colleagues are welcome to participate in the discussion without hesitation, thank you!
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