2.1 Medical history
Patient: 52 years old, male
Chief Complaint: Physical examination revealed a nodule in upper left pulmonary more than 2 months(Figure 1).
Family history: Denial of related familial genetic medical history.
Past history: The patient had diabetes for 11 years for more than 5 years, irregularly taking reglinide and metformin for treatment; the patient was diagnosed as syphilis positive in other hospital one year ago without formal treatment. Denial of surgery.
Current medical history: The patient was found a nodule in the upper left pulmonary by physical examinations about 2 months ago, without hemoptysis, chills and fever. Who was also no chest tightness or shortness of breath. When he was admitted to our hospital, CT showed that: 1. the nodule was cavity with thick wall in the upper left lobe, considering that the MT might be large; 2. the left hilar lymph node was enlarged; 3. there was a small nodule in the upper right pulmonary. And he didn’t receive any treatment in our hospital. Then he went to the other hospital for treatment. CT showed that there was a hollow-like lesion in the posterior segment of the upper left lobe, considering the possibility of tuberculosis. After 2 weeks of treatment in the infectious disease hospital, the PDD test was strongly positive during the course of the disease, and then he was treated with isoniazid, rifampicin, bisazinamide, ethambutol for anti-tuberculosis, however, after treatments for a month, CT showed that the size of nodule in the upper left lobe was 2.1cm * 1.8cm cavity-like lesions; so lung cancer cannot be completely ruled out. Now the patient was coming to our clinic for further treatment again. Who had no headache, vomiting, coma, convulsions and fever.
2.2 Hematology examination
Blood routine examination: normal
2.3 Image examinations
CT scanning: The lung window showed that the two lung fields are clear, the light transmission is good, and the lung texture is natural. The left lung has a thick-walled hollow shadow in the upper lobe, about 2.1 * 1.7 cm, lobulated, rough edges, and the inner wall was still smooth, and no obvious calcification and liquid level were seen. In the posterior segment of the upper right lung, irregular small nodules are seen, and the border is clear. The nodule in the upper left lobe was cavity with thick wall, considering that the nodule was more likely MT. (Fig. 1)
PET-CT: Cavity-like nodules with a thickness of about 2.3cm * 2.1cm in the posterior segment of the upper lobe of the left lung are shallowly divided, with rough edges, and the inner wall is smooth. There are no obvious calcifications and fluid levels. Increased radioactive uptake, SUVmax 5.13. Thick wall hollow nodules in the posterior segment of the upper left lobe with enlarged left hilar lymph nodes, increased metabolic activity, considering the possibility of granulomatous lesions (tuberculosis? Other chronic infections?), MT to be scheduled, please combine clinical, Mycobacterium tuberculosis and PPD tests Etc. Histological examination if necessary.
2.4 Operation findings
The mass was located in the posterior segment of the left upper lung near the fissure, with a diameter of about 2.5 cm. The pleural cavity was visible. No obvious metastases and effusions were seen. The wedge resection has been performed and the biopsy has been made in the operations, suggesting: (left upper lung) epithelial malignant tumors, tend to squamous cell carcinoma. Intraoperative diagnosis: upper left lung cancer. Then we decided to perform radical operation of left upper lung cancer.
2.5 Postoperative pathology
Pathological examination: (left upper lung) differentiated squamous cell carcinoma, cancer tissue did not invade the lung membrane, no obvious nerve and vascular invasion. Epithelial granulomas with coagulative necrosis were seen around the cancerous tissue, and combined tuberculosis was considered. (Fig. 2A,B)
Immunohistochemistry: P53 (+) Ki-67 (75% +) TOPOⅡ (+) NSE (-) CDX-2 (-) EGFR (+) VEGF (-) ERCC-1 (+) RRM-1 (-) AE1 / AE3 (+) P40 (+) CD68 (histological cells +) combined with HE sections were considered as (upper left lung) squamous cell carcinoma with tuberculosis. (Fig. 2C)
2.6 Postoperative follow-up
Sputum culture and sputum smear examination were performed according to postoperative pathological results. No tuberculosis bacilli were found. It is recommended that the patient should go to the infectious disease hospital for further treatment and be also followed up regularly in our hospital. The general condition of the patient was acceptable, and he was discharged one week after the operation. Until now, it has been more than one year after the operation. The patient has no complaints of discomfort and the relevant examinations were normal one year after the operation.