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• W4387249432 abstract "SESSION TITLE: Lung Cancer Case Report Posters 13 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Classically miliary nodules are associated with tuberculosis (TB); however, the differential for miliary nodules is broad, including fungal infections, metastatic disease, sarcoidosis, etc. Here we present a case of metastatic lung adenocarcinoma that was found after biopsy of miliary nodules. Metastatic disease with miliary nodules can occur in a variety of cancers including lung adenocarcinoma, renal cell carcinoma, melanoma, and thyroid carcinoma. An awareness of the multiple potential causes of miliary nodules will aid accurate diagnoses. CASE PRESENTATION: A 54-year-old non-smoking Filipino, nonsmoking woman who works as a nurse presented with a non-productive cough for 3 weeks. She had previously received the BCG vaccine as a child and had prior positive PPD results. Chest x-ray (CXR), revealed numerous diffuse micronodules in a miliary pattern in bilateral lungs, and was found to have a positive interferon gamma release assay (IGRA). CT scan of the chest revealed a retrocardiac left lower lobe 4.2 x 4 x 5 cm lung mass that was not appreciated on the initial CXR. Pathology from bronchoscopy with biopsy showed lung adenocarcinoma with negative AFB staining with negative cultures. Additional workup was significant for metastases to the liver and brain consistent with Stage IV lung adenocarcinoma with human epidermal growth factor receptor 2 (HER2) pathogenic variant and Programmed death-ligand 1 (PDL-1) positivity. The patient began carboplatin/pemetrexed as first line chemotherapy and was treated concurrently for latent TB due to IGRA positivity. Most recently, she started targeted immunotherapy against HER2 with trastuzumab-deruxtecan and is pending follow up imaging to evaluate progression. DISCUSSION: This case is the only reported case of HER2/PDL-1 positive adenocarcinoma presenting as miliary metastases. The most common diagnosis worldwide for miliary nodules is disseminated tuberculosis. Adenocarcinoma is the most common lung cancer worldwide with a prevalence of 40% of all lung malignancies. This case demonstrates the need for a broad differential for pulmonary micronodular disease even in the presence of a positive IGRA and CXR. Furthermore, this case highlights CXR as an inadequate solo imaging modality. Lung malignancy presenting as miliary nodules is rare and only a handful of cases are reported in the medical literature. This case is number 19 reported in the literature. The size of the nodules in miliary tuberculosis typically range from 1-3 mm with the miliary metastatic disease exhibiting slightly larger sizes of up to 1 cm. Lung adenocarcinoma presenting as miliary nodules is inevitably metastatic and is thought to represent widespread hematogenous dispersal through the lung via the pulmonary vasculature. As the few reports in literature suggest, there is a predominance for epidermal growth factor receptor (EGFR) mutations in patients with miliary metastases, of which HER2 is a subtype. Both HER2 and PDL-1 mutations may be targeted by immunotherapy. CONCLUSIONS: It is important to recognize that miliary nodules may be a presentation of malignancies rather than the classical association with tuberculosis. A positive IGRA and miliary pattern on CXR should prompt expedited workup to exclude miliary metastatic disease and miliary tuberculosis given widespread prevalence in the adult population worldwide. REFERENCE #1: Pillai S, Khan A, Khan S. Adenocarcinoma of the Lung Presenting with Intrapulmonary Miliary Metastasis. Cureus. 2019 Aug 19;11(8):e5430. doi: 10.7759/cureus.5430. PMID: 31632879; PMCID: PMC6797010. REFERENCE #2: Seifi A, Shafiee N, Moradi M. Pulmonary adenocarcinoma mimicking miliary tuberculosis in a 20-year-old man: A clinical case report. Clin Case Rep. 2023 Mar 2;11(3):e7028. doi: 10.1002/ccr3.7028. PMID: 36873069; PMCID: PMC9981568. REFERENCE #3: Khan D, Danjuma M, Saddique MU, Murshed KAH, Yassin MA. Adenocarcinoma of the Lung Mimicking Miliary Tuberculosis. Case Rep Oncol. 2020 Feb 13;13(1):139-144. doi: 10.1159/000505685. PMID: 32231535; PMCID: PMC7098354. DISCLOSURES: No relevant relationships by Kelly Quinn No relevant relationships by David Silberstein" @default.
• W4387249432 created "2023-10-03" @default.
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• W4387249432 date "2023-10-01" @default.
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• W4387249432 title "A CASE OF LUNG HUMAN EPIDERMAL GROWTH FACTOR RECEPTOR 2 ADENOCARCINOMA PRESENTING AS MILIARY NODULES" @default.
• W4387249432 doi "https://doi.org/10.1016/j.chest.2023.07.2830" @default.
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