Advanced lung cancer presenting with a generalized seizure in pregnancy

Abstract

This case describes the initial presentation of lung cancer as a generalized seizure in a woman at 31 weeks gestation. Histologic examination revealed evidence of placental metastases without evidence of fetal involvement. Case reportA 34-year-old primigravida was admitted as an emergency to the Labour Suite after a generalized self-limiting seizure at 31/40 gestation. On admission she was drowsy, her blood pressure was 116/68 and catheter urine tested positive for protein (1'/). On examination there was epigastric and right upper quadrant tenderness. Lung auscultation revealed left-sided basal crepitations and there were three beats of clonus and a positive Babinski reflex in the left lower limb. Cardiotocograph was normal and there was no significant edema. Blood tests revealed normochromic normocytic anemia (Hb 10.0), mildly elevated liver enzymes (gGT 83, ALT 55) and a CRP of 34. Platelets, white cell count, urate, urea and electrolytes, random glucose and remaining parameters of liver function were normal. Although there were some unusual features, eclampsia was considered to be the most likely diagnosis.Treatment with magnesium sulfate was commenced according to protocol on the high dependency area of the Labor Suite and 16 mg of dexamethasone was given intramuscularly. Six hours after admission the patient underwent a cesarean section under regional anesthesia. A male infant was delivered in good condition (cord gases normal; birth weight 2.01 kg).Postoperatively the patient remained normotensive and aproteinuric. However, the oxygen satura-tion was only 80% on room air and there was extensive left-sided bronchial breathing on auscultation. A portable chest X-ray revealed shadowing over the left mid-zone, and the diagnosis of pneumonia was considered. A departmental chest X-ray on day 2 demonstrated a left-sided pleural effusion. Cytological examination of a pleural aspirate revealed adenocarcinoma cells. A CT brain/thorax/abdomen was arranged. This revealed multiple brain metastases with evidence of raised intracranial pressure and a mid-line shift, a left-sided bronchial mass and multiple liver metastases. At bronchoscopy there was evidence of a large malignant looking bronchial mass and biopsies were obtained. Histology revealed an invasive poorly differentiated adenocarcinoma. Immuno-histochemistry indicated primary lung cancer. The placental histology revealed microscopic metastatic disease on two separate placental blocks prepared for histology.Subsequently the patient received palliative whole brain radiotherapy and chemotherapy, but the tumor did not respond.The baby made good progress and was discharged. Subsequent follow up to this date has shown no evidence of metastatic disease in the baby. Discussion

Lung cancer in the pregnant woman: To treat or not to treat, that is the question

“…Two patients elected to go for abortion [15,24] while spontaneous abortion was not reported in any case. The gestational age at delivery was reported in 34/43 with a median of 32 weeks (range: [27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42]. Post-partum maternal outcome was known in 37 patients, in which 28 were known to be dead within 1 year after delivery.…”

“…Diagnostic delay is often (median gestational age at diagnosis is 27 weeks) due to the reluctance in performing radiological investigations from one side and the non-specific nature of the early symptoms of the disease from another. This is demonstrated in the patients earlier discussed in whom the majority presented with advanced manifestations including hemoptysis [36], brain metastases [29,31,32,42] and Horner syndrome secondary to local invasion of the sympathetic plexus [37].…”