A 43-year-old man comes to the office due to several weeks of nagging, left-sided chest pain that worsens with deep inspiration. He has also had a progressive, nonproductive cough and mild dyspnea. The patient denies fever or chills. He was diagnosed with Hodgkin lymphoma in his early 20s and was treated with chemotherapy and radiation. Blood pressure is 144/90 mm Hg and pulse is 92/min. The patient appears thin. Examination is otherwise normal. Chest x-ray is shown in the image below: Which of the following is the most likely cause of this patient's current manifestations?

Question

A 43-year-old man comes to the office due to several weeks of nagging, left-sided chest pain that worsens with deep inspiration.  He has also had a progressive, nonproductive cough and mild dyspnea.  The patient denies fever or chills.  He was diagnosed with Hodgkin lymphoma in his early 20s and was treated with chemotherapy and radiation.  Blood pressure is 144/90 mm Hg and pulse is 92/min.  The patient appears thin.  Examination is otherwise normal.  Chest x-ray is shown in the image below:  Which of the following is the most likely cause of this patient's current manifestations?

Quizplus · Accepted Answer

11ec25c8_d4ba_ee1c_bc81_c7eb1cf4cbba_MD0003_00 This patient with a history of Hodgkin lymphoma (HL) has chest pain, dyspnea, nonproductive cough, and a large peripheral lung lesion, raising strong suspicion for lung cancer. Although HL is curable with chemotherapy and radiation therapy, patients are at high risk for long-term, treatment-related sequalae, particularly cardiac disease, radiation-induced hypothyroidism, and secondary malignancy. In patients with cured HL, the lifetime risk of secondary malignancy is >30%. Most cases arise >10 years after initial HL treatment. Solid tumors in the lung, breast, and gastrointestinal system are most common, but hematologic malignancy (eg, acute leukemia, non-HL) also frequently occurs. Secondary lung cancers typically arise within or close to the area of previous chest irradiation. Smokers are at greatest risk. (Choice A) Aspergillus typically infects a preexisting lung cavity caused by tuberculosis, sarcoidosis, bronchial cysts, or neoplasm. Manifestations include hemoptysis, cough, dyspnea, and fever. Imaging usually shows a cavitary mass with air in the periphery, not a solid lung lesion. In addition, this patient has no history of underlying lung disease. Aspergillus (Choice C) Pulmonary tuberculosis typically presents with progressive fever/night sweats, cough, hemoptysis, and weight loss. Chest x-ray usually shows apical cavitary lesions, not a solid mass in the lung periphery. Pulmonary tuberculosis (Choice D) Radiation-induced fibrosis is a consequence of previous lung irradiation. Dyspnea, nonproductive cough, and chest pain typically develop 4-24 months after therapy. Chest x-ray usually shows volume loss with coarse opacities, not a solid lung lesion. Radiation-induced fibrosis (Choice E) HL usually responds well to treatment; the survival rate is generally >90% at 5 years. Recurrence after 20 years is very uncommon and would be unlikely to cause a peripheral lung lesion. Educational objective: Patients with Hodgkin lymphoma who are treated with chemotherapy and radiation are at high risk for secondary malignancy later in life (generally >10 years after therapy). Solid tumors in the lung (especially in smokers), breast, and gastrointestinal system (eg, colorectal, esophageal, gastric tumors) are most common. References: High risk of subsequent neoplasms continues with extended follow-up of childhood Hodgkin's disease: report from the Late Effects Study Group. (http://www.ncbi.nlm.nih.gov/pubmed/14645429) Symptoms and weight loss in patients with gastrointestinal and lung cancer at presentation. (http://www.ncbi.nlm.nih.gov/pubmed/16786329)

A 43-Year-Old Man Comes to the Office Due to Several