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History of dysphagia and abdominal pain

Publish date: November 30, 2021

Reviewed by Maurie Markman, MD

Scott Camazine/Science Source

A 59-year-old woman presents with a 4-month history of dysphagia when eating solids in addition to nausea and abdominal pain. She also reports recent hemoptysis and the onset of hoarseness. She has had an unintentional 22-lb weight loss over the past 6 months. She has a history of emphysema. She takes no medication. She has a 26 pack-year history of cigarette smoking. She is 5 feet 4 in tall and weighs 105 lb, with a BMI of 18. Her vital signs are within normal limits. Chest auscultation reveals diminished breath sounds over the right lung fields. Chest radiography reveals a right-sided 6-cm hilar mass. Laboratory studies show a serum calcium level of 12 mg/dL (normal range, 8.5-10.5 mg/dL). A CT scan revealed a spiculated lesion and hepatic metastases. A biopsy was performed. Keratinization was found in the form of keratin pearls.

On the basis of the clinical presentation and histologic findings, what is the diagnosis?

Adenocarcinoma

Small cell carcinoma

Squamous cell carcinoma

Carcinoid tumor

The diagnosis is squamous cell carcinoma. A central or hilar mass is most likely to be a squamous cell carcinoma or a small cell tumor and less commonly an adenocarcinoma. Histologically, when there is lack of cohesion among the epithelial cells due to malignant changes, the cells get arranged in a concentric manner. The fate of a squamous cell is to form keratin, so these cells lay down keratin in a concentric manner and then appear as keratin pearls.

This patient's tumor is found to have programmed cell death–ligand 1 ≥ 1% and has no actionable molecular markers. The patient has a performance status score of 1. In a patient with advanced or metastatic squamous cell carcinoma with a performance status score of 1, the National Comprehensive Cancer Network recommends pembrolizumab/carboplatin/paclitaxel or pembrolizumab/carboplatin/albumin-bound paclitaxel as preferred regimens. The pembrolizumab component is based on the results of the KEYNOTE-407 trial. In patients with previously untreated metastatic, squamous non-small cell lung cancer, the addition of pembrolizumab to chemotherapy with carboplatin plus paclitaxel or nab-paclitaxel resulted in significantly longer overall survival and progression-free survival than chemotherapy alone.

Maurie Markman, MD, President, Department of Medical Oncology, Cancer Treatment Centers of America.

Maurie Markman, MD, has disclosed the following relevant financial relationships:

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Merck
Serve(d) as a speaker or a member of a speakers bureau for: AstraZeneca; Novis; Glaxo Smith Kline
Received research grant from: AstraZeneca; Novis; GSK; Merck

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