For the fear of doctors: a late presentation of lung cancer

Abstract

DESCRIPTIONA 60-year-old man presented to the hospital with a large, unusual looking mass protruding from his right infra/supraclavicular region (figure 1). He first noticed a small lump at the base of his neck while shaving and over the course of 6 months, the painless lump grew rapidly and soon extended from the anterior fold of his axilla almost up to his jaw.He reported feeling dyspnoeic on exertion but denied having haemoptysis. He also reported back pain and bilateral lower limb paraesthesia. He has a 45 pack-year smoking history and had previously worked in the dry cleaning industry. His right arm was oedematous and there was an associated weakness and paraesthesia, consistent with a lower brachial plexopathy.Despite his worrying symptoms, the patient was reluctant to seek medical attention as he had a fear of doctors and profoundly disliked the idea of being hospitalised. It was only at the insistence of his daughter that he eventually attended his local general practitioner.A CT of the thorax ( figure 2A) demonstrated a large tumour in the apical lobe of the right posterior lung with an associated large infra/supraclavicular nodal mass. The fine needle aspirate revealed an adenocarcinoma. MRI spine (figure 2B) revealed diffuse bone metastases and a soft tissue mass encroaching on the thecal space at S2 level.The patient declined chemotherapy but was agreeable to palliative radiation therapy (RT). Hypofractionated RT (16 Gray, 2 fractions) was delivered to his right upper chest and singlefraction RT (8 Gray) targeted towards the bone lesions. Figure 1 An unusually shaped large mass protruding from the patient's infra/supraclavicular region. There is also an associated area of local skin involvement (red arrow).