Keywords: Pleuro-cutaneous fistula; Pneumonectomy; Metastases; Rib erosions.

Copy right Statement: Content published in the journal follows Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0). © Wickramasinghe S (2024)

Journal: Open Journal of Clinical and Medical Case Reports is an international, open access, peer reviewed Journal mainly focused exclusively on the medical and clinical case reports.

Citation: Baig T, Mehdi S, Wickramasinghe S. Metastatic pleuro-cutaneous fistula following a pneumonectomy for a squamous cell carcinoma: A journey of 34-years. Open J Clin Med Case Rep. 2024; 2216.

An 84-year-old male presented with right chest wall swelling for 4 weeks and a productive cough. There was no weight loss, fever or haemoptysis. On examination, right sided breath sounds were absent and soft tissue swelling was noted in the chest wall (Figure 1A). He was treated with right pneumonectomy in 1989 for a squamous cell carcinoma of the lung. Contrast CT chest revealed evidence of previous pneumonectomy, fluid in the right hemithorax with multiple fluid collections eroding to the chest wall with multiple rib erosions (Figure 2). Appearance was suspected of a tumour recurrence. USS guide fluid aspiration showed thick red cloudy fluid and was negative for malignant cells. He refused further intervention. His case was discussed in lung multi-disciplinary meeting and concluded to have a tumour recurrence. It was decided to manage him with best supportive care based on frailty and patient’s wishes.

Lung cancer metastases in thorax has myriad of presentations and can be masquerading with a varied time gap from the original diagnosis. This include fistula formation, effusions, rib erosions, pulmonary deposits, lymphadenopathy, adjacent organ infiltration, superior vena cava and other vessel compression and thrombosis. Higher degree of suspicion is needed to avoid fatal outcome.

Tumour recurrence after 34 years is an extremely rare. Metastasis can present in multiple ways including pleuro-cutaneous fistula and rib erosions. Higher degree of suspicion is needed in certain circumstances as the diagnosis can be easily missed due to longer duration between current presentation and primary tumour

Figure 1: CXR showing evidence of right sided pleural effusion, volume loss and rib erosions and soft tissue swelling in the right chest wall. B-CT Chest showing fluid in the right hemithorax and within the right lower zone this appears to communicate with multiple loculated pockets of collection eroding to the chest wall. Erosions of right 6^th, 7^th and 9^th ribs sewen. These collections indent the superior aspect of the liver with no invasion.

Figure 2: Soft tissue swelling in the right chest wall and USS showing fluid collection in the right hemithorax lower zone with rib erosion.