What happened, in summary

This 69-year-old man had a 60 pack-year smoking history and presented with mild shortness of breath. Chest imaging found a 3.1 x 2.6 cm mass in the left upper lobe of the lung, mild mediastinal lymphadenopathy, and a 1.5 cm prominence of the left adrenal gland. Biopsy of the lung lesion showed poorly differentiated carcinoma. The tumor stained positive for CK7, CEA, and Ber-EP4, and negative for CK20, p63, TTF-1, CK5/6, PSA, chromogranin, and synaptophysin. PET/CT showed uptake in the lung lesion but no uptake elsewhere, including the adrenal gland. Because the adrenal finding still needed clarification, he underwent endoscopic ultrasound-guided fine-needle aspiration of the lymph nodes and adrenal gland. The lymph nodes were negative, but the left adrenal mass was positive for metastatic carcinoma. Mediastinoscopy removed 19 lymph nodes, all benign. He chose to proceed with surgery and received 1 preoperative cycle of carboplatin and paclitaxel. He then underwent robot-assisted left upper-lobe lobectomy, lymphadenectomy, and left adrenalectomy during the same operation, without changing body position. Surgical margins and frozen-section lymph nodes were negative. Final pathology showed a 4.5 cm poorly differentiated large-cell carcinoma of the lung with negative margins. All 25 examined lymph nodes were benign, and the 1.5 cm adrenal metastasis was completely excised. The final pathologic stage was T3N0M1bR0, meaning metastatic disease had been removed with no residual tumor at the margins. He recovered quickly and was discharged on postoperative day 3. At 6-month follow-up, he had no evidence of recurrence.