What happened, in summary

This 80-year-old woman was being followed for sarcoidosis when CT for pulmonary sarcoidosis showed a 1.5 cm ground-glass opacity in the left upper lung. She had a complex cardiac history, including aortic valve replacement, mitral valve replacement, tricuspid valve annuloplasty, cardiac sarcoidosis on myocardial biopsy, and severe bradycardia from complete atrioventricular block requiring a dual-chamber pacemaker. PET showed no FDG uptake in the lung lesion, and uptake elsewhere was attributed to inflammation after cardiac surgery. Because persistent ground-glass opacity can represent early lung adenocarcinoma, she underwent CT-guided biopsy. Pathology showed pulmonary adenocarcinoma. Workup found no distant metastasis, including no brain involvement, and the cancer was staged T1aN0M0, Stage I. Surgery was considered too risky because her ejection fraction was below 30% and she had significant cardiac disease. Radiation was preferred, but the lung tumor overlapped the pacemaker in the radiation field. To make SBRT safe, doctors inserted an 85 cm pacing lead from the opposite side into the right ventricle, tunneled it under the skin, and moved the pacemaker generator to an abdominal wall pocket. The older pacemaker was removed. Two weeks after discharge, she received stereotactic body radiation therapy, 60 Gy in 5 fractions. Pacemaker checks before and after radiation showed no malfunction, and no chemotherapy or immunotherapy was used. Her later cardiac course still required monitoring because severe tricuspid regurgitation and heart-failure symptoms persisted, though steroid treatment for cardiac sarcoidosis improved her ejection fraction to about 30%. As of December 2024, 4 years and 10 months after radiation, CT showed complete resolution of the lung lesion and no cancer recurrence.