Stage IVA lung adenocarcinoma: fatal hemoptysis from pulmonary artery pseudoaneurysm after chemoradiotherapy

What happened, in summary

This 47-year-old woman was admitted with 3 months of low back pain and no major prior medical history. Examination found abdominal distension without a palpable mass. Blood counts were within normal range, but CEA was elevated to 62 ng/mL, while CA19-9 and neuron-specific enolase were normal. Chest CT on 19 December 2023 showed a soft-tissue mass in the lower lobe of the right lung involving the right lower pulmonary artery, along with bone destruction in the 11th thoracic vertebra. CT-guided biopsy confirmed adenocarcinoma. The diagnosis was right lower-lobe lung adenocarcinoma, cT2bN0M1, Stage IVA, with vertebral bone metastasis. On day 14 of hospitalization, she started intensity-modulated radiation therapy to the lung cancer, 40 Gy in 20 fractions. She then received 4 cycles of pemetrexed, bevacizumab, and cisplatin, which stabilized the cancer and gradually improved her symptoms enough for discharge and home observation. Follow-up chest CT on 14 February 2024 showed that the solid component of the tumor had significantly decreased, leaving a cavity with trapped air. The next day, she developed massive hemoptysis of about 400 mL. Review of the prior CT identified a small protrusion from the pulmonary artery in the posterior basal segment of the right lower lobe, about 0.5 × 0.4 cm, consistent with pulmonary artery pseudoaneurysm. A multidisciplinary review later ruled out infection, vascular malformation, coagulopathy, and other hemorrhagic tumor foci, leaving treatment-related pseudoaneurysm at the tumor-invaded artery as the explanation. Before planned embolization could be performed, the pseudoaneurysm ruptured, causing fatal airway obstruction. She died from massive hemoptysis.