Lung cancer presenting with brain and leptomeningeal spread

What happened, in summary

A 72-year-old man with a 60-pack-year smoking history was brought to hospital with acute confusion and haemoptysis after 2–3 days of poor appetite and fatigue. His neurological status fluctuated, and imaging raised concern for a brain lesion with possible leptomeningeal involvement in the setting of suspected lung cancer.

Because his consciousness was worsening, he underwent emergency surgical debulking of the cystic brain tumour. Pathology confirmed metastatic adenocarcinoma consistent with a lung primary. The tumour had PD-L1 expression of 100% and was negative for EGFR mutation and ALK rearrangement. His lung cancer was Stage IV, with brain metastasis and leptomeningeal spread.

After surgery, he received whole-brain radiotherapy of 20 Gy in 5 fractions, with systemic treatment planned afterward. Within weeks, however, his condition declined sharply. He became wheelchair-dependent, fatigued and doubly incontinent, then returned to hospital with community-acquired pneumonia. A repeat brain CT showed an acute haemorrhage in the right frontal lobe. Despite treatment for the infection, he died within 1 week of admission. Metastatic adenocarcinoma of the lung was recorded as the cause of death.