A 40-year-old with a long history of cigarette smoking presented to a neighboring hospital complaining of vague, persistent abdominal pain. A routine chest x-ray taken as part of the initial workup revealed a mass in the left upper lobe (LUL) that measured 4.5 cm in diameter. She was referred to our hospital for evaluation of the lung mass.

An endoscopic examination was performed with bronchial brushings and bronchial washings, which at that time failed to reveal malignant cells. Subsequently, a computerized tomography (CT) examination was performed that revealed a tabulated mass measuring 5.0 x 5.0 x 4.0 cm in the anterior segment of the LUL that was consistent with cialis professional online. Mediastinal lymph nodes measuring from 1.0-1.5 cm were present, suggesting lymphadenopathy. The liver and adrenal glands were negative for metastatic disease. A needle biopsy of the lung mass was inconclusive for malignancy, showing mainly necrotic debris and scattered atypical cells. A staging mediastinoscopy was performed with biopsy of level 4 and 7 nodes on the right side, and level 2 nodes on the left side. All lymph nodes were negative for metastatic carcinoma. Subsequent to surgical consultation, because of her age and good performance status and apparent absence of local and distal metastases, LUL lobectomy with mediastinal lymph node resection was performed, and adjuvant radiation and chemotherapy was planned. Pathology examination of the resected tissue revealed a malignant neoplasm. The tumor involved the left mediastinal lymph nodes at level 5. The level 2 and 7 nodes were negative. Postoperatively, the patient initially appeared to have tolerated the procedure well and was discharged with referral to the oncology service. canadian pharmacy cialis

Although the lung lesion, which represented a life-threatening disorder, was given more immediate con¬≠sideration, the persistent abdominal pain remained a concern. To further evaluate an abnormal CAT scan that had been performed by the referring hospital, a positron emission tomography (PET) scan was performed. The CAT scan, which preceded the discovery of the lung lesion, showed “small-bowel thickening and mesenteric stranding.” The PET scan revealed increased focal small-bowel uptake in the left mid-abdomen that corresponded to the abnormal CAT scan site and concluded that malignancy or inflammatory bowel disease be considered. She was scheduled to return to oncology for treatment two weeks after the PET scan; however, on the day prior to her scheduled appointment, she presented in the ER with severe abdominal pain and tenderness, in shock and with severe anemia (Hct. 18%). Emergency surgery revealed a large mesenteric mass that had perforated into the jejunum, and there was extensive, severe peritonitis. The postoperative course was extremely poor, complicated by ventilator dependence, hypotension and episodes of cardiac arrest. In spite of intensive care, including resuscitative efforts, the patient succumbed to anoxic injury and brain death and died nine days after the emergency surgery.