A 50-year-old female with a medical history of bronchial asthma and hypothyroidism was admitted to the hospital after experiencing a progressive increase in the frequency of asthma exacerbations, necessitating more frequent use of her Salbutamol inhaler. She had been diagnosed with asthma previously and controlled her hypothyroidism with a daily dose of 75 mg of levothyroxine. The patient had no smoking history but reported a family history of malignancy.
Her condition was complicated by the development of right upper quadrant abdominal pain, prompting further evaluation. A computed tomography (CT) scan of the abdomen incidentally revealed a mass in the right lung's lower lobe. Further investigations, including a bronchoscopy and biopsy, confirmed the diagnosis of low-grade primary pulmonary mucoepidermoid carcinoma. A subsequent whole-body positron emission tomography (PET) scan demonstrated a hypermetabolic lesion in the right lower bronchus, measuring approximately 1.6 × 1.5 cm, with a maximum standardized uptake value (SUV max) of 6.8. The scan also revealed nonspecific bilateral pulmonary micronodules, which did not show significant metabolic activity. Upon presentation, the patient was afebrile and in good general health, with no signs of pallor, pain, or jaundice. Her vital signs were stable, with a heart rate of 75 beats per minute, blood pressure of 122/74 mmHg, and an oxygen saturation of 95% on room air. Examination revealed bilateral chest wheezes, a regular heart rhythm, and normal heart sounds. The patient's abdomen was soft and lax, with active bowel sounds.
The diagnosis of low-grade primary pulmonary mucoepidermoid carcinoma was confirmed based on the results of the bronchoscopy and biopsy. The lesion in the right lower bronchus demonstrated hypermetabolic activity on the PET scan. Further staging was done with CT and PET, which revealed additional findings of nonspecific micronodules in both lungs, but these did not show any significant metabolic activity. The final staging of the mucoepidermoid carcinoma was pT1eN0, indicating a tumor confined to the primary site with no regional nodal involvement.
The patient underwent a right lung lower lobectomy via a uniportal video-assisted thoracoscopy (VATS) with lymph node dissection. The surgery proceeded without complications, and the patient was closely monitored in the surgical intensive care unit (SICU) with a right-sided chest tube. On the second postoperative day, she was transferred back to the general ward. Although prophylactic anticoagulation was initiated, the patient developed a pulmonary embolism, which was diagnosed via pulmonary CT angiography. Therapeutic anticoagulation with Enoxaparin was promptly started. Additionally, a collapsed right middle lung lobe was noted, and she underwent bronchoscopy with removal of a mucus bulge. Over the following days, the patient’s respiratory status improved, and the chest tube was removed.
Histopathology results received ten days post-surgery confirmed the diagnosis of mucoepidermoid carcinoma, staged as pT1eN0 with complete excision. The dissected lymph nodes were negative for malignancy.
Three months post-surgery, the patient underwent a follow-up PET scan, which revealed a hypermetabolic lesion at the surgical site in the right lower bronchus, along with new hypermetabolic nodules in the right pleura, paratracheal lymph node, and small right internal mammary lymph nodes. The patient was scheduled for a second surgery, a VATS with biopsy of the hypermetabolic nodule. During surgery, an iatrogenic injury to the right azygos vein occurred, necessitating conversion to a thoracotomy with ligation of the vein. Two units of packed red blood cells were transfused, and the patient was again transferred to the SICU for close monitoring. After three days, she was transferred back to the ward. Over the next few days, her condition stabilized, and the chest tubes were removed. The biopsy results showed fibrous tissue, with no malignant cells.
At her two-week follow-up, the patient was in good clinical condition and reported no new symptoms. She continued routine follow-up visits for monitoring. Several months later, a subsequent PET scan showed normalization of the previously noted hypermetabolic activity at the right paratracheal lymph node, right pleural nodule, and surgical site, indicating a favorable response to treatment. The patient's general health remained stable, and she continued her routine follow-up appointments.