A case of spontaneous pneumothorax following radiation therapy for non-small cell lung cancer
A 64-year-old male with 50-pack-year of smoking history and moderately severe chronic obstructive lung disease (COPD-FEV1 54%) was recently diagnosed with right lower lobe non-small cell lung cancer (NSCLC Stage IIB T3N0M0-Squamous Cell). On the computerized tomographic scan, the lower lobe pulmonary mass was associated with significant post-obstructive atelectasis suggesting endobronchial location [Figures and ]. This lung mass was deemed inoperable due to close proximity to the carina. It was decided to start patient on intensity-modulated radiation therapy (IMRT) with a planned total dose of 6660 cGy over 37 cycles. Right after the 12th cycle of his treatment, patient developed sudden shortness of breath and right-sided chest pain. He was tachypneic but normotensive. Physical exam showed hyper resonant right chest with absent breath sounds and left sided tracheal deviation concerning for pneumothorax. No jugular venous distention was noted. An arterial blood gas analysis showed hemoglobin oxygen saturation of 96%, partial pressure of oxygen (PaO2) at 80 mmHg, partial pressure of carbon dioxide (PaCO2) at 40 mmHg, and pH 7.36. Chest radiograph and computerized tomographic scan confirmed the presence of large right-sided pneumothorax involving around 50 percent of right lung field with some left mediastinal shift [Figures and ]. A small bore 14-French pigtail catheter was inserted into right pleural cavity resulting in complete resolution of the pneumothorax and re-expansion of the lung []. Air leakage stopped in the pleural pigtail catheter drain setup within 48 hours and the catheter was removed. Patient refused pleurodesis for recurrence prevention.