79 year old man with a history of bronchitis, diabetes, prostate cancer (s/p radiation therapy in 2000 and stable normal PSA), and chronic lymphocytic leukemia (since the 1970s, not treated and stable) presents with cough. Since 2009 his WBC count has been progressively increasing along with decrease in Hb/Hematocrit and platelet count. His Lymphocyte Doubling Time (HDT) is less than 12 months, predicting progression (1). Recent CT scan showed axillary, mediastinal, retroperitoneal, pelvic and inguinal lymphadenopathy, hepatosplenomegaly, and a new right upper lobe lung nodule, measuring 1.3 cm.

PET-CT show focal hypermetabolism in the right upper lobe lung nodule (SUV measuring 3.0) consistent with neoplastic involvement, likely a second primary lung cancer. CT-guided biopsy of the lung nodule showed squamous cell lung cancer and CLL. CLL is associated with a greater risk for a second malignancy such as lung cancer compared to the general population (2).

Mild hypermetabolism is also seen in the axillary and inguinal lymphadenopathy (SUV max of 2.2) suspicious for a low grade neoplastic process (CLL). A focus of hypermetabolism is also seen in the prostate (SUV measuring 3.3) which could be neoplastic or inflammatory.

1. Molica S and Alberti A. Prognostic value of the lymphocyte doubling time in chronic lymphocytic leukemia. Cancer 1987 Dec 1;60(11):2712-6.

2. Hisada M, Biggar RJ, Greene MH, Fraumeni JF Jr and Travis LB. Solid tumors after chronic lymphocytic leukemia. Blood 2001 Sep 15;98(6):1979-81.

This case was complied by Dr. Niraj Patel, BCM