C78-43 Seeing Beyond the Obvious: A Pulmonologist’s Diagnostic Win

Abstract Introduction Cavitary lung lesions in older adults frequently raise concern for primary malignancy or infection. However, clinical insight and early tissue diagnosis can uncover unexpected realities. We present a case that underscores the pivotal role of pulmonologists in recognizing subtle historical clues and securing timely pathology to avoid a major diagnostic pitfall. Case presentation A 70-year-old man with a remote history of resected skin cancer presented with a cavitary right lower-lobe mass and mediastinal lymphadenopathy, highly suggestive of primary bronchogenic carcinoma. Recognizing the incongruity between imaging findings and his clinical background, the pulmonary team pursued early robotic bronchoscopy with EBUS-guided biopsy. Pathology revealed metastatic basal cell carcinoma, an exceedingly rare cause of pulmonary lesions. Discussion Basal cell carcinoma metastasizes in fewer than 0.5% of cases, typically to the lungs and lymph nodes. Misclassification as primary lung cancer could have led to unnecessary chemoradiation. This case highlights how integrating prior oncologic history with imaging features can direct the diagnostic pathway, emphasizing the value of early tissue acquisition and multidisciplinary collaboration with pathology. Conclusion Clinical intuition, timely biopsy, and collaboration were key in revealing an unexpected diagnosis. This case demonstrates how pulmonologists can “see beyond the obvious” to ensure precise diagnosis and management. Radiologic and histopathologic images will accompany the final presentation. This abstract is funded by: none