SELECTED CASE A 45-year-old asymptomatic white man with a 60-pack-year history of cigarette abuse presented with an upper lobe pulmonary nodule apparent on the right side on a routine chest roentgenogram. Physical examination was unrevealing. Computed tomography demonstrated an irregular noncalcified mass suggestive of neoplasm. Results of transbronchial biopsy were positive for adenocarcinoma. Evaluation for metastases, including a computed tomographic scan of the head, radionuclide bone scan, and serum liver function tests, yielded negative results. The patient subsequently underwent upper lobectomy of the right lung with curative intent and was pathologically staged as having stage I (T2N0)1 adenocarcinoma of the lung.
The patient did well until 14 months after surgery, when he developed cough, dyspnea, and hemoptysis. A few days later, he noted a right-sided facial droop, clumsiness of the right hand, blurring of vision, and a severe headache. He presented in the emergency department, where physical examination revealed facial