Discussion

Xeroderma Pigmentosum is an unusual autosomal recessive genetic skin condition caused by nucleotide excision repair mutations or DNA Damage. Severe photosensitivity in Ultraviolet rays, skin pigmentary changes, malignant tumor formation, and, on rare occasions, progressive neurologic deterioration distinguish the illness. Patients may also exhibit oral, ophthalmologic, and neurologic signs of the condition (7). Patients with Xeroderma Pigmentosum have congenital abnormalities in the deoxyribonucleic acid (DNA) damage repair system, which makes their skin very vulnerable to UV exposure (5). Though rare, Xeroderma Pigmentosum can be associated with Lung malignancy. Lung cancer in XP patients is caused by the carcinogen benzo(a)pyrene binding to their DNA, which is caused by defective DNA damage repair mechanisms (8). When associated with lung cancer, common symptoms include cough, wheezing, dyspnea, and hemoptysis (9). In this case, we present a case of a 22-year-old male with a known history of Xeroderma Pigmentosum who came with a nonproductive cough associated with hemoptysis, intermittent fever, and shortness of breath. Blood parameters have emerged as significant prognostic factors in lung cancer patients. There can be deranged lymphocyte count, platelet count, albumin level, and other inflammatory markers (10). Metastasis can further derange other blood markers, including thyroid and liver function tests, depending upon the organ it invades. In this, total leukocyte count, neutrophils, erythrocyte sedimentation rate (ESR), prothrombin time, and alkaline phosphatase were found to be increased.   Non-small cell lung cancer has various histological subtypes and treatment approaches (12). One of the non-small cell lung cancers is Spindle Cell Carcinoma. This is the first case report associated with Spindle cell carcinoma and xeroderma pigmentosum. Spindle cell carcinoma is an aggressive and unusual form of lung cancer, representing only 0.2-0.3% of primary pulmonary cancers (11).  In a study of lung tumors, spindle cell carcinoma was among the rarer, with squamous cell carcinoma being the most common. It can metastasize to the brain, causing neurological symptoms such as vertical one-and-a-half syndrome. Endobronchial biopsy findings reveal that squamous cell carcinoma is the most common centrally arising lung tumor, followed by small cell carcinoma and adenocarcinoma, with spindle cell carcinoma being relatively uncommon (11). Endoscopic ultrasound-guided biopsy has emerged as a valuable alternative to conventional biopsy methods for various tissues. Endoscopic and ultrasound-guided biopsies are effective techniques for diagnosing lung cancer and mediastinal lymphadenopathy (13). In this case, the patient underwent an endoscopic ultrasound-guided trust biopsy of left lung mass, and it revealed multiple cores of necrotic tissues composed of small areas of the viable tumor with a sheet of fascicles of spindle cells with a diagnosis of Spindle cell Tumor. Multi-detector computed tomography (MDCT) has shown promise in lung cancer screening and diagnosis. MDCT and its post-processing techniques can accurately detect primary trachea and central bronchus tumors, providing crucial information for surgical treatment (15). Recent studies have highlighted the significance of electrocardiogram (ECG) changes in non-small-cell lung cancer (NSCLC) patients. Specific ECG abnormalities, such as increased ventricular rate, QRS voltage decrease, ST-segment depression, and new atrial fibrillation, were associated with higher mortality within three months in NSCLC patients compared to controls (14). In this, the patient had sinus rhythm, left atrial abnormality, and left fascicular block with average QRS voltage and ST segment.  The main treatments for lung cancer include surgery, chemotherapy, radiotherapy, and immunotherapy, often used in combination as multimodality therapy (16). While survival is a primary goal, patients and caregivers also prioritize quality of life and functionality when defining treatment success (17). Treatment decisions should consider factors such as expected performance status, toxicity, and hospitalization rates (18). For Spindle cell Lung Cancer, first-line treatment typically involves platinum-based chemotherapy, with the addition of immunotherapy agents like atezolizumab or durvalumab in some cases (18). However, due to expensive chemotherapy and immunotherapy, the patient was under palliative care with different medications. The limitation of the research is that this study could not track the effectiveness of cancer therapy, which includes platinum-based chemotherapy and immunotherapy, due to the patient chosen palliative care; however, this case report has highlighted the critical association between xeroderma pigmentosum and spindle cell carcinoma and tracked the diagnostic and treatment approach.