A young female with multiple cavitary lung lesions.

A 21-year-old female with a history of HPV and recurrent laryngeal papillomatosis has required frequent removal of laryngeal papilloma through direct laryngoscopy and has been treated with interferon alpha since she was 7 months old. She now presented with worsening dyspnea, hemoptysis, night sweats and significant weight loss. Infectious work up was negative. CT thorax showed significantly increasing right lower lobe mass with thick septation, debris and fluid concerning for malignant transformation. CT-guided biopsy of the mass showed features concerning for necrotic squamous cell carcinoma (SCC). Multidisciplinary tumor board classified this as malignant transformation due to bilateral lungs involvement and aggressive nature of the disease and recommended treatment with combination of chemotherapy and immunotherapy. Unfortunately, she continued to have declining performance status with multiple hospitalizations for hypoxic respiratory failure. Repeat CT scan of the chest showed progression of the lung lesions with extensive mediastinal involvement. She was unable to tolerate any additional therapy and decided with her family to pursue inpatient hospice. Malignant transformation into squamous cell carcinoma in recurrent respiratory papillomatosis is rare and is associated with worse outcomes.