Dr. Pepe’s Diploma Casebook: CASE 126 – SOLVED!

Dear Friends,

Today I am showing radiographs of a 43-year-old man with dyspnea. In your opinion, what will be the probability of him having a lung carcinoma?

1. Low
2. Moderate
3. High
4. Can’t tell

Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.

Click here for the answer

Findings: The main findings are seen in the PA radiograph, which shows a poorly-defined right paramediastinal opacity (A, arrow) accompanied by numerous Kerley lines in the RUL (A, circle), better seen in the cone-down view (B, circle).

Enhanced coronal CT taken one week before the chest radiograph shows the paramediastinal opacity (C, red arrow), as well as numerous Kerley lines in the RUL (C, circle). Axial CT better shows the Kerley lines (D, circle). Pericardial and pleural effusions are also visible (C, yellow arrow). Bronchoscopy confirmed adenocarcinoma.

Final diagnosis: adenocarcinoma with mediastinal metastasis and lymphangitic spread

In Diploma case 124 and Diploma case 125 I discussed the two most common presentation forms of lung carcinoma: lobar collapse (50%) and pulmonary nodule (30%). Today I want to review other, less common forms of presentation. I have selected four which, in my opinion, are not rare and easy to identify. They are:

1. Pulmonary infiltrate with lymphangitis
2. Widespread involvement of both lungs
3. Enlarged mediastinal lymph nodes
4. Superior sulcus tumor

1. Pulmonary infiltrate with lymphangitis.

A neoplasm of the lung, breast, stomach, or colon is the most common source of lymphangitic carcinomatosis. A unilateral distribution suggests lung cancer, as most of the other tumors result in bilateral involvement. In my experience, a unilateral pulmonary infiltrate accompanied by Kerley lines is a reliable indication of lung carcinoma with lymphangitic spread (Fig. 1).

Fig. 1. PA radiograph shows a right perihilar infiltrate (A, arrow) accompanied by pleural fluid and Kerley lines, better seen in the lateral view (B, circle).

Coronal and sagittal CT images confirm numerous Kerley lines (C and D, circles). There is an incidental pneumothorax secondary to thoracentesis. Diagnosis: adenocarcinoma of the lung with lymphangitic spread

2. Widespread involvement of both lungs.

Occasionally, lung cancer (usually mucinous BAC) presents with diffuse lung involvement (Figs. 2 and 3). It is unclear whether this occurs because of a multicentric origin of the tumor or secondary to endobronchial spread.

Fig. 2. 78-year-old woman with dyspnea. No fever. PA radiograph shows a widespread miliary pattern in both lungs (A) that was not visible in a previous chest film taken one year earlier (B).

Axial and coronal CT confirm the presence of multiple miliary nodules in both lungs (C and D). Note that the nodules are not uniform in size. A macronodule in visible in the apical segment of the RLL (D, arrow). Final diagnosis: widespread adenocarcinoma of lung (BAC subtype). The presence of a large nodule with disseminated disease raises the possibility of endobronchial spread from a primary tumor.

Fig. 3. Disseminated adenocarcinoma of the lung presenting as macronodules in the chest radiograph (A). Axial CT shows considerable RLL involvement (B, arrow), raising the possibility of a primary RLL tumor with endobronchial spread. Diagnosis: adenocarcinoma of lung (Case courtesy of Alberto Villanueva, MD)

3. Mediastinal nodes.

In 35% of cases, lung carcinomas are accompanied by enlarged mediastinal lymph nodes at the time of discovery. Occasionally lymph nodes may be be the sole manifestation, raising the possibility of other pathologies, such as lymphoma or a mediastinal mass (Figs. 4 and 5). The nodes are commonly seen in the middle mediastinum and usually occur in primary small cell tumors.

Fig. 4. 54-year-old man with chest pain and dyspnea. PA radiograph shows enlarged hilar lymph nodes, more obvious on the left side (A, arrows). The lateral view shows a typical donut sign (B, arrows).

Enhanced coronal and axial CT images confirm the enlarged hilar and mediastinal nodes (C and D, white arrows). Note the large metastases to the left adrenal gland (C, red arrow). Diagnosis: widespread metastases from small cell carcinoma of the lung.

Fig. 5. 72-year-old man with cough and weight loss. PA radiograph shows a large mass adjacent to the upper right mediastinum (A, arrow). Axial CT confirms a large irregular mediastinal mass (B, arrow). Diagnosis: mediastinal lymph node metastasis from primary small cell carcinoma of the lung.

4. Superior sulcus tumor (Pancoast)

Superior sulcus tumor (Pancoast) accounts for about 5% of lung carcinomas. It is characterized by the typical triad of shoulder pain, rib destruction, and Horner syndrome (Fig. 6). In many cases, all three factors are not present. Current criteria recommend that any patient with upper chest pain and asymmetrical apical pleural thickening greater than 5 mm should undergo further study (Fig. 7).

Fig. 6. 49-year-old man with pain in the upper left thorax. PA radiograph shows pleural thickening in the left apex (A, arrows). The posterior arch of the second left rib is missing (A, asterisk). Coronal CT confirms an apical mass (B, arrow) and destruction of the second rib (B, asterisk).

Fig 7. 59-year-old man with mild upper chest pain. The initial film shows discrete pleural thickening (A, arrow) that was not considered significant. Three years later, the pleural thickening has increased markedly (B, arrow). Coronal CT shows an apical soft tissue mass with chest wall invasion (C, arrows), confirming the diagnosis of superior sulcus tumor.

It is important to avoid confusing a Pancoast tumor with innocuous apical pleural thickening (apical cap), which is a common occurrence. In my experience, the best approach is to compare with previous films (Fig. 8).

Fig. 8. Asymptomatic 61-year-old woman with obvious right apical pleural thickening (A, white arrow). Comparison with a previous film taken three years earlier shows no change (B, white arrow), confirming the diagnosis of an innocuous right apical cap. There is an incidental right cervical rib (A and B, red arrows).

Follow Dr. Pepe’s advice:

1. Unilateral pulmonary infiltrate with Kerley lines is a reliable sign of lung malignancy.

2. Diffuse neoplastic involvement of both lungs is usually secondary to mucinous BAC.

3. In enlarged mediastinal lymph nodes, think of metastasis from small cell carcinoma.

4. Upper chest pain and apical thickening of more than 5 mm should be investigated to exclude Pancoast tumor

17 thoughts on “Dr. Pepe’s Diploma Casebook: CASE 126 – SOLVED!

  1. Very challenging case as usual.
    Very low possibility of cancer as AP CXR have minimum signs. There seems
    redistribution of the pulmonary vasculature, with increased size of the upper lobe vessels compared to the lower ones hence possible lower lobe embolism in clinical context of the case?


  2. Very challenging case as usual.
    Very low possibility of cancer as AP CXR have minimum signs. There appears
    increase pulmonary vasculature , with increased size of the upper lobe vessels compared to the lower ones hence possible lower lobe embolism in clinical context of the case?


  3. Very low possibility of cancer as AP CXR have minimum signs. There seems
    increased pulmonary vasculature, with increased size of vessels ?PE and will need CTPA to confirm in my opinion.


  4. On AP I see widened right mediastinum, elevated right hilum and slightly elevated right hemidiaphragm, so LUL atelectasis is highly suspected, therefore moderate probability of having lung carcinoma. On lateral view my eyes may be deceiveing me but I see doughnut sign.


  5. High , because dominant changes are bilateral reticulonodular opacities that corespondent with Lymphangitis carcinomatosis, from lung carcinoma


  6. High risk of cancer, atelectasis of the middle lobe of the right lung (raised right dome of the diaphragm, right heart border is indistinct on the AP film, on the lateral projection – raised and thickened lower portion of the major fissure).


  7. In my (unauthorized) opinion, risk of carcinoma is high because of the presence of unilateral Kerley lines,. Have to congratulate Kash and Gem because they were the first to mention it.


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