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?
4. Can’t tell
Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.
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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).
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.
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.
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).
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).
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