Cáceres Corner Case 231 – Vignette

Dear Friends, 

Recommendations for this week: The apartment directed by Willy Wilder (any of his pictures are excellent). A book: Lonesome dove by Larry McMurtry. Both of them are oldies, but very good.

Today’s case: radiographs of a 60-year-old woman  in whom a chest abnormality was discovered during initial workup for breast carcinoma.

Diagnosis:

1. McLeod syndrome
2. LLL collapse
3. Agenesis of left pulmonary artery
4. None of the above

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Findings: PA radiograph shows a hyperlucent left lung with loss of volume. The left hilum is descended and hidden behind the cardiac silhouette (A, arrow). The heart is rotated to the left showing a straight left heart border. There is an ill-defined opacity behind the heart shadow (A, red arrow).
In the lateral view there is an ill-defined opacity in the posterior lower lung (B, arrow) and blurring of the left hemidiaphragm.
Al these findings are typical of LLL collapse with compensatory overinflation of the left upper lobe.

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Enhanced CT of the chest was obtained. What would be your diagnosis?

1. Hamartoma
2. Carcinoid
3. Endobronchial metastasis
4. Any of the above

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Findings: Coronal CT shows marked LLL collapse with bronchiectasis (C, arrow). Coronal MIP shows a rounded mass at the origin of the LLL bronchus (D, circle). Mediastinal window demonstrates popcorn calcifications in a low-enhancing mass (E, circle).

Of the diagnoses offered I believe endobronchial metastasis can be excluded because of the coarse calcification of the nodule.
The differential diagnosis lies between hamartoma and carcinoid. Both may appear as rounded masses with calcification. Endobronchial carcinoids are far more frequent than endobronchial hamartomas, but they usually have higher contrast enhancement.
When I saw the images, I favored hamartoma, but I was wrong. Biopsy and subsequent surgery discovered a carcinoid tumor.

Final diagnosis: Type I carcinoid tumor causing collapse of LLL with bronchiectasis.

I chose this case because it is a nice example of LLL collapse. It is also interesting that a slow-growing process may cause severe collapse without significant symptoms.

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