Cáceres Corner Case 233 – Vignette

Dear Friends,

Recommendations for this week: A history of the world in 100 objects written by Neil McGregor, Director of the British Museum. Series: Good omens (Amazon). 

Today’s radiographs belong to a 51-year-old man with moderate cough.
 
Do you see any abnormality?
If so, where?

1.  Upper third
2. Middle third
3. Lower third
4. Don’t see it

Click here to see the answer

Findings: PA radiograph shows a left parahilar opacity (A, arrow), seen as an anterior elongated opacity in the lateral view (B, arrow). Its shape in the lateral view suggests mucous impaction.

Click here to see more images

Enhanced CT was done. What would be your diagnosis?

1. Benign endobronchial tumor
2. Allergic aspergillosis
3. Foreign body
4. None of the above

Click here to see the answer

Findings: enhanced axial CT shows an endobronchial obstruction with a distal mucous impaction (C, arrow), also visible in the coronal reconstruction (D, arrow). The clue to the diagnosis lies in recognizing two small lung nodules in the axial view ( C, red arrows) and another one in the right lung in the coronal view (D, red arrow). In addition, there is an enhancing nodule in the gallbladder (D, yellow arrow). These findings suggest widespread malignancy and the correct answer should be 4. None of the above.

Click here to see more images

Bronchoscopy discovered a dark tumor in the lingular bronchus (E), as well as numerous small implants in the trachea, also visible in the CT (F, arrow).
Review of the clinical history discovered that the patient had been operated on for melanoma of the back four years earlier.

Final diagnosis: widespread metastases from melanoma, one of them causing bronchial mucous impaction

Mucous impactions may be multiple or localized. Multiple impactions are related to respiratory diseases that cause bronchiectasis and thick mucus (allergic aspergillosis, cystic fibrosis) whereas localized ones are secondary to segmental endobronchial lesions.

The prevalence of bronchogenic carcinoma makes it the most common cause of localized mucus impaction in clinical practice. Other malignant tumoral lesions are metastases and carcinoids.

Endobronchial metastases represent about 2% of lung metastases. They are usually accompanied by metastatic nodules. They may occur in association with any tumor, but the most common sources are colon, breast, kidney and melanoma.

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