Diagnosis and Discussion
DIAGNOSIS: Percutaneous biopsy of the upper lung mass
was obtained revealing adenocarcinoma, non-small cell lung
At this point, the oncologist recommended a (PET) Positron
Emission Tomography on October 27th, 2000 to clarify the status
of the indeterminate 8 mm module in the anterior aspect of
the right upper lobe, as well as to stage the bronchial carcinoma,
looking for uptake in the mediastinal lymph nodes, which was
suggested a previous CT scan.
PET SCAN FINDINGS:
Click images for close-up and further audio discussion by Dr. Jeff Rich
is a PET scan
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-Intense hypermetabolism was noted throughout the
3.5 cm biopsy-proven carcinoma.
-Multiple focal areas of hypermetabolism in the left hilum
were noted compatible with metastatic disease to the lymph
nodes in this region. This corresponds to the region of
prominence seen on the CT scan examination.
-No uptake in the region of the 8 mm module in the
right upper lobe, suggesting a benign etiology.
-Focal hypermetabolism in the right chest wall apparently
suggesting metastasis to the rib cage, however, focal
trauma could produce a similar finding.
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-Adenocarcinoma, non-small cell bronchial carcinoma, with
metastatic spread to the mediastinal lymph nodes and right
-Rotator cuff arthropathy
TREATMENT AND FOLLOW-UP:
Patient is reportedly receiving chemotherapy as well as being
treated conservatively at the chiropractic clinic. The first
chemotherapy agent did not halt tumor growth and he was placed
on a more potent agent which is physically harder on him.
His diabetes mellitus is harder to control while undergoing
chemotherapy as the insulin level fluctuate severely probably
contributing to overall lethargy. Patient is relying on family
support as he deals with this malignancy.
The rotator cuff tear which occurred approximately three
years ago has led to secondary rotator cuff arthropathy with
the following classic findings: superior subluxation of the
humerus, acromiohumeral distance less than approximately
7 mm, cystic stress-related change at insertion site of
the rotator cuff tendon on the greater tuberosity. These radiographic
findings are consistent with a chronic rotator cuff tear.
To directly visualize the rotator cuff tendon, MRI would be
the appropriate imaging modality, especially if surgical intervention
was being considered.
bronchial carcinoma is currently the most common cause
of death from malignancy in adult men and women. Survival
rates for lung cancer are poor, however, accurate radiographic
diagnosis and staging is very important in the management
of patients with lung cancer. bronchial carcinoma is a malignant
neoplasm that typically arises from bronchiolar or alveolar
epithelium. Most of these tumors arise from the bronchi or
lung instead of the trachea. bronchial carcinoma is divided
into four main histologic subtypes based on their gross and
microscopic features: small cell carcinoma, squamous cell
carcinoma, adenocarcinoma, and large cell carcinoma.
A. Small cell carcinoma makes up approximately 25
percent of all bronchial carcinomas and typically arise centrally
within the main or lobar bronchus. Radiographically they typically
present with a hilar or mediastinum mass with extrinsic bronchiall
compression and obstruction, typically with lymph node enlargement
and with hematogenous dissemination at the time of presentation.
B. Squamous cell carcinoma is the most common subtype
of bronchial carcinoma, accounting for approximately 35 percent
of cases. Typically this tumor arises centrally within the
lobar or segmental bronchus and may grow into the bronchiall
lumen resulting in typical presenting complaints such as cough
and hemoptysis. Central necrosis is quite common and cavitation
may be seen in these tumors.
C. Adenocarcinoma accounts for approximately 25 percent
of all bronchial carcinomas and typically arise from the bronchiolar
or alveolar epithelium in the lung periphery. Typically they
have a quite irregular or spiculated appearance as they invade
the adjacent lung. There can be fibrosis within the tumor
and at the periphery. Radiographically, they present as a
peripheral, ill-defined pulmonary mass. The localized form
of adenocarcinoma presents as a quite large solitary pulmonary
nodule, however, diffuse disease may present as airspace opacification
simulating pneumonia or diffuse bilateral nodular airspace
D. Large cell carcinoma accounts for only 15% of bronchial
carcinoma and tends to arise in the periphery as a solitary
mass, often times large at the time of presentation.
The histologic diagnosis in this case was non small cell
adenocarcinoma, and the irregular mass like appearance in
the lung periphery is quite typical.
Most patients with bronchial carcinoma are cigarette smokers,
men the most commonly affected although the percentage of
lung cancer patients with women has risen steadily. Squamous
cell carcinoma and small cell carcinoma are the two subtypes
with the strongest association with cigarette smoking.
Asbestosis exposure, previous Hodgkin's disease treated
by radiation and \ or chemotherapy, and exposure to inhaled
radioactive material are other well recognized risk factors
for the development of bronchial carcinoma. It has also been
suggested that local lung scarring as a result of inflammation
can induce the development of a "scar carcinoma" which is
most commonly adenocarcinoma. In our case, there was no visible
scar identified on prior radiographs in the region of the
carcinoma. Computed tomography is important to follow-up chest
films to look for the presence of lobar atelectasis, subtle
calcification, and the extent of the tumor. CT scanning also
is able to look at central necrosis and cavitation. One of
the most important reasons for obtaining a computed tomography
exam in all patients with possible bronchial carcinoma is to
guide efforts at tissue sampling and to aid in radiographic
staging of the lung cancer, looking for associated more
subtle regions which may have been missed on plain film and
evaluating for presence of nodal involvement especially in
the mediastinal region. There is a quite detailed classification
system utilized with lung cancer which looks specifically
at the size and location of the primary tumor as well
as evaluation for the extent of nodal metastasis.
This case is unique due to the lack of clinical and historical
findings which suggested malignancy. The key clinical points
to obtain from this case study are as follows:
- always include the soft tissues in your radiographic
- follow-up solitary pulmonary nodules or masses visualized
on plain film with computed tomography
- obtained previous films for comparison, and most
importantly, remember that the patient does not read the textbook
and present with classic clinical symptoms for a given diagnosis.
You really have to be on your toes.
Case courtesy of Patrick Napoli, DC of White Bear Lake, Minnesota.
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