NWHSU logo
Challenge of the Unknowns—Unknown 7

Diagnosis and Discussion

DIAGNOSIS: Percutaneous biopsy of the upper lung mass was obtained revealing adenocarcinoma, non-small cell lung carcinoma.

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.


Click images for close-up and further audio discussion by Dr. Jeff Rich

**What is a PET scan

play sound file

-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.

"A clinical viewpoint"

play sound file


-Adenocarcinoma, non-small cell bronchial carcinoma, with metastatic spread to the mediastinal lymph nodes and right rib cage.

-Rotator cuff arthropathy


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 opacities.

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 search pattern

- 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.


Click here to continue to self assessment



Questions? Comments? Send e-mail to Northwestern Health Sciences University Web Coordinator.
2001 Northwestern Health Sciences University/ www.nwhealth.edu - All Rights Reserved
Copyright Information