Aggressive lung cancer with cardiac metastases, pulmonary artery tumor thrombus, and Budd-Chiari

Case contributed by Michael P Hartung


Patient with history of lung cancer with concerning of progressive disease.

Patient Data

Age: 50 years
Gender: Male


1. Severely abnormal exam. Large left pleural collection with peripheral enhancement/pleural thickening. This could represent empyema in the correct clinical setting.

2. Complete thrombosis of the left main pulmonary artery with what appears to be enhancing tumor thrombus. The majority of the left lung is collapsed.

3. 3.2 x 2.5 cm mass in the intraventricular septum and 1.7 x 1.2 cm mass along the anterior right ventricular border. These are worrisome for cardiac metastases.

4. Diffusely abnormal right lung evidenced by numerous irregular interstitial opacities, areas of consolidation, and septal thickening at the lung base. This could represent lymphangitic spread of tumor, drug reaction, infection, or ARDS.

5. Heterogeneous hypoenhancement of the entire liver (nutmeg liver), worrisome for Budd-Chiari syndrome. This could be related to tumor thrombus involving the intrahepatic hepatic segment of the IVC. Correlation with Doppler ultrasound of the liver is recommended. If there is occlusion of the IVC/hepatic veins due to tumor thrombus, this could be responsible for the suspected tumor thrombus in the left main pulmonary artery.

6. Heterogeneous low-attenuation lesions in the left hepatic lobe, incompletely characterized given abnormal liver perfusion. These could represent hepatic metastases and could be evaluated with ultrasound if indicated.

7. Large presumed splenic infarct with several smaller low-attenuation lesions. The spleen has a rounded appearance. This could be related to hemorrhage of splenic metastases or vascular etiology.

8. 2.8 x 3.1 cm right adrenal lesion, likely metastasis.

Case Discussion

An extremely abnormal exam with very limited patient history provided (volunteer teleradiology). This case provides a good illustration about how aggressive a dedifferentiated tumor can be, with suspected Budd-Chiari syndrome, tumor thrombus in the pulmonary arteries, and cardiac metastases.

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