Lung cancer with lymphangitis carcinomatosis and situs inversus

Case contributed by Dr Alexandra Stanislavsky

Presentation

New deterioration and dyspnoea in a patient known to the respiratory unit.

Patient Data

Age: 70
Gender: Female

There are many findings to observe in this case.

1. Of most immediate importance is the large left paramediastinal mass.  Associated thickened reticular markings in the left midzone suggest associated lymphangitis carcinomatosis. Note the surgical clip over the left hemithorax; there has been prior surgery and this is either a recurrent or metachronous malignancy.  The lungs are hyperexpanded, indicating COPD as the background risk factor.

2. The patient has had prior breast cancer.  Bilateral breast implants are present, of which the right is calcified, and there is a surgical clip in the right axilla, which points to a prior axillary disseciton.

3. There is situs inversus.  Note the dextrocardia, right sided aortic arch and the gastric bubble located below the right hemidiaphragm.  

If not appreciated, the latter finding might confuse localisation of the lung mass. The aortic border is well visualised on the left. It is important to realise that this represents the ascending aorta located anteriorly, and not the descending aorta. The mass is therefore likely postrerior/prevertebral - and this is confirmed on the subsequent CT.

CT helps to clarify the multiple findings seen on chest x-ray

Case Discussion

This is an "observational" case.  No complex pathology, but much to see.  

The distorted anatomy due to dextrocardia and a right sided aortic arch, as well as the "distractor factor" of a calcified breast implant and evidence of prior breast cancer, might draw one's attention away from the main finding - the large left paramediastinal lung cancer with lymphangitis carcinomatosis.

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Case Information

rID: 37084
Case created: 25th May 2015
Last edited: 6th May 2017
System: Chest
Inclusion in quiz mode: Included

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