Presentation
Past history of carcinoma of the lung and right pneumonectomy many years ago. Now persistent cough and right lower pleuritic chest pain.
Patient Data
Figure 1 (current presentation) - Typical features of right pneumonectomy. Displacement of mediastinal structures to the right. The left upper lobe of the lung has herniated to the right and is obscured by the vertebral column thus the mass lesion is barely visible through the head of the left clavicle.
Figure 2 (7 years ago).
The patient has had a right pneumonectomy with a right 6th rib defect. Gross displacement of mediastinal structures towards the right including the trachea and esophagus. Herniation of the left lung across the midline into the right hemithorax anteriorly. Small residual fluid collection within the right pleural space.
Within the hyperinflated left lung (apical segment left upper lobe) there is an irregular mass lesion measuring approximately 4cm in diameter. It abuts the stretched left subclavian, vertebral and common carotid arteries as they arise from the aortic arch independently to enter the left side of the neck and left upper limb. Appearances are highly suggestive of a primary lung neoplasm. There is associated substantial left hilar and mediastinal lymphadenopathy involving predominantly the aortopulmonary window.
The left lung is otherwise clear without further metastatic lesion. Little if any pleural fluid. No pneumothorax. The adrenals are normal.
Conclusion:
Grossly distorted mediastinum as a result of a previous pneumonectomy. Trachea and esophagus are now markedly displaced towards the right with minimal fluid in the residual right pleural space. There is associated pleural thickening together with a rib defect consistent with thoracotomy.
Grossly hyperinflated left lung crossing the midline to enter the right hemithorax. Within this hyperinflated right upper lobe just anterior to the vertebral column there is an irregular mass abutting the stretched left aortic arch arterial branches (left common carotid, left vertebral and left subclavian arteries). Substantial left hilar and mediastinal lymphadenopathy. No other evidence of metastatic disease within the chest nor indeed the adrenal glands.
Case Discussion
Pneumonectomy causes marked distortion to the mediastinum with hyperinflation of the residual lung, often herniating to the contralateral hemithorax anteriorly. In this case, a cancer has developed in that herniated lung and is obscured by the vertebral column on the anterior chest radiograph, thus is very difficult to identify.
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