Metastatic adenocarcinoma of the lung

Case contributed by Dr Ammar Ashraf

Presentation

Slurred speech and right-sided weakness 5 days. No history of fever or seizures.

Patient Data

Age: 55 years
Gender: Male

A cystic/necrotic lesion measuring about 29 mm is seen in the left temporoparietal region, associated with marked surrounding vasogenic edema, and severe mass effect on the ipsilateral lateral ventricle with contralateral midline shift (subfalcine herniation) of 15 mm.

FINDINGS: A loculated cystic lesion showing peripheral enhancement, associated with marked surrounding vasogenic edema, and mass effect over the ipsilateral lateral ventricle with contralateral midline shift of 15 mm, is seen in the left temporal lobe. Multiple small enhancing lesions are noted in both cerebellar hemispheres, cerebellar vermis, right temporal lobe, and right high frontal lobe.

CONCLUSION: Multiple enhancing lesions in the brain as described above, suggestive of cerebral metastases

Triangular opacity in the left infra-hilar/retro-cardiac region, with partial loss of the left medial hemidiaphragm outlines. The right lung is clear. No significant pleural effusion or pneumothorax is seen. 

FINDINGS: A heterogeneously enhancing mass measuring ~3 X 4 cm, is seen centered over the left lower lobe bronchus, 30 mm from the carina. This is causing severe bronchial narrowing and is associated with distal atelectasis. This is inseparable from the left lower lobe pulmonary artery and vein. Multiple left hilar, subcarinal, and AP window lymph nodes are noted. Multiple soft tissue density nodules are seen in both lungs. An enhancing solid nodule is noted in either the adrenal gland. The visualized bony skeleton is unremarkable apart from degenerative changes. 

IMPRESSION: Left perihilar mass associated with left hilar/mediastinal lymphadenopathy and soft tissue nodules in both lungs and adrenals. These CT findings are suggestive of metastatic lung carcinoma

CT

CT chest & abdomen 5 months later

FINDINGS: An interval increase is noted in the size of left lower lobe pulmonary mass and its associated mediastinal lymphadenopathy. An interval increase is also noted in the size & number of bilateral pulmonary nodules and the size of bilateral adrenal lesions. There is also an interval development of multiple mildly sclerotic lesions in the spine and pelvic bones.

CONCLUSION: Progressive disease.

Nuclear medicine

Tc-99m MDP bone scan after 2nd CT chest & abdomen

FINDINGS: 3 hours delayed phase images demonstrate multiple foci of intense uptake involving the vertebral column, ribs, pelvis, shoulders,, and proximal femora.

IMPRESSION: Widespread osseous metastases.

Case Discussion

Procedure: CT guided left lung mass biopsy.

Diagnosis: Primary pulmonary adenocarcinoma (bronchoalveolar type).

Immunohistochemistry: Tumor cells are positive for pan CK, CK7, EMA, and TTF-1 and negative for CK20 and CDX2. 

EGFR mutation test: Negative.

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Case information

rID: 79273
Published: 23rd Jun 2020
Last edited: 25th Jun 2020
System: Chest
Inclusion in quiz mode: Included
Institution: King Abdulaziz Hospital Al Ahsa (MNGHA)

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