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Metastatic pleural effusion due to lung adenocarcinoma

Case contributed by Jennifer Luna
Diagnosis certain

Presentation

Increasing shortness of breath and background of lung cancer

Patient Data

Age: 75 years
Gender: Female

There is a large opacity of the right hilar, suprahilar and upper zone region which is consistent with the known primary lung cancer. The right lower zone is opacified which could represent right lower lobe collapse with an elevated right hemi diaphragm. The opacity could alternatively represent a soft tissue lesion or loculated pleural effusion.

There is a partially necrotic mass lesion in the right upper lobe which is consistent with known lung adenocarcinoma. The lesion involves the distal trachea and the right main bronchus with narrowing then cut off of the right upper lobe bronchus. The superior vena cava is significantly narrowed as it traverses the lung lesion. There are associated enlarged ipsilateral and contralateral mediastinal lymph nodes. The right mid to lower zone demonstrates a large likely loculated pleural effusion causing inferior displacement of the adjacent hemidiaphragm and elevation and collapse of the right upper lobe. In addition there is further loculated fluid in the right upper lobe with air fluid level. The pancreas demonstrates extensive calcification and dilation of the pancreatic duct. There are multiple retroperitoneal lymph nodes. 

Case Discussion

This is an interesting case of abnormal chest x-ray which can be mistaken for an elevated hemidiaphragm. The mediastinum is displaced to the left and the right hemidiaphragm is displaced inferiorly because the volume of the loculated pleural collection is greater than the loss of volume in the right lung. 

The patient had multiple previous pleural taps for pleural effusion. The pleural fluid had previously been sent for cytology which had showed malignant cells consistent with lung adenocarcinoma. The appearance of the pleural effusion compared to previous had evolved from a simple pleural effusion to a loculated effusion. This explains why the appearance on the CXR no longer shows the typical meniscus sign and instead artificially gives the impression of an elevated hemidiaphragm. 

Regarding cancer staging the tumor size (>7cm) equates to T4, the involvement of contralateral mediastinal lymph nodes equates to N3 and the presence of malignant pleural effusion equates to M1a. The overall IASLC 8th edition staging being IVa. 

 

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