Non-small cell lung carcinoma

Case contributed by Benjamin Li Shun Chan
Diagnosis certain

Presentation

Dry cough for 8 weeks.

Patient Data

Age: 45 years
Gender: Female

CXR

x-ray

Band shadow in the right upper lobe adjacent to elevated minor fissure.

Right hilar and mediastinal mass.

Elevated right hemidiaphragm.

Cardiomegaly.

Otherwise normal. No destructive bone lesions.

CTPA

ct

No pulmonary emboli.

Partial collapse of the right upper lobe which contains irregular opacities. Peribronchovascular thickening and smooth interlobular septal thickening in the right upper lobe.

Large right hilar and mediastinal mass narrowing the right main bronchus, right pulmonary artery and right superior pulmonary vein, and occluding the SCV and azygous arch.

Collateral venous distension, some of which carry opacified blood from the right upper limb via the azygous, internal thoracic and superficial right lateral thoracic veins. These anastomose with superior epigastric, medial diaphragmatic and hepatic capsular veins and the superior vein of Sappey in the falciform ligament. Systemic-portal anastomoses through peripheral branches of the left portal vein are associated with hyper-enhancement in the anterior portion of the left lobe of the liver on arterial phase CT. Non-opacified distended bilateral superficial chest wall collateral veins are draining the neck and left upper limb.

Elevated right hemidiaphragm and symmetrical diaphragmatic crura. No atrophy.

Pericardial effusion with no CT features of tamponade.

Case Discussion

Her cough was initially treated with antibiotics with no improvement.

Chest radiograph suggested underlying malignancy and CT demonstrated extensive disease.

Right upper lobe atelectasis with decreased perfusion and lymphovascular obstruction and/or invasion.

Right diaphragmatic elevation due to right upper lobe collapse.

Hepatic pseudolesions are a feature of collateral venous drainage in SVC obstruction.

Lung cancer can cause pericardial effusion if lymphatic drainage is impaired or if tumor directly involves the pericardial surface thereby reducing fluid absorption.

Bronchoscopy and Histopathology:
Bronchoscopy demonstrated mucosal infiltration in the proximal right main bronchus.

Histological diagnosis was non-small cell lung carcinoma, not otherwise specified.

Immunohistochemistry and genotype: CK7 and ROS-1 positive. BRAF, EGFR and KRAS were not detected.

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