Presentation
4 week history of thoracic back pain - worse on inspiration.
Patient Data
PA erect film. Ill-defined 3.5 cm opacity projected inferior to the left hemidiaphragm. In addition, there is destruction of the inferior cortex of the medial left posterior fifth rib and focal increased density projected over the aortic knuckle. The heart is not enlarged. Unfolding of the descending aorta as previously.
3.4 cm well-circumscribed mass in the basal left lower lobe is not typical of a primary lung tumor. No thoracic lymphadenopathy. Several further subcentimeter pulmonary nodules elsewhere consistent with metastases.
A 6 cm x 4 cm left posterior 5th rib metastasis destroys the adjacent left T5 pedicle and transverse process. This narrows the left T4/5 and T5/6 neural exit foramen but no central spinal cord compression. Further T11 vertebral body metastasis.
Case Discussion
Biopsy confirmed widespread metastatic malignant melanoma. Further history noted previous excision of abdominal and forearm cutaneous melanomas.
This case is a classic example of an easily overlooked left basal pulmonary mass projected over the diaphragmatic and cardiac shadows. The importance of tracing each rib cortex is highlighted to ensure subtle findings of bone destruction are not missed.
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