Presentation
62 year old male with right-sided Pancoast tumor treated with radiotherapy
Patient Data
Pulmonary scarring/collapse in the posteromedial aspect of the lung apex is associated with edema and intramuscular enhancement in the adjacent intercostal and scalene musculature and also within serratus posterior, likely to be secondary to radiation change. Similar appearances in the right apex were identified on a CT chest from September 2013. T1 hypointense soft tissue thickening partially surrounds the brachial plexus most pronounced where it crosses the first rib. This appears to draw-in and distort the lower trunk and to a lesser extent the middle trunk of the brachial plexus, and also involves the medial and probably posterior cords. This is associated with mildly asymmetric thickening of the C8 and T1 nerve roots.
Conclusion:
Distortion of the lower trunk and medial cords and to a lesser extent middle trunk and posterior cord of the right brachial plexus by abnormal soft tissue at the thoracic outlet. The similarity of right apical lung change to a CT from 2013 and the morphology of the brachial plexus abnormality ( drawn in rather than enveloped ) would be more compatible with radiation plexopathy than tumor infiltration.
Report courtesy of Royal Melbourne Hospital Radiology Department
Distortion of brachial plexus trunks.
Case Discussion
Radiation is the most common cause of non-traumatic brachial plexopathy and much of this is iatrogenic. Symptoms may be delayed for months to years with peak onset being 10-20 months. MRI can be used to distinguish brachial plexopathy due to radiation as opposed to incidence or recurrence of a mass. Unfortunately, both tumors and radiation plexopathy can exhibit hypointensity on T1-weighted imaging and hyperintensity on T2-weighted imaging as well as enhancement following gadolinium contrast; the most reliable sign is the detection of a visible mass in the case of tumor recurrence. The MRI features of acute and chronic brachial plexus changes following radiation are outlined below 1,2:
Acute radiation plexopathy
- diffuse, uniform, symmetric swelling, hyperintense on T2-weighted imaging
- slight to moderate hyperintensity on STIR images
- can have mild contrast enhancement
- surrounding fat and muscles appear diffusely T2-hyperintense
- radiogenic pneumonia and pleura thickening possibly present
Chronic radiation fibrosis
- usually hypo or iso-intense on T1 and T2
- does not enhance with gadolinium
- architectural distortion and more diffuse thickening of brachial plexus without a focal mass
- surrounding fibrovascular scar tissue
This case has more features of chronic radiation fibrosis.
Case courtesy of Dr Craig Hacking and A/Prof Pramit Phal.
Unable to process the form. Check for errors and try again.