Recurrent laryngeal nerve palsy due to hilar mass

Background COPD. Large soft tissue density mass in the superior left hilum.  Proximal airways are patent. Trachea is deviated to the right at the level of the aortic arch/left hilum.  No evidence of infective process, pleural effusion or atelectasis seen. Bilateral apical pleural thickening.

Mottled appearance of the posterior left third rib.

Neck

Pathologically enlarged enhancing left supraclavicular lymph node. No additional cervical level lymph nodes by size criteria.

Aerodigestive tract is patent. Enlarged left piriform fossa. Thickening of the left aryepiglottic fold with cord asymmetry and medialisation in keeping with recurrent laryngeal involvement. Partially imaged enhancing left superior mediastinal soft tissue mass.

Enhancing soft tissue mass encasing the C2 spinous process with associated permeated appearance of the underlying bone with erosion and fragmentation. Mass measures 26 x 30 x 30mm (AP x TR x CC), and causes posterior effacement of the thecal sac at the C2 level. Multilevel degenerative change of the cervical spine with no additional lytic bony lesion.

Chest

Large mediastinal and left hilar mass located below the aortic arch, encasing the left pulmonary artery extending into the left perihilar region (77.9 x 50.6mm, axial plane). Mass causes mild extrinsic compression on left pulmonary artery with near complete compression of the left anterosuperior segmental artery. The carina is mildly displaced to the left. No other perihilar or mediastinal lymphadenopathy.

Diffuse, mild centrilobular emphysematous change with multiple bullae located apically and anteriorly. Ground glass change adjacent to the left perihilar region. Cluster of small pulmonary nodules in the apicoposterior segment of the left upper lobe. No pleural effusion.

Abdomen/Pelvis

Innumerable enhancing lesions throughout the liver, the largest in segment 5. Multiple lesions along the periphery of the liver expand the liver capsule. Portal and hepatic veins are patent.

Trace amount of fluid in the right pericolic gutter adjacent to the inferior liver edge. No free gas.

Large cluster of pathologically enlarged periportal / porta hepatic lymph nodes, immediately posterior to the main portal vein. Prominent para-aortic lymph nodes do not meet size criteria. No pathological pelvic lymphadenopathy, noting that sensitivity is decreased due to streaking artefact from contrast in the bladder.

Bladder is grossly distended, contains contrast. Increased mural trabeculation and two right-sided bladder diverticuli noted. Further small left posterior bladder diverticulum. Calcifications within the prostate.

No suspicious osseous abnormality. Small presacral soft tissue mass.

IMPRESSION

• Left hilar mass has a differential diagnosis of lung cancer and melanoma. It is causing a left recurrent laryngeal nerve palsy.

• Left supraclavicular and periportal / porta hepatis lymphadenopathy.

• Metastases in the liver, lungs and bones (C2 and sacrum).