Squamous cell carcinoma of the lung with hilum overlay sign

Case contributed by Ian Bickle
Diagnosis almost certain


Hemoptysis. No weight loss. Non-smoker.

Patient Data

Age: 70 years
Gender: Female

This CXR 7 mth prior to...


This CXR 7 mth prior to this presentation.

3cm well delineated right perihilar mass.  No effacement of the paratracheal stripe suggests this is pulmonary rather than nodal in nature.

Left lung clear.

Seven months passed with no further investigation from the initial chest x-ray. The patient represented and a new chest x-ray was undertaken.

Large right perihilar mass.   The hilum overlay sign is evident, indicating this does not arise from the hilum.

Marked interval enlargement from the prior chest x-ray.

8.5 x 6.4cm partially necrotic mass in the medial aspect of the anterior segment of the right upper lobe.  The mass invades the mediastinum abutting the ascending aorta and SVC.  No evidence of SVC obstruction.
1.7cm right paratracheal node.   9mm left percarinal node. No other lung lesions.
No solid organ metastases. Gallstones. No focal bone lesions.
Comment:   Right upper lobe lung tumor.
Radiological stage:  T4,N1,M0

Given the peripheral ...


Given the peripheral location Bx was undertaken

Ultrasound of right chest wall

Anterior upper lobe mass with significant central necrosis.

Two 18G core biopsies performed, with care taken to acquire tissue in the peripheral aspect of the mass to ensure a diagnostic specimen given the necrotic nature of the mass.

Case Discussion

A good learning case on several levels for a fairly common pathology.

  1. Alert system: all institutional shoulds have alert systems and methods for ensuring these are acted upon. This abnormality was on the initial chest x-ray and reported.
  2. Radiological sign: sure the radiologist can just say it's abnormal and 'do a CT' but it's enjoyable to see a radiological sign on plain x-ray.
  3. CT is not always needed and the greater time and people involved to biopsy a lung mass.
  4. Institutional and self-reflection: Could we have done better for this patient? If so how, and can we implement change for future better practice?

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