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Case 8 - Malignancy

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0:01

As a companion case to the benefit of CT

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and looking at radiography,

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this is a patient, 66-year-old female, presenting to the ED with complaints

0:14

of weight loss, chest pain, and shortness of breath.

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And so as we go through in our systematic approach, through the left lung here,

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we notice that there's a rounded focal opacity here.

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And there's a little bit of loss of the left

0:29

hemidiaphragm, with maybe some blunting of the costophrenic angle.

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So this could be atelectasis, maybe a small pleural effusion.

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But really, our attention is drawn to this nodular opacity here.

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And there's a question of prominence here along the left mediastinum

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and the AP window is actually quite full of soft tissue.

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The airway we can see pretty nicely, and it's midline.

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The right lung looks predominantly clear.

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There's a nodular opacity right here, but it's a similar nodular opacity right here.

1:00

And these are likely just nipple shadows.

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If we do the edge enhancement, we'll see again that there's this nodular

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opacity with some fullness of the left hilum.

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You can see pretty nicely, again, that the nodular opacities at the lung

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bases are really just corresponding to nipple shadows.

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The hemidiaphragm here on the left is seen a little bit better.

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So not as concerned that there might be a large effusion there,

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but perhaps it was just some atelectasis that we're seeing.

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So, again, given the history of cough and fever, and chest pain,

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shortness of breath, initially we thought, hey, this could certainly be pneumonia,

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but there are other things to be concerned about.

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This is a 66-year-old woman,

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you know, is oncology something that we should be concerned about.

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So, we did recommend at least consideration

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for CT, and they did provide or did obtain a CT.

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And so we can take a look and see what CT shows.

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And again, if we look at the scout view

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on the CT, it's a little bit hard to see the opacity that's sitting right here.

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But we see really nicely on the coronal

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view that opacity that we saw on the radiograph.

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And what we see more clearly now is that it's a pretty dense consolidation

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with a rim of ground glass opacity that's surrounding it.

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But as we scroll through, you know, we see some other atelectasis and then

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perhaps some other areas that are also involved.

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So let's take a look at the axial images

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where I think we'll get a better lay of the land.

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All right, so there's some pleural

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and parenchymal scarring, which in a 66-year-old patient is not unusual.

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But we do have this ground glass

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and consolidative opacity here at the right apex.

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We've got similar areas that are coming into view here on the left side.

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And we see that dense consolidation, which is primarily what we're seeing

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on the radiograph, but you're seeing it much more pronounced.

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And we suspected some stuff at the left base, and it looks like that's more going

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to be atelectatic changes, which you see bilaterally.

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And there is likely a small left pleural effusion that's here.

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So, sometimes you're right, sometimes you're almost right.

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The CT is helpful for putting it all together.

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Now, the one thing I'll do is we come back through and look at on the soft tissue

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windows, is all of this soft tissue that's coming into view here in a subcarinal

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and the perihilar area, that's seen on both sides of the midline.

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And for me, given the history of weight loss and this cough, and the appearance

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of this consolidation, I became much more concerned that this was a malignancy.

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And again, if you're looking at all the nodes here in the AP window,

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this is a little bit more than I would expect and a little bit more than we saw

3:54

in the last case, where we did see a few reactive lymph nodes.

3:57

These are huge lymph node conglomerates that are on both sides of the midline.

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And as it turns out, after this patient was really continued

4:05

to be worked up, this was a patient with a bronchogenic cancer.

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So, sometimes pneumonia can masquerade as many things, cancer can masquerade as many

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things, and you want to keep in mind your patient population.

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So this was an elderly patient.

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There wasn't an initial history, given that she was a long-term smoker,

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but certainly that isn't...

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them giving you the history of smoking does not preclude the fact

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that there is a history of smoking or that there could be malignancy.

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So, again, when you're seeing big, bulky,

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extensive lymph nodes like this, mass like consolidation, consider malignancy.

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So this is a case on radiograph, we thought it was pneumonia.

4:47

The CT provided a lot more information in terms of the extent of the disease

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and some of the factors that were associated with it, that really helped make

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us or push us into a direction of a much more accurate diagnosis of malignancy.

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So CT, again, can be a helpful tool in problem solving in the ED.

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I think it's very much dependent

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on understanding when to appropriately use it.

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And a lot of that is a lot easier when you can actually understand what's going on

5:15

with the patients and confer with your referring clinicians.

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Faculty

Jamlik-Omari Johnson, MD, FASER

Chair, Department of Radiology

University of Southern California

Tags

X-Ray (Plain Films)

Neoplastic

Mediastinum

Lungs

Emergency

Chest

CT

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