0:00

All right, so let's go on to the next case.

0:05

This is case three. So this is another patient,

0:11

middle aged, mid 60s male who presented with chest pain and also had a

0:16

CTPA for rule out of PE and this is the scan.

0:24

Big right heart and some reflux. You can see that's a little bit

0:27

of an incidental finding. I'll just come slowly through here. The right

0:32

lower lobe is our area of concern. I'll put that on long windows.

0:44

All right, so we have question three. So when you have an area

0:56

of low bar consolidation, which finding would make neoplasm most likely?

1:01

An occluded bronchus, full area of hypo enhancement or speculated margins?

1:10

Great. So yes, I agree. An occluded bronchus is the most

1:17

specific find. Often we will have an area of hypo enhancement, but as

1:20

we saw in the last case, we could also see that in pneumonia.

1:24

So if we look at this case, there's obviously

1:28

a fairly large effusion and there's collapse in the right lower lobe.

1:33

And then going through here, we see this area of low density and

1:42

following the airway here, we can see that it

1:46

abruptly terminates in the soft tissue of this area of low density.

1:51

I'm not sure, I think this area of low density was discussed and

1:57

it was suggested that the patient had a pneumonia. And then the patient

2:03

came back, and let me just put up

2:07

the next part of this. So this was

2:13

a little bit later and you can see now this is a little

2:16

bit of a different phase, a little bit of a later phase,

2:18

which I prefer when looking at lung. You can see that the lung parenchyma

2:22

is enhancing much more and we don't have all that bright contrast from

2:25

the CTPA. And again, we're seeing this bronchus come down

2:31

and become occluded by this mass. I agree that

2:35

speculated margins isn't really that helpful. I think we see speculations

2:39

long and short in a number of settings, both inflammatory and neoplastic.

2:45

I couldn't just use that term very sparingly.

2:50

And in this case, now what we see are these bronchi filled with

2:54

fluid. Some call this brown lung because the bronchi are occluded and can

3:00

no longer drain, and so fluid just backs up into that area of

3:05

lung. And so this was indeed a malignancy. And if we go to

3:14

the final one, you can see he did have a pet in the

3:18

end, and it hadn't really grown that much. It did take a little

3:22

while to diagnose this cancer with thinking initially it was pneumonia,

3:29

but it wasn't a particularly fast growing cancer. And this was an SCC,

3:36

I believe, yeah, it was a screen cell carcinoma on histology.

3:41

So I personally will look very carefully for occluded bronchi, and particularly

3:45

the more centrally they are occluded. And when they suddenly abruptly

3:50

stop, and I'm not seeing mucus in them, I'm just no longer seeing

3:53

them. Similar to the way we might see a vessel occluded elsewhere in

3:58

the body by a cancer where it just simply

4:01

is compressed from like extrinsic compression and disappears. I find that

4:05

to be a very specific sign from malignancy. And I can't think of

4:10

a time when I've seen that when it's been incorrect. And so I'll

4:13

usually lean very heavily on that and say, you know, you need to

4:17

work this up for cancer now rather than

4:20

wait or get follow up because I find that just simply delays.

4:26

Okay, so I have a companion to this one.

4:35

Just to look at this a little bit

4:40

more. So this is another case of a malignancy. This is a sarcoma plagued

4:45

carcinoma, a little bit of an unusual histology in the right upper lobe.

4:50

And as we come up, we can see, maybe there's what might look

4:54

like a little bit of inflammatory change, but really the margin of the

4:58

lesion is fairly sharp with these lobulated borders. And again, we've got

5:03

an occluded bronchus so that if you know your bronchial segments,

5:08

then we have our apical and posterior segments that are kind of escaping

5:14

around the mass, but our anterior segment is gone.

5:19

And so I would be quite certain that this was going to be

5:22

a malignancy rather than a round pneumonia with adjacent inflammation because

5:27

of that occluded bronchus. Another companion, actually, I'll just

5:40

show you this part two. I thought this was

5:43

another way to look at this. If you're not as comfortable with your

5:48

bronchial segments, you know, this one had a prior, you can see this is

5:52

just a year before. This was a very aggressive cancer that developed,

5:55

but we can see our middle lobe and our lower lobe and then

5:58

coming up and we see this beautiful anterior segment on the prior and

6:03

on the current that has disappeared, right? So you can use your prior

6:10

to sort of cheat and say, okay, was there a bronchus there that

6:15

is no longer present? And I find that can sometimes be helpful.

6:23

And then my next companion case for this one is here.

6:33

Now, here we have a CT without contrast, and I think,

6:38

after I've shown a few with the contrast, you can see how

6:43

the absence of contrast, it certainly makes me feel like I've got less

6:48

information than I like to have when looking at these. And we've got

6:52

a left lower lobe atelectasis or it's actually completely collapsed. If

6:59

I go to lung windows here, sorry, my notepad shortcuts are not working

7:07

and we'll have a faster way to do that.

7:10

So we can see that the left upper lobe is completely aerated and

7:14

then the left lower lobe is completely collapsed. Now, you know, and so

7:18

the first thing you think, well, this is an older individual,

7:21

and is this collapse because of obstruction? I'm not really seeing airways.

7:28

I'm not seeing air all the way through the airways, or is it

7:31

simply atelectasis? And I guess, for me, I favored atelectasis in this case

7:38

mainly because I can still see air in distal bronchi. And as we

7:44

come up, most of this looks a little bit like

7:49

mucus in the airway. It's not an airway that's just absolutely vanished.

7:53

Yes, it sort of disappears here, but it

7:57

looks like some air is getting through. And I'm not seeing a rounded mass

8:01

like area. I'd be a lot more comfortable if there was contrasting board

8:05

to make sure that there was no hypo enhancing lesion in there.

8:10

But this did turn out to be simple atelectasis, and

8:13

with a little chest therapy the lung came up and

8:17

was well aerated in the future.