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Alright, so let's do case seven. Now, these are my most challenging cases.

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I've got a main case and then I've got

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a couple of companions, and then we'll do some questions. So, and these

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are all really similar and they're all really large. And I find these the

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most challenging, and I have to say, I think I was right on

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one of these and almost right on two of them. And hopefully,

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after I go through them, you'll be more right when I challenge you

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on the third case. Okay. So, here's the first case. We see,

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this is a patient who came in... They

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were... 65 year old woman... No sorry, this is

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a 70 year old male and he came in with a stroke. And so

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this is one of those, does he have CHF, chest x ray? So totally

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incidental. See this very large opacity at the left apex

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and here is the CT, really large mass. Is it infection or is it malignancy?

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And I don't think any of us are gonna think, "Okay,

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this is just atelectasis." And we know it's incidental, so that is gonna

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make us think that malignancy is gonna be more likely,

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just because you would think, if this is a big abscess,

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he'd be symptomatic. Although lung abscess can be surprisingly clinically

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occult, so don't let that trip you up.

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But what can we see specifically that might make us really lean toward

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malignancy? Well, one thing I'm noticing here is that this really seems

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to be reaching out into the chest wall, into the intercostal space. And

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I take advantage of my reformats to look at that a little bit

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better, to make sure that's a real finding. And I can see that,

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in fact, yeah, it is really coming out into this intercostal space and

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kind of wrapping itself a little bit about around the ribs.

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I think that would be very unusual for

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a lung abscess to do that, if you know, lost that plural fat.

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And then what about our sign that we know we like, the occluded bronchus,

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it looks like here, looking at the vessels, this is the pulmonary artery,

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if we go back centrally. So, here's the pulmonary artery and we've lost

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this apicoposterior branch, right? It just dead ends right there and if

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we go to lung windows, similarly, we have the anterior segmental branch

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and we see just a little bit of a nubbin of that apicoposterior branch.

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So, I think with those two findings, I felt comfortable that this was

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gonna be malignancy which is what it was.

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And I said, "Yes go, I would just biopsy it," and we did.

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It was squamous cell carcinoma actually. But is there another finding?

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What about that rough on the outside, smooth on the interior,

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is an abscess, and this corollary, which is smooth on the outside.

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This is quite smooth, this is the fissure here, so that's not fissure, that's

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really a sharp margin, right? So, that's smooth on the outside and what

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about the inside? It looks like there's some enhancing tissue in there.

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This looks really liquefied, but the interior... It's not like I can draw

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a sharp line. Maybe I can in here, but elsewhere it looks really

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rough. So, I would say that this is a smooth on the outside,

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rough on the inside appearance, which goes along with cancer. So,

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we know that one's cancer. So, now let me show you the next

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one, companion one, which looks surprisingly similar. So, this is a

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65 year old woman with a persistent cough, and she had an elevated

3:58

white count. Very high, 20 or something, so quite high, so that's helpful.

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And the main question here was, is it in the pleural space or

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is it in the lung? And I think it's in the lung,

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but it also looks a lot like that other lesion. And I don't

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think before this, I'd seen a lung abscess, which is what this turned

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out to be, to be quite this large without spilling into the pleural space.

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But if we look at some of the features that we've gone over,

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we can... There's not much next to it outside. This is along the

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fissure. We do see a little bit of lung here, it looks like

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there's some inflammatory change, there's some air in there. That looks

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not that smooth to me, but mostly around here, this is a really

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thin wall with a really thin, thin border. And I didn't see any... I saw

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some branches that were sort of dead ending,

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so I was really not sure about this, whether it would be a

5:02

cancer or an abscess. Anyway, it turned out to be an abscess.

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And now, let me give you this last case

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and see how you go with determining what it is.

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So, this is a 70 year old woman, she has no elevated white

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count and she has hemoptysis. And so the question to me was,

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do you think this is cancer or do you think this is an infection?

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And so, here's this very large mass, let me just put on lung windows

5:39

for you for a second... There's a little bit of

5:47

inflammatory change around. She's had hemoptysis. Sometimes when people

5:51

have hemoptysis, say, if this bled, then it can kind of be aspirated

5:56

within the same lobe, so, maybe that's what that is.

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If we look at the margins of the mass, the mass margins are

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really quite smooth. Looking at the airways, most of them seem to come

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around. I don't really see any large airways that are

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occluded. There are some lymph nodes, but obviously we're gonna see lymph

6:23

nodes in both infection, and in the setting of cancer, so that's not

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really very helpful. And what about the internal contours? I think it's

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a little hard to tell on here, again it would be nice if

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this wasn't a CTPA. I think with a CTPA, you get all this bright contrast

6:43

in the vessels that can be hard to see. But let me put

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on... Just do these little quick for that...

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There's a little bit of streak. Just trying to get an idea of,

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what is the internal architecture like? Well, we do have some vessels that

7:00

are coming into it, so which is how I decided this was in

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the lung, not in the fissure. And the inside, I don't know,

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I'll let you make up your mind whether you think that's more smooth

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or rough, and I'll tell you, when I was looking at this and

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the pulmonologist asked me, I said, "I'm 60/40 and I'm not sure whether

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it's 60% infection or 60% malignancy." Having looked at it some more and

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knowing the answer, I think... I hope the next time I would see

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this, I'd be a little more confident than that, but I don't know

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that I would be. But let's see how you guys do.

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So, question seven, which is our last question, the most likely diagnosis,

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and my answer was the last one. So, I said, I just really

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don't know... Yeah, so I think we're the same. So, this ended up

7:56

being an adenocarcinoma, which surprised me, 'cause I was really kind of

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more on the infection side. So does that negate everything we've just gone

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over? I hope not. I think these cases can be really challenging and

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really hard. And when we have some positive clues,

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like a clearly obstructed bronchus and a vessel,

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that can say, "Yes. Okay, this is really cancer, go for your biopsy."

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If we have some signs that really point toward infection, I think we

8:30

can feel comfortable doing a short term follow up.

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But the reality is, there is a lot of overlap in these cases, but

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I hope going through them has given you some tools to help make

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up your minds on your challenging cases, and I'd be happy to take

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any questions.