May 2022 Imaging Case of the Month: Asymmetric Apical Opacity–Diagnostic Considerations

Michael B. Gotway MD

Department of Radiology

Mayo Clinic, Arizona

Phoenix, Arizona USA

Clinical History: A 64–year–old woman presented to the emergency room with complaints of right arm pain for 2 months accompanied by subjective low-grade intermittent fevers.  

The patient’s past medical history was unremarkable and she had never had surgery. She had been a smoker for most of her life, at least 25-pack-years. She denied allergies, admitted to moderate daily alcohol use, and denied illicit drug use.

The patient’s physical examination showed no clear focal abnormalities and she was afebrile. She did have some right scapular tenderness to palpation, although there were no abnormal skin changes over this region. Her pulse rate and blood pressure were within normal limits, and her room air oxygen saturation was 96%. Basic laboratory data, including a complete blood count and electrolytes were largely within the normal range. The patient’s white blood cell count was technically abnormal at 9.7 x10⁹ (normal, 3.4 - 9.6 x 10⁹), but there was no left shift and the treating emergency room physician felt the mildly elevated white blood cell count was of no clinical significance.

Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following represents an appropriate interpretation of her frontal chest and lateral radiograph? (Click on the correct answer to be directed to the second of twelve pages)

1. Frontal chest radiography shows multifocal consolidation
2. Frontal chest radiograph shows numerous small nodules
3. Frontal chest radiography shows a focal mass
4. Frontal chest radiography shows a destructive bone lesion
5. Frontal chest radiography shows pleural effusion

Cite as: Gotway MB. May 2022 Imaging Case of the Month: Asymmetric Apical Opacity–Diagnostic Considerations. Southwest J Pulm Crit Care Sleep. 2022;24(5):64-71. doi: https://doi.org/10.13175/swjpccs019-22 PDF

Medical Image of the Week: Pancoast Tumor

Figure 1. Chest radiograph demonstrating pleural and parenchymal mass in the right lung apex (red arrow) with tracheal deviation to the left (blue arrow).

Figure 2. Right shoulder radiograph demonstrating the apical mass (blue arrow).

Figure 3. Chest CT (axial image) demonstrating a large mass in the right lung apex with tracheal deviation to the left.

A 39 year-old man presented to the Emergency Department with right shoulder, back and abdominal pain. He had no significant medical problems except for a 20 pack-year history of smoking. Laboratory work and an abdominal ultrasound were unremarkable and he was discharged. Approximately one week later he returned to the Emergency Department with persistent right shoulder and back pain and mild numbness and tingling of the second, third and fourth digits of his right hand. He also described weakness of his right upper eyelid and noticed he was sweating only on the left side of his face.  On physical exam, anisocoria was noted with the right pupil being smaller than the left pupil.

A chest x-ray and right shoulder x-ray revealed extensive pleural and parenchymal mass in the right apex and tracheal deviation to the left (Figures 1 and 2). A CT chest with contrast showed findings consistent with extensive Pancoast neoplasm in right upper lobe, left tracheal deviation, and partial destruction of right first rib and transverse process of first dorsal vertebral body, with evidence of extension into right lower neck (Figure 3). An MRI revealed widespread metastatic disease of the spine with right-sided T10 intraspinal extradural neoplasm causing severe thoracic spinal cord compression.  He underwent surgical decompression. Biopsy of the lung lesion revealed poorly differentiated sarcomatoid carcinoma. The patient received chemotherapy with doxorubicin and ifosfamide and radiation to the right lung, cervical and thoracic spine.

Pancoast’s syndrome includes Horner’s syndrome (ptosis, miosis and anhidrosis), upper extremity pain, and atrophy of the hand muscles. These symptoms result from an apical thoracic mass, most commonly a bronchogenic carcinoma that invades into the thoracic inlet and causes destruction of the cervical sympathetic nerves and brachial plexus (1). Shoulder pain is the most common initial symptom and patients may receive treatment for osteoarthritis or bursitis resulting in delay in diagnosis. While malignancy is the most common cause, infectious etiologies are an important consideration as well. A recent review documented 31 cases of Pancoast’s syndrome secondary to a variety of infectious causes including bacterial, fungal, mycobacterial and parasitic organisms (2).  

Emily Des Champs MS, ACNP-BC, ACHPN, CCRN¹ and Linda Snyder MD²

¹Department of Medicine, Geriatrics, Palliative and General Medicine, Banner University Medical Center-Tucson

²Department of Medicine, Pulmonary, Critical Care and Palliative Medicine, Banner University Medical Center-Tucson

References

1. Glassman LR, Hyman K. Pancoast tumor: a modern perspective on an old problem. Curr Opin Pulm Med. 2013;19:340-3. [CrossRef] [PubMed]
2. White HD, White BA, Boethel C, Arroliga AC. Pancoast's syndrome secondary to infectious etiologies: a not so uncommon occurrence. Am J Med Sci. 2011;341(4):333-6. [CrossRef] [PubMed] 

Reference as: Des Champs E, Snyder L. Medical image of the week: Pancoast tumor. Southwest J Pulm Crit Care. 2015;11(2):82-3. doi: http://dx.doi.org/10.13175/swjpcc069-15 PDF