June 2024 Medical Image of the Month: A 76-year-old Man Presenting with Acute Hoarseness

Figure 1. Anterior-posterior chest x-ray (A) showing moderate elevation of left hemidiaphragm (arrow) and an ill-defined nodular opacity in the left perihilar region (*) suspicious for a hilar mass. Axial image from a contrast enhanced chest CT (B) showing central left upper lobe mass extending into the hilum resulting in narrowing of the vascular and bronchial structures of the left upper lobe.

Figure 2. 400x magnification hematoxylin and eosin-stained endobronchial biopsy (A) demonstrating malignant cells with large hyperchromatic nuclei (circle) infiltrating through stromal tissue. Compare with the nuclear size of the nearby normal submucosal glands (arrows), 200x magnification image (B) demonstrating poorly differentiated carcinoma cells filling the subepithelial stroma. Normal ciliated mucosal cells are in the upper left of the image (arrowheads).

A 76-year-old man with a past medical history significant for coronary artery disease, diabetes mellitus, and 40-pack-year smoking history presented to the emergency department with 1 week of progressive hoarseness. Associated symptoms included a cough initially productive of green sputum that progressed to scant hemoptysis, as well as intermittent hiccups. Four days prior to presentation he sought treatment at a clinic in Mexico, where he was diagnosed with influenza and treated with Tamiflu and Moxifloxacin. His symptoms did not improve, prompting him to seek care at our hospital.

On interview, he denied fevers, chills, dysphagia, otalgia, odynophagia, dyspepsia, chest pain, dyspnea, or weight changes. His temperature was 36.3°C, heart rate 75 beats per minute, blood pressure 150/77 mmHg, respiratory rate 22 breaths per minute, and oxygen saturation 93% on room air. On physical examination, the patient was found to have a hoarse voice, with an otherwise normal oropharyngeal exam. Cardiopulmonary exam was notable for bowel sounds auscultated in the left lower lung fields. The remainder of the exam was unremarkable. Laboratory testing including CBC, CMP, and a respiratory pathogen PCR panel did not detect any viruses.

A chest X-ray was obtained (Figure 1A); imaging was significant for moderate elevation of left hemidiaphragm (A), an ill-defined nodular opacity in the left perihilar region, and suspicion for a hilar mass (B). Chest CT confirmed a large central left upper lobe hilar mass compressing regional vascular and bronchial structures (Figure 1B). The patient underwent Endobronchial ultrasound-guided fine needle aspiration (EBUS FNA) and endobronchial biopsy, which confirmed the diagnosis, recurrent laryngeal nerve injury secondary to left upper lobe non-small cell lung carcinoma (Figure 2).

Hoarseness can be caused by a diverse array of conditions, ranging from local inflammatory processes (e.g., laryngitis or benign vocal cord lesions), to more systemic, neurologic, or oncologic conditions. A systematic evaluation is therefore essential to create an appropriate differential and guide the diagnostic evaluation. This evaluation begins with a detailed history probing for any red flag symptoms: symptoms persisting greater than two weeks, dysphagia, odynophagia, weight loss, or hemoptysis, as was seen in the case above.

Recurrent laryngeal nerve injuries are a less common cause of hoarseness. An understanding of the anatomic course of the recurrent laryngeal nerve (RLN) aids in localizing pathology. The RLN branches off cranial nerve X, also known as the Vagus nerve, and supplies most of the laryngeal muscles. The left RLN extends inferiorly into the chest, and loops posteriorly under the aortic arch before returning superiorly through the neck. Similarly, the right RLN loops posteriorly around the right subclavian artery before traversing superiorly back through the neck. The majority of recurrent laryngeal nerve injuries are iatrogenic, secondary to thyroid or cardiothoracic surgery. However, in the absence of surgery, understanding the anatomy paired with further imaging can help localize the pathology.

The patient’s radiographic findings suggested an intrathoracic mass concerning for a primary lung malignancy. This mass was further characterized on chest CT, which confirmed a large central left upper lobe hilar mass compressing regional vascular and bronchial structures. In the setting of hoarseness, the malignancy was likely causing injury to the recurrent laryngeal nerve. Additionally, given the symptom of hiccups paired with image findings of an elevated hemidiaphragm, the phrenic nerve was also likely being compressed. A biopsy would then further identify the lung mass.

Bronchoscopy showed patent airways and extensive nodular mucosa and endobronchial tumor at the left upper lobe / lingula. Endobronchial biopsy of the left upper lobe revealed infiltrating malignant cells in the submucosal connective tissue. No keratin production or gland formation was seen. Further work-up with immunohistochemical preparations showed the tumor cells to be negative for TTF-1 and p40, markers indicative of pulmonary adenocarcinoma and squamous cell carcinoma, respectively. In light of these features, the most accurate diagnosis is non-small cell carcinoma, not otherwise specified (NOS).

The differential for dysphonia in an adult extends beyond the anatomic boundaries of the laryngopharynx, including an intrathoracic malignancy causing recurrent laryngeal nerve injury. Additionally, phrenic nerve palsy secondary to a mediastinal mass should be included in the differential for an elevated hemidiaphragm.

Alexandra Fuher MD¹, Carrie B. Marshall MD², William Aaron Manning MD³

¹Department of Internal Medicine, University of Colorado Anschutz Medical Campus

²Department of Pathology, University of Colorado Anschutz Medical Campus

³Department of Pediatrics, University of Colorado Anschutz Medical Campus

References

1. Culp JM, Patel G. Recurrent Laryngeal Nerve Injury. [Updated 2023 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560832.
2. Reiter R, Hoffmann TK, Pickhard A, Brosch S. Hoarseness-causes and treatments. Dtsch Arztebl Int. 2015 May 8;112(19):329-37. [CrossRef] [PubMed]
3. Feierabend RH, Shahram MN. Hoarseness in adults. Am Fam Physician. 2009 Aug 15;80(4):363-70. [PubMed]
4. Travis WD, Brambilla E, Noguchi M, et al. Diagnosis of lung cancer in small biopsies and cytology: implications of the 2011 International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society classification. Arch Pathol Lab Med. 2013 May;137(5):668-84. [CrossRef] [PubMed]

Cite as: Fuher A, Marshall CB, Manning WA. June 2024 Medical Image of the Month: A 76-year-old Man Presenting with Acute Hoarseness. Southwest J Pulm Crit Care Sleep. 2024;28(6):78-80. doi: https://doi.org/10.13175/swjpccs002-24 PDF

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 Month: Mucinous Adenocarcinoma of the Lung Mimicking Pneumonia

Figure 1. A contrasted, coronal-reformatted CT image of the chest demonstrates unilateral ground glass opacification of the right lung with superimposed interlobular septal thickening (blue arrows). There is also volume loss of the left lung with elevation of the left hemidiaphragm (red arrow).

Clinical Scenario: A 60-year-old man with a history of chronic obstructive pulmonary disease presented to the hospital with worsening shortness of breath over a period of 3 days. He had a 50-pack-year history of smoking, coronary artery disease, and a previous history of a left lung mass of unknown pathology status post left upper lobectomy. He was bought to the emergency room via ambulance after being found at home with oxygen saturations in the 60s. Upon arrival to the emergency room, he required continuous oxygen at 15 L/min to maintain his oxygen saturations above 88%. He had a progressive, markedly productive cough over the last few weeks prior to presentation. He had been treated for pneumonia with multiple courses of antibiotics over the last two months without any significant improvement. His blood work was significant for a leukocytosis with neutrophilia and an elevated D-dimer. He underwent a CTA of the chest in the emergency room to evaluate for a pulmonary embolism. The CTA of the chest had no evidence of pulmonary thromboembolic disease. However, there was unilateral ground glass opacification of the right lung with interlobular septal thickening along with volume loss of the left lung and associated elevation of the left hemidiaphragm (Figure 1). He was admitted to the medical ICU and started on broad-spectrum antibiotics. He underwent a bronchoscopy which demonstrated mucinous adenocarcinoma of the lung. His oxygen requirement was eventually weaned after multiple days in the ICU. He was discharged with follow up in the oncology clinic.

Discussion: Mucinous adenocarcinoma of the lung is the rarest type of adenocarcinoma of the lung. It is characterized as mucinous adenocarcinoma in situ, minimally invasive adenocarcinoma, and invasive mucinous adenocarcinoma. Mucinous adenocarcinoma of the lung is morphologically characterized by tall columnar cells with abundant cytoplasm that contain varying amounts of mucin. Mucus secreted by these cells can commonly be discharged as sputum. However, if airway obstruction occurs secondary to excessive mucus production, a post-obstructive pneumonia may develop. The prognosis of mucinous adenocarcinoma of the lung is poor.

Nicholas Blackstone MD¹, Tammer El-Aini MD²

¹Department of Internal Medicine and ²Department of Pulmonary and Critical Care, South Campus, Banner University Medical Center – Tucson, Tucson, AZ USA

References

1. Liu Y, Zhang HL, Mei JZ, Guo YW, Li RJ, Wei SD, Tian F, Yang L, Wang H. Primary mucinous adenocarcinoma of the lung: A case report and review of the literature. Oncol Lett. 2017 Sep;14(3):3701-3704. [CrossRef] [PubMed]
2. Marchetti A, Buttitta F, Pellegrini S, Chella A, Bertacca G, Filardo A, Tognoni V, Ferreli F, Signorini E, Angeletti CA, Bevilacqua G. Bronchioloalveolar lung carcinomas: K-ras mutations are constant events in the mucinous subtype. J Pathol. 1996 Jul;179(3):254-9. [CrossRef] [PubMed]
3. Travis WD, Brambilla E, Noguchi M, Nicholson AG, Geisinger KR, Yatabe Y, Beer DG, Powell CA, Riely GJ, Van Schil PE, Garg K, Austin JH, Asamura H, Rusch VW, Hirsch FR, Scagliotti G, Mitsudomi T, Huber RM, Ishikawa Y, Jett J, Sanchez-Cespedes M, Sculier JP, Takahashi T, Tsuboi M, Vansteenkiste J, Wistuba I, Yang PC, Aberle D, Brambilla C, Flieder D, Franklin W, Gazdar A, Gould M, Hasleton P, Henderson D, Johnson B, Johnson D, Kerr K, Kuriyama K, Lee JS, Miller VA, Petersen I, Roggli V, Rosell R, Saijo N, Thunnissen E, Tsao M, Yankelewitz D. International association for the study of lung cancer/American Thoracic Society/European Respiratory Society international multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol. 2011 Feb;6(2):244-85. [CrossRef] [PubMed]
4. Cai D, Li H, Wang R, Li Y, Pan Y, Hu H, Zhang Y, Gong R, Pan B, Sun Y, Chen H. Comparison of clinical features, molecular alterations, and prognosis in morphological subgroups of lung invasive mucinous adenocarcinoma. Onco Targets Ther. 2014 Nov 18;7:2127-32. [CrossRef] [PubMed].
5. Xie GD, Liu YR, Jiang YZ, Shao ZM. Epidemiology and survival outcomes of mucinous adenocarcinomas: A SEER population-based study. Sci Rep. 2018 Apr 17;8(1):6117. [CrossRef] [PubMed]

Cite as: Blackstone N, El-Aini T. Medical image of the month: mucinous adenocarcinoma of the lung mimicking pneumonia. Southwest J Pulm Crit Care. 2021;22(1):8-10. doi: https://doi.org/10.13175/swjpcc072-20 PDF

February 2019 Imaging Case of the Month: Recurrent Bronchitis and Pneumonia in a 66-Year-Old Woman

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 66–year old woman presented with complaints of a non-productive cough worsening over the previous several weeks. She complained that her cough had also occurred several months earlier, but resolved, and then subsequently returned.

The patient indicated that she has had bouts of bronchitis off and on for many years. Her smoking history included only 3 cigarettes / day for two years, quitting 20 years earlier. She did not note any allergies and her list of medications included only vitamin supplements, baby aspirin, omeprazole, and lisinopril. Her surgical history was remarkable only for remote tonsillectomy and hysterectomy.

Her physical examination was largely unremarkable, although some course breath sounds were detected over the medial right base. Her vital signs showed normal pulse rate and blood pressure, breathing at 12 breaths / minute. Her room air oxygen saturation was 97%.

Frontal chest radiography (Figure 1) was performed.

Figure 1. Initial frontal chest x-ray.

Which of the following represents the most accurate assessment of the chest radiographic findings? (Click on the correct answer to be directed to the second of sixteen pages)

1. Chest radiography shows a vague solitary pulmonary opacity
2. Chest radiography shows basilar fibrotic opacities
3. Chest radiography shows cavitary pulmonary lesions
4. Chest radiography shows marked cardiomegaly
5. Chest radiography shows numerous small nodular opacities

Cite as: Gotway MB. February 2016 imaging case of the month: Recurrent bronchitis and pneumonia in a 66-year-old woman. Southwest J Pulm Crit Care. 2019;18(2):31-49. doi: https://doi.org/10.13175/swjpcc006-19 PDF

Medical Image of the Week: Chylothorax

Figure 1. A: CT of the chest (coronal image) demonstrating large right hilar and mediastinal adenopathy, leading to moderate to severe narrowing of the superior vena cava (SVC). B: CT of the chest (axial image) demonstrating moderate to severe narrowing of the pulmonary artery trunk due to compression from mediastinal adenopathy. A left pleural effusion is noted.

Figure 2. Pleural fluid sample demonstrating milky, pink fluid. The triglyceride level was 532 mg/dl and cholesterol level 63 mg/dl.

A 73-year-old man with untreated stage IV adenocarcinoma of the lung was admitted to the hospital with several days of progressively worsening dyspnea on exertion. The chest CT showed a large left pleural effusion with enlarging bilateral hilar and mediastinal lymphadenopathy, compression of the superior vena cava and right main pulmonary artery consistent with progressive lung cancer (Figure 1). Therapeutic and diagnostic left sided thoracentesis was performed, removing approximately 450 ml of milky, pink fluid suggestive of hemochylothorax (Figure 2). Analysis of the fluid was significant for 27,720 red blood cells, 476 total nucleated cells with lymphocyte predominance (87%), glucose 158 mg/dl, cholesterol 63 mg/dl, and amylase 28 U/L. The pleural fluid was exudative (protein 4.4 g/dl) with a significantly elevated triglyceride level of 532 mg/dl. No malignant cells were identified in the fluid.

This case illustrates a nontraumatic chylothorax secondary to metastatic adenocarcinoma of the lung. The leading cause of non-traumatic chylothorax is malignancy by compression and/or lymphangitic invasion (1). Thoracic duct invasion or leak can only be seen with nuclear medicine scintigraphy; however, this test was not performed on this patient. The appearance of the pleural fluid in chylothorax can be deceiving as less than half of pleural fluid samples will be milky in appearance (2). In addition, milky appearing pleural fluid is not specific for a chylothorax, as milky fluid can be seen in a cholesterol pleural effusion (pseudochylothorax) or an empyema. The detection of chylomicrons on pleural fluid lipoprotein electrophoresis is the definitive diagnostic criterion for chylothorax, however it is not widely available and is costly (3). The classic diagnostic criterion is a pleural fluid triglyceride level of >110 mg/dl in an appropriate clinical setting of mediastinal malignancy, lymphoma, recent thoracic surgery or penetrating trauma to the neck or thorax (4). A pleural fluid triglyceride level between 50 and 110 mg/dl does not exclude the diagnosis of chylothorax and clinicians should perform lipoprotein electrophoresis of the pleural fluid to detect chylomicrons. To distinguish a chylothorax from a pseudochylothorax (both have milky appearance), clinicians should obtain a cholesterol level on the fluid. The cholesterol level in a chylothorax is usually less than 200 mg/dl while a pseudochylothorax will have high levels, typically greater than 200 mg/dl.

The patient chose to undergo palliative radiation of the chest and symptomatic treatment of his dyspnea.  

John Dicken MD¹, Madhav Chopra MD², Faraz Jaffer MD² and Linda Snyder MD²

¹Department of Internal Medicine and ²Division of Pulmonary, Allergy, Critical Care and Sleep

Banner University Medical Center-Tucson

Tucson, AZ USA

References

1. McGrath EE, Blades Z, Anderson PB. Chylothorax: aetiology, diagnosis and therapeutic options. Respir Med. 2010 Jan;104(1):1-8. [CrossRef] [PubMed]
2. Maldonado F, Hawkins FJ, Daniels CE, Doerr CH, Decker PA, Ryu JH. Pleural fluid characteristics of chylothorax. Mayo Clin Proc. 2009 Feb;84(2):129-33. [CrossRef] [PubMed]
3. Hooper C, Lee YC, Maskell N; BTS Pleural Guideline Group. Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010 Aug;65 Suppl 2:ii4-17. [CrossRef] [PubMed]
4. Staats BA, Ellefson RD, Budahn LL, Dines DE, Prakash UB, Offord K. The lipoprotein profile of chylous and nonchylous pleural effusions. Mayo Clin Proc. 1980 Nov;55(11):700-4. [PubMed]

Cite as: Dicken J, Chopra M, Jaffer F, Snyder L. Medical image of the week: Chylothorax. Southwest J Pulm Crit Care. 2018;17(2):70-1. doi: https://doi.org/10.13175/swjpcc100-18 PDF 

Medical Image of the Week: Asbestos Related Pleural Disease

Figure 1. Chest radiograph demonstrates bilateral coarse calcification, most elongated and vertically oriented in nature (white arrows). Also note coarse calcification outlining the hemidiaphragms (dark arrows). Editor's note: the patient's only chest x-ray was two different AP views which are merged above.

Figure 2.  Holly leaf. Its shape is similar to the irregular thickened nodular edges of pleural plaques on chest radiograph, referred to as “the holly leaf sign”.

Figure 3. Thoracic CT shown in soft tissue (A: top) and lung (B: bottom) windows clearly localizes the calcifications to the parietal pleura.

Pleural plaques are strongly associated with inhalational exposure to asbestos (1). The lesions may take up to thirty years to develop. Plaques are typically bilateral, involve the parietal pleura, commonly along the sixth through ninth ribs and are usually absent at the lung apices and costophrenic sulci (Figures 1 and 3). On chest radiograph, the “holly leaf sign” refers to the shape of the calcifications with thickened rolled and nodular edges (Figure 2). The plaques per se are benign in nature. However, they can potentially impair lung function, resulting in restriction.  They are also markers of the individual’s greater risk of developing a lung cancer or mesothelioma.

Wesley Hunter MS IV¹, Veronica Arteaga MD², and Diana Palacio MD²

¹College of Medicine and ²Department of Medical Imaging

University of Arizona

Tucson, AZ USA

Reference

1. Norbet C, Joseph A, Rossi SS, Bhalla S, Gutierrez FR. Asbestos-related lung disease: a pictorial review. Curr Probl Diagn Radiol. 2015 Jul-Aug;44(4):371-82. [CrossRef] [PubMed] 

Cite as: Hunter W, Arteaga V, Palacio D. Medical image of the week: asbestos related pleural disease. Southwest J Pulm Crit Care. 2017;15(3):116-7. doi: https://doi.org/10.13175/swjpcc104-17 PDF

Medical Image of the Week: Superior Sulcus Tumor with Neural Invasion

Figure 1. Computed tomography of the chest (axial image) shows a large left upper lobe cavitary mass (red arrow), consistent with known squamous cell carcinoma.

Figure 2. MRI of cervical and thoracic spine (sagittal image) reveals the mass abuts the spinal column with tumor invasion through the neural foramen at C7-T1 and T1-T2 (blue arrow).

Figure 3. A 22-guage needle is advanced with its tip anterior to the longus coli muscle at the level of C6 (yellow arrow). Ethanol solution was injected into this space.

A 78-year-old woman with left upper lobe squamous cell carcinoma presented with severe left arm and upper posterior chest pain. The pain was described as a severe burning sensation with “pins and needles”, and there was loss of motor function in the arm. This neuropathic pain was refractory to escalating doses of opioids and gabapentin. She was receiving chemotherapy with paclitaxel and carboplatin and completed five radiation treatments. On physical examination, there was atrophy of the left forearm and hand muscles. No evidence of Horner’s syndrome was noted.

A CT of the chest with contrast (Figure 1) showed a 5.8 cm apical segment left upper lobe cavitary mass consistent with a superior sulcus tumor and concomitant pulmonary embolism. An MRI of the cervical and thoracic spine (Figure 2) showed a large apical necrotic tumor abutting the upper thoracic spine with invasion of the neural foramina at C7-T1, T1-T2, and T2-T3, consistent with invasion into the brachial plexus.

In an attempt to improve her symptoms, the interventional radiologist performed a left stellate ganglion block with 1% lidocaine and 0.25% bupivacaine (Figure 3). There was minimal initial improvement so a repeat block was done three days later with notable reduction in arm pain. For a permanent block, a stellate ganglion block was performed with 2% lidocaine and 98% ethanol. The patient had significant palliation of the neuropathic pain in her left arm and shoulder.

Sue Cassidy ANP-BC ACHPN, Tina Skrepnik MD, Bree Johnston MD MPH, and Linda Snyder MD

University of Arizona College of Medicine

Departments of Internal Medicine and Radiation Oncology

Tucson, AZ USA

References

1. Kratz JR, Woodard G, Jablons DM. Management of lung cancer invading the superior sulcus. Thorac Surg Clin. 2017 May;27(2):149-157. [CrossRef] [PubMed]
2. De Leon-Casasola OA. Critical evaluation of chemical neurolysis of the sympathetic axis for cancer pain. Cancer Control. 2000 Mar-Apr;7(2):142-8. [PubMed]

Cite as: Cassidy S, Skrepnik T, Johnston B, Snyder L. Medical image of the week: superior sulcus tumor with neural invasion. Southwest J Pulm Crit Care. 2017;14(6):320-1. doi: https://doi.org/10.13175/swjpcc071-17 PDF

Medical Image of the Week: The Luftsichel Sign

Figure 1. Anteroposterior chest radiograph demonstrating partial opacification of the left hemithorax, with preservation of the diaphragmatic border. A central mass is seen (thin arrow), as well as a radiolucent stripe bordering the aorta (thick arrows). Tracheal deviation to the left, a right-sided chest tube and a small right-sided pneumothorax are also noted.

Figure 2. Axial computed tomographic of the chest at the level of the carina (A) and left upper lobe bronchus (B) demonstrate opacification and volume loss of the left upper lobe with occlusion of the left upper lobe bronchus. The superior segment of the left lower lobe is interposed between the aorta and the atelectatic upper lobe (arrows). The right-sided pneumothorax is demonstrated and ground glass opacities are noted in the left lower lobe (arrowheads).

A 59-year old woman with recently diagnosed small cell carcinoma with metastases to liver and spine presented after a fall presented with lower extremity weakness and incontinence. She was diagnosed with intertrochanteric femoral fracture and prior to planned transfer to our hospital for neurosurgical evaluation she underwent operative fixation of the fracture. An indwelling venous access port was also placed on the same day which was complicated by a pneumothorax requiring chest tube placement

Upon arrival to our institution, she had normal vital signs and was in no distress. On respiratory examination, breath sounds were clear bilaterally on auscultation of the posterior chest but reduced on the left side on anterior auscultation. A chest tube was in place in the right mid-axillary line with no evidence of an air leak.

Chest x-ray demonstrated the right-sided chest tube and partial opacification of the left hemithorax, with a left hilar mass (Figure 1). The radiographic findings of left tracheal deviation, preservation of the left hemidiaphragm, and identification of the luftsichel sign suggested collapse of the left upper lobe. Computed tomography (CT) scan of the chest confirmed left upper lobar collapse due to extrinsic compression of the left upper lobar bronchus by a left upper lobe lung mass (Figure 2).

The luftsichel sign, a long-described marker of left upper lobe collapse on chest radiography, is a para-aortic stripe of radiolucency so-named for its course along the straight proximal descending aorta and curved aortic knob (in the German, luft for air, sichel for sickle) (1). Once theorized to be a result of herniation of the right lung into the left hemithorax after left-sided volume loss, CT correlation studies of radiographic signs in the 1980s verified the superior segment of the left lower lobe as the source of the lucency (2). Collapse of the left upper lobe displaces the major fissure anteriorly; the consequent movement of the left lower lobe results in expansion and interposition of its superior segment between the aorta and the atelectatic lung, as demonstrated in the correlate CT images in our patient.

Luke Gabe MD and Linda Snyder MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner-University Medical Center, Tucson, AZ USA

References

1. Blankenbaker DG. The luftsichel sign. Radiology. 1998 Aug;208:319-20. [CrossRef] [PubMed]
2. Khoury MB, Godwin JD, Halvorsen RA Jr, Putman CE.CT of obstructive lobar collapse. Invest Radiol. 1985 Oct;20(7):708-16. [CrossRef] [PubMed]

Cite as: Gabe L, Snyder L. Medical image of the week: the luftsichel sign. Southwest J Pulm Crit Care. 2017;14(1):26-7. doi: https://doi.org/10.13175/swjpcc003-17 PDF 

Medical Image of the Week: Superior Vena Cava Syndrome

Figure 1. Thoracic CT in soft tissue windows. Panels A, B, C and G show extensive collateral circulation along the right chest wall especially subcutaneous vessels and subcapsular hepatic vessels during contrast injection in the right arm (arrows). There are also prominent right hepatic and capsular enhancing vessels with vascular shunt within the posterior subcapsular right hepatic lobe. Panels D, E, F and I show extensive collateral circulation on the left side when the contrast is injected (on a different admission) in the left arm (arrows). Panel H shows absent blood flow in the totally thrombosed SVC stent.

Superior vena cava (SVC) syndrome results from obstruction of blood flow in the SVC. Most cases are secondary to malignancy, the most common being lung cancer or non-Hodgkin lymphoma. Other less encountered etiologies include fibrosing mediastinitis and thrombosis associated with intravascular devices (1,2). Here, we present a case of advanced lung cancer undergoing chemo-radiation therapy who presented with typical symptoms of SVC syndrome including progressive shortness of breath and facial swelling/ fullness over weeks to months. His chest CT scan showed SVC obstruction due to his tumor mass (Figure 1). The patient underwent stenting and improved partially for sometime. However, he returned again with worsening symptoms over a few weeks with discovery of SVC in-stent thrombosis. He was started on therapeutic enoxaparin and his symptoms improved partially with time.

Huthayfa Ateeli, MBBS¹, Kawanjit Sekhon, MD² and Dena K. L'Heureux, MD³.

¹Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy Medicine; ²Department of Medicine, Internal Medicine Residency Program, Main Campus; and ³Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Allergy Medicine, University of Arizona, Southern Arizona VA Health Care System, Tucson, AZ USA

References

1. Wilson LD, Detterbeck FC, Yahalom J. Clinical practice. Superior vena cava syndrome with malignant causes. N Engl J Med. 2007 May 3;356(18):1862-9. [CrossRef] [PubMed] 
2. Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: clinical characteristics and evolving etiology. Medicine (Baltimore). 2006 Jan;85(1):37-42. [CrossRef] [PubMed] 

Cite as: Ateeli H, Sekhon K, L'Heureux DK. Medical image of the week: superior vena cava syndrome. Southwest J Pulm Crit Care. 2016;13(2):99-100. doi: http://dx.doi.org/10.13175/swjpcc065-16 PDF

Medical Image of the Week: Superior Vena Cava Syndrome

Figure 1. Contrast-enhanced CT of the chest in the arterial phase in the coronal plane demonstrates a large paratracheal mass (blue circle) that is invading the SVC resulting in the tumor thrombus noted in right heart chambers.

Figure 2. Contrast-enhanced CT of the chest in the arterial phase at the level of the right atrium (blue arrow), tricuspid annulus (yellow arrow), and right ventricle (green arrow) demonstrates a thrombus extending from the right atrium across the tricuspid valve in to the right ventricle.

A 65 year old Native American man with past medical history significant for hypertension presented with a two week history of generalized edema, most prominent in the face and upper extremities. The patient had gained 30 lbs in the previous 6 months. He denied any fever, night sweats, dyspnea, hemoptysis, change in voice, chest pain, abdominal pain, nausea, vomiting, or hematemesis but did acknowledge a 40+ pack-year smoking history. Family history was significant for two brothers deceased from lung cancer. On presentation, he was hemodynamically stable, had visibly distended neck veins and collateral veins on the chest and abdomen. Routine laboratory tests included a comprehensive metabolic panel remarkable for mild transaminitis, complete blood count with thrombocytopenia (69,000) and mild anemia (hemoglobin 13.5).  Urinalysis and infectious workup were unremarkable. A CT chest/abdomen/pelvis confirmed superior vena cava (SVC) syndrome from a thrombus in the right atrium extending cephalad into the SVC and left brachiocephalic vein. Patient was started on dexamethasone 4mg every 6 hours and a heparin drip. A fine needle biopsy of the large mediastinal paratracheal mass showed non-small cell lung carcinoma.  He received cycle 1 of carboplatin and docetaxel. Five days after chemotherapy, patient had large volume hemoptysis. Repeat CTA chest demonstrated enlargement of the right suprahilar mass invading the mediastinum/SVC with extension into the right atrium and crossing into the right ventricle (Image 1 and 2). Considering severity of the disease and poor prognosis patient and patient’s family accepted comfort care.

SVC syndrome results from mechanical obstruction of the SVC. Dyspnea, facial swelling and distended neck veins are the characteristic clinical manifestations (1). In the era of antibiotics, 70-90% of cases are due to mediastinal malignancies (2). Symptomatic relief with steroids, radiation/chemotherapy and intravascular stents are mainstays of emergent treatment (1). However, similar to our case, due to aggressive nature of the disease the mortality is inevitable.

Manjinder Kaur DO, Charity Adusei MS III, Tammer Elaini MD, and Laura Meinke MD

Department of Medicine

The University of Arizona and Sourthern Arizona VA Health Care System

Tucson, AZ, USA

References

1. Khan UA, Shanholtz CB, McCurdy MT. Oncologic mechanical emergencies. Emerg Med Clin North Am. 2014;32(3):495-508. [CrossRef] [PubMed]
2. Rossow CF, Luks AM. A 68-year-old woman with hoarseness and upper airway edema. Ann Am Thorac Soc. 2014;11(4):668-70. [CrossRef] [PubMed]

Cite as: Kaur M, Adusei C, Elaini T, Meinke L. Medical image of the week: superior vena cava syndrome. Southwest J Pulm Crit Care. 2015;11(3):114-5. doi: http://dx.doi.org/10.13175/swjpcc084-15 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 

June 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 63-year-old man with a history of early-stage Parkinson disease and coronary artery disease presented with a painful “lump” in the lower left neck. Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Frontal (panel A) and lateral (panel B) chest radiograph.

Which of the following statements regarding the chest radiograph is most accurate?

1. The chest radiograph shows a mediastinal mass
2. The chest radiograph shows an asymmetric linear, interstitial pattern
3. The chest radiograph shows bilateral symmetric linear and reticular opacities
4. The chest radiograph shows multifocal, bilateral consolidation
5. The chest radiograph shows numerous small nodules

Reference as: Gotway MB. June 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;8(6):320-7. doi: http://dx.doi.org/10.13175/swjpcc074-14 PDF

Medical Image of the Week: Lung Cancer with Vascular Invasion

Figure 1. Panel A: Representative axial view of the thoracic CT scan showing tumor invading the left atrium via the right superior pulmonary vein (arrow). Panel B: Coronal view showing tumor invasion (arrow).

A 73-year-old woman presented to the emergency department with seizures and a subacute history of mild dyspnea on exertion. Her admission chest x-ray demonstrated a large right upper lobe lung mass, and MRI of the brain demonstrated multiple bilateral enhancing lesions concerning for a cardiac embolic source. Representative axial (Figure 1A) and coronal (Figure 1B) images from her chest CT scan demonstrate tumor invading the left atrium via the right superior pulmonary vein (arrow). The tumor was confirmed to be small cell carcinoma of the lung.

Joshua Malo, MD and Franz Rischard, DO

Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine

University of Arizona, Tucson, AZ 

Reference as: Malo J, Rischard F. Medical image of the week: lung cancer with vascular invasion. Southwest J Pulm Crit Care. 2014;8(4):235. doi: http://dx.doi.org/10.13175/swjpcc040-14 PDF

May 2013 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History

A 21-year-old woman presented with complaints of cough. Frontal and lateral chest radiography (Figures 1A & B) was performed. A detail comparison chest radiograph from several years prior (Figure 1C) is presented as well.

 

Figure 1. Frontal (A) and lateral (B) chest radiography at presentation and a radiograph from several years earlier (C).

Which of the following statements regarding the chest radiograph is most accurate?

1. The chest radiograph predominantly shows bilateral linear and reticular abnormalities
2. The chest radiograph shows a combination of nodules, masses and thin-walled cysts
3. The chest radiograph shows multifocal consolidation with air bronchograms
4. The chest radiograph shows multifocal pleural abnormalities
5. The chest radiograph shows mediastinal widening & hilar lymphadenopathy

Reference as: Gotway MB. May 2013 imaging case of the month. Southwest J Pulm Crit Care.2013;6(5):218-30. PDF 

Medical Image of the Week: Extensive Small Cell Lung Cancer with Cardiac Invasion

A 73 year old woman was seen with a lung mass and acute onset of ataxia. MRI of the brain was notable for multifocal infarcts (Figure 1). Echocardiography (ECHO) was obtained to identify cardiac source of emboli and was notable for freely mobile mass tethered to the lateral left atrial wall, crossing the mitral valve into the left atrium (Figure 2). A contrast enhanced CT scan of the chest was obtained which confirmed the presence of a large right upper lobe mass with extension to the right pulmonary vein, left atrium and into the left ventricle (Figures 3 and 4). The biopsy confirmed small cell lung cancer.

Figure 1. Axial MRI brain showing multifocal embolic infarcts.

Figure 2. Transthoracic ECHO 4-chamber view showing a mobile mass originating within the left atrium, across the mitral valve, and into the left ventricle.

Figure 3. Axial CT of the chest showing tumor extension into the right pulmonary vein (arrow).

Figure 4. Coronal CT of the chest showing large right apical mass extending into the left atrium and across the mitral valve into the left ventricle (arrow).

Ryan Nahapetian MD, MPH.

Internal Medicine Residency.

University of Arizona at South Campus.

Carmen Luraschi-Monjagatta MD.

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine.

Arizona Respiratory Center

University of Arizona

Tucson, Arizona.

Reference as: Nahapetian R, Luraschi-Monjagatta C. Medical image of the week: extensive small cell lung cancer with cardiac invasion. Southwest J Pulm Crit Care. 2013;6(3):143-4. PDF

Medical Image of the Week: Squamous Cell Carcinoma Presenting as an Endobronchial Mass

Figure 1. CT axial cut showing large endobronchial mass (arrow) at the junction of the right upper lobe bronchus and bronchus intermedius.

Figure 2. Endobronchial lesion with view from trachea before (Panel A) and after (Panel B) removal by APC.

A 65 year old woman with previously diagnosed emphysema presented with two weeks of worsening dyspnea on exertion. CT scan of the chest showed a 14mm x 12mm irregular endobronchial lesion (arrow) occluding the bronchus intermedius. Right-sided compensatory “ball-valve” emphysematous changes are noted.  Right posterior atelectasis is also seen.  Endobronchial biopsy revealed squamous cell carcinoma. The patient later underwent palliative argon plasma coagulation (APC) therapy with removal of the tumor (Figure 2) with re-expansion of the right middle lobe.

Sage P. Whitmore, MD; James L. Knepler, Jr. MD and Linda Snyder, MD

Division of Pulmonary and Critical Care Medicine

Arizona Respiratory Center

University of Arizona

Tucson, Arizona

Reference as: Whitmore SP, Knepler JL Jr, Snyder L. Medical image of the week: squamous cell carcinoma presenting as an endobronchial mass. Southwest J Pulm Crit Care 2013;6(2):85-6. PDF

September 2011 Case of the Month

Michael B. Gotway, M.D.
Associate Editor, Imaging

Reference as: Gotway MB. September 2011 case of the month. Southwest J Pulm Crit Care 2011;3:58-63. Click here for PDF version

Clinical History

A 44-year-old man presents for chest radiography for pre-operative screening prior to surgical repair of a meniscal tear in his right knee. An abnormality was noted on this study. 

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

What abnormality is seen on the chest X-ray? (Depending on your computer settings, you may need to enlarge the chest x-ray with your browser to identify the abnormality.)

1. Right lower lobe consolidation
2. Left lower lobe consolidation
3. Right lower lobe nodule
4. Left upper lobe nodule
5. Left lower lobe nodule

August 2011 Case of the Month

Michael B. Gotway, M.D.

Associate Editor, Imaging

Reference as: Gotway MB. August 2011 case of the month. Southwest J Pulm Crit Care 2011;3:54-7. Click here for PDF version

Clinical History

A 60-year-old woman with no significant previous medical history complains of shortness of breath. Chest radiography was performed (Figure 1).

Point to the lesion on the chest X-ray on the chest x-ray to proceed.