June 2018 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Imaging Case of the Month CME Information  

Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.75 hours

Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives: As a result of completing this activity, participants will be better able to:

1. Interpret and identify clinical practices supported by the highest quality available evidence.
2. Establish the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Translate the most current clinical information into the delivery of high quality care for patients.
4. Integrate new treatment options for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2017-December 31, 2018

Clinical History: A 63-year-old non-smoking woman presented with complaints of nausea, vomiting and abdominal pain, which prompted CT of the abdomen and pelvis (images not shown). The CT of the abdomen and pelvis disclosed several small basilar nodules, for which dedicated thoracic CT (Figure 1) was performed. 

 

Figure 1. Panels A-H: Representative images from unenhanced axial thoracic CT displayed in lung windows. Lower panel: video of thoracic CT in lung windows.

Which of the following represents the most accurate assessment of the thoracic CT findings? (click on the correct answer to be directed to the second of nine pages)

1. Thoracic CT shows bibasilar fibrotic-appearing opacities
2. Thoracic CT shows cavitary pulmonary lesions
3. Thoracic CT shows multifocal bronchiectasis
4. Thoracic CT shows multifocal ground-glass opacity
5. Thoracic CT shows small pulmonary nodules

Cite as: Gotway MB. June 2018 imaging case of the month. Southwest J Pulm Crit Care. 2018;16(6):311-23. doi: https://doi.org/10.13175/swjpcc069-18 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: Mediastinal Metastases Causing Right Ventricular Outflow Obstruction

Figure 1. Computed tomography (CT) of chest showed large right mediastinal mass (arrow) causing mass effect on the heart.

Figure 2.  Echocardiography showing large extra-cardiac mass (white arrow) compressing on right ventricle and its outflow tract (black arrow).

A 36-year-old man with a history of testicular choriocarcinoma with metastases to the lung presented with a 2-days history of hemoptysis. Initial diagnosis of the malignancy was made about 5 months earlier and he was treated with platinum based chemotherapy with a partial response.

He reported two days of significant hemoptysis, associated with shortness of breath and pleuritic chest pain and rapidly developed acute hypoxic respiratory failure requiring emergent intubation and mechanical ventilation. Computed tomography (CT) of chest showed large right mediastinal mass with diffuse reticular and nodular opacities predominantly in the left lung (Figure 1).

A pulmonary angiogram was performed that showed multiple active bleeding sites in the bronchial arterial system. These were treated with embolization. He developed shock and during investigations the echocardiogram showed a significant compression of the superior vena cava, right atrium and right ventricle by the malignant mass (Figure 2). Despite aggressive therapy and resuscitative therapies he continued to deteriorate and did not survive the hospital stay.

Mediastinal tumors are a rare cause of extrinsic right ventricular outflow tract (RVOT) obstruction. Echocardiography is an important tool in the assessment of hemodynamic effects caused due to such pathology including degree of compression and pressure gradients.

Kai Rou Tey MD¹, Bhupinder Natt MD²

¹Department of Internal Medicine, University of Arizona College of Medicine- South Campus, Tucson, AZ USA

²Division of Pulmonary, Critical Care, Allergy and Sleep, University of Arizona Medical Center, Tucson, AZ USA

Cite as: Tey KR, Natt B. Medical image of the week: mediastinal metastases causing right ventricular outflow obstruction. Southwest J Pulm Crit Care. 2016:12(1):22-3. doi: http://dx.doi.org/10.13175/swjpcc145-15 PDF