Radiology Case - A 55-year-old Male with a Cough and Hemoptysis
Paul Hegener, MD
CASE PRESENTATION
The patient is a 55 year old male who presented to his primary medical doctor with a two-week history of cough and hemoptysis. The hemoptysis began as streaks of blood in his sputum progressing to approximately ½ cup per day of frank blood. Approximately one month prior the patient started to feel a "burning" sensation in his chest. The patient had been seen by the primary medical doctor two days prior to this presentation and had been prescribed azithromycin with no significant relief. The patient was then referred to the South Clinical Campus as an outpatient for a chest x-ray and then sent to the Emergency Department based upon the results of the x-ray.
In the Emergency Department the patient further reported dyspnea, chills, nausea and one episode of bilious vomiting per day without hematemesis. The patient denied fevers, orthopnea, constipation, diarrhea, melena, joint pain, or rashes. His past medical history was significant for HIV with a CD4 count of 548 cells/mm3 approximately three months prior to admission. A colonoscopy was performed in 2003 with normal results. Current medications included flunisolide MDI, acetaminophen-hydrocodone, albuterol MDI and a multivitamin daily. His social history is significant for current tobacco use, 1 pack per day with a 30 pack-year history. Review of systems was negative except as stated above. On exam the patient was afebrile, blood pressure 76/54, pulse 75, respiratory rate 14 and SaO2 98% on room air. Lung exam revealed bilateral expiratory wheezing. Labs were not performed at the time of presentation.
Chest X-Rays and CT of the chest are shown below. What is the most likely diagnosis?
Figure 1- Chest X-Ray, PA view
Figure 2- Chest X-Ray, Lateral view
Figure 3 - Chest CT
RADIOLOGICAL INTERPRETATION
Chest X-Ray: Two views of the chest demonstrate a large cavitary lesion in the central perihilar portion of the right lung that measures approximately 7.0 x 5.7 cm in size and contains an air fluid level. Differential diagnosis would include a lung abscess versus a cavitary malignancy. There is also a right lower lobe pneumonia and/or atelectasis.
CT Scan: There is a large 5.5 x 6 cm thick-walled cavitary mass within the lower right upper lobe adjacent to the hila with encasement of the right interlobar and segmental basilar vessels. This is most concerning for cavitating bronchogenic carcinoma. There is increased subcarinal soft tissue density, which may represent mediastinal extension of this mass or necrotic lymphadenopathy. Right hilar and right paratracheal lymphadenopathy is also noted.
There are also patchy areas of air-space disease within the right middle lobe and right lower lobe most compatible with obstructive atelectasis from the large cavitating mass. Bullous emphysematous change of the bilateral lungs is also present, more prominent within the right lung.
DIAGNOSIS
Although this patient has HIV, he is not significantly immunocompromised as his CD4 count is greater than 200 cells/mm3. Considering his immune status and significant smoking history, bronchogenic cancer was the primary candidate. Had he been immunocompromised, the differential diagnosis would have been much wider, including coccidioidomycosis, tuberculosis, aspergilloma/fungoma and histoplasmosis.
Two days after admission the patient underwent bronchoscopy with biopsy of the mass which did indeed reveal bronchogenic carcinoma, with a histological classification of moderately-differentiated squamous cell carcinoma.
DISCUSSION
Although a variety of benign and malignant tumors may arise in the lung, 90-95% of them are bronchogenic carcinomas. The term bronchogenic refers to the origin of these tumors arising from the epithelium of the bronchi, and occasionally the bronchioles.
Incidence
Worldwide, lung cancer is the most frequently occurring cancer and the leading cause of cancer mortality. Lung cancer now accounts for 13% of all cancers in both men and women. Bronchogenic arcinoma is the most common visceral malignancy in men accounting for more than 1/3 of all cancer deaths in men and more than 7% of all deaths in both sexes. Internationally, trends have shown a marked increase in lung cancer incidence among women. From 1985-1990, the incidence increased by 4% in men compared to 21% in women. Lung cancer occurs most often between the ages of 40 and 70 with a peak incidence in the 50s and 60s.
Risk Factors
Increased risk for bronchogenic cancer has been associated with occupational exposure to asbestos, radon, uranium, nickel, chromates, mustard gas, arsenic, beryllium, nickel, and iron. Far and away, however, the most common risk factor for developing bronchogenic lung cancer is cigarette smoking. Compared with non-smokers, average smokers of cigarettes have a 10-fold greater risk for developing lung cancer and heavy smokers (>40 cigarettes per day for several years) have a 20-fold greater risk. Eighty percent of lung cancers occur in smokers. Asbestos workers who smoke have a 50 to 90 times greater risk of developing lung cancer than non-smoking, non-asbestos workers.
Symptoms
Patients with bronchogenic carcinoma may present with cough (75%), weight loss (40%), chest pain (40%), dyspnea (20%), hemoptysis, hoarseness, Superior Vena Cava syndrome, and Horner's syndrome. Other complaints include bone/joint pain, jaundice, and pericarditis/tamponade occurring from distant metastases. Patients may also present with any of the paraneoplastic syndromes including SIADH, Cushing syndrome, and Lambert-Eaton/myasthenic syndrome.
Classification
Lung cancers are divided into two categories: small cell carcinoma and non-small cell carcinoma. The category of non-small cell carcinoma include: squamous cell carcinoma, adenocarcinoma, and large-cell carcinoma. Treatment of non-small cell carcinomas depends upon the TNM stage of the carcinoma, with surgical resection possible for Stage IIIA or less. Stage IIIB tumors are usually considered unresectable. Unfortunately, approximately 65-80% of patients with non-small cell carcinoma present with Stage IIIB disease or worse. Prognosis is poor with a 5-year survival rate for men with squamous cell carcinoma of approximately 10%. Small cell carcinomas usually are metastatic at the time of presentation and thus are not able to be treated via surgery, although there is a high initial response to chemotherapy.
This patient was diagnosed with squamous cell carcinoma. Squamous cell carcinoma accounts for 30-40% of cases of bronchogenic carcinoma and has a strong association with smoking. The lesion is usually located centrally, and among all bronchogenic carcinomas, it is most likely to cavitate. Squamous cell carcinomas grow within the lumen of the bronchi and are least likely to metastasize distantly. The mode of spread is usually direct extension to the local lymph nodes.
On chest radiography, common findings of bronchogenic carcinoma include bronchial stenosis, partial or complete atelectasis distal to the lesion and postobstructive pneumonia in a segmental or lobar distribution. The most common sign is distal atelectasis. Other findings may include a hilar mass or a solitary pulmonary nodule, commonly with a doubling time of 30-365 days. Indirect signs of involvement of contiguous structures may also be found such as osteolytic lesions and pathologic fractures of rib and vertebra. Phrenic nerve involvement causing diaphragmatic paralysis may be seen as ipsilateral elevation of the involved diaphragm on imaging. Mediastinal lymph node enlargement causes the following changes on imaging: widened mediastinum, convex margin of the mediastinum, increase in the right paratracheal stripe, absence of concavity in the aortopulmonary window, and splaying of the carina.
When an abnormality is detected, comparison with old chest x-rays is an important first step. Most consider a two-year interval without change a good indicator of a benign lesion. If a change is noted or no old chest x-rays are available for comparison, a chest CT is warranted. Further workup can include a PET scan or invasive testing such as bronchoscopy.
REFERENCES
- Kobzik L. The Lung. In: Cotran RS, Kumar V, Collins T. (eds). Robbins Pathological Basis of Disease. 6th Edition. W.B. Saunders, 1999:741-747.
- Sharma S, Maycher B, Tsuyuki, S. Lung Cancer, Non-Small Cell. eMedicine August 10, 2005.
- Patz EF. Imaging Bronchogenic Carcinoma. Chest 2000;117:90-95.