Presentation
Chest x-ray elsewhere. Repeat chest x-ray performed. Lung biopsy requested.
Patient Data
2 cm opacity medially at the extreme left lung apex. No cavitation. No bony destruction.
Right lung clear.
Heart size normal.
3.4 cm smooth walled heterogeneous mass within the left T2 paravertebral space. No internal calcification. No bony erosion or hyperostosis.
The mass lies immediately posterior to the origin of the left subclavian artery.
The remainder of the thoracic cavity is normal in appearance.
3.5cm well circumscribed T1 hypodense/mildly T2 hyperdense heterogeneously enhancing mass in the T2/T3 left paraspinal space at the superior aspect of the mediastinum.
The mass lies immediately posterior to the origin of the left subclavian artery at its origin. No extension into the left T2/T3 foramen.
The lung and pleura surface is normal.
Normal craniocervical junction. Normal spinal cord.
Case Discussion
This is a good learning case - both practical and for fellowship examinations.
- One could easily miss the chest x-ray findings. Review areas are highlighted for a purpose.
- A biopsy however well done is invasive and comes with risks. Reserve biopsy for when one's intelligence and full range of diagnostic tests have been exhausted. A CT guided biopsy was requested after the diagnostic CT and the radiologist advised MRI cervical spine first.
- Not every apical mass is in the lung and not every mass is cancer. Have a differential.
- The MRI illustrates this is a neurogenic and almost certainly benign nerve sheath tumor.
- Clinicoradiological discussion almost always adds positively to patient care
No biopsy was undertaken. The differential for this neurogenic tumor includes schwannoma, neurofibroma and ganglioneuroma.
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