Presentation
Referral history of unresolved pneumonia.
Patient Data
There is a large, well-defined, right upper lobe mass, with bulging of the horizontal fissure. There are no air-bronchograms, no cavitation, no calcification, no overlying rib erosion, and no obvious extrathoracic extension. The trachea is central with a normal cardiomediastinal contour. There is right apical veiling, suggestive of obstructive pneumonitis. The hyperinflated lung fields are otherwise clear.
There are no right hilar lymph nodes identified on plain film.
There is an exaggerated thoracic kyphosis with mid-thoracic vertebral volume loss and degenerative change.
There is a large, heterogeneous, solid, necrotic, right upper lobe mass measuring at least 9.3 x 11.4 x 13.1 cm( AP X width x craniocaudal). There is bulging of the right horizontal fissure, well appreciated on the coronal and sagittal reformats. There is regional obstructive pneumonitis, with apical ground glass opacities. There is no calcification and no air-bronchograms. There is mass effect with attenuation of the SVC and azygos vein, which appear otherwise patent. There is sluggish flow with the right internal jugular and subclavian vein, with suspicion of right subclavian venous thrombosis. There is a right endobronchial ovoid necrotic mass suggesting endobronchial spread. There are CT insignificant retrosternal and right superior mediastinal lymph nodes present.
There were no hepatic, adrenal, or osseous metastases (CT imaging of the abdomen and pelvis has not been uploaded).
The annotated lateral view demonstrates the endobronchial lesion that is difficult to appreciate in the absence of CT confirmation due to its superimposition overlying the pulmonary artery on the lateral view.
Histopathology confirms a stage IIIA, squamous cell carcinoma of the right upper lobe, measuring 16 cm in length, with endobronchial spread, and the noted absence of any lymphatic spread.
Case Discussion
A histopathologically proven squamous cell carcinoma (SCC) of the right upper lobe on pneumonectomy. The right endobronchial lesion was likely the endobronchial spread of the upper lobe tumour rather than the primary source of the right upper lobe mass. On retrospective chest X-ray review, the endobronchial lesion is identified on the lateral view overlying the pulmonary artery.
The histology is surprising in view of the absence of significant and/or necrotic lymph adenopathy with such a large tumour on CT imaging. This is confirmed on histology by the reported absence of metastases within the 10 lymph nodes excised at the time of pneumonectomy.
The bulging fissure is also unusual for an SCC of the lung however explained by the unusually large right upper lobe mass and consequent displacement of the minor fissure.
The patient was clinically well for a pulmonary parenchymal abscess or complicated lobar pneumonia and a non benign mass lesion lesion was suspected on chest X-ray, especially in view of her age.
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