Tuesday, April 26, 2016

57-year-old female presented

A 57-year-old female presented with a 3-month history of weight loss, lethargy, shortness of breath and pleuritic left-sided pain. She has never smoked. On examination, she was apyrexial, breathless and in pain.

1. What does the first CXR show?
2. What does the second CXR show?
3. What is the most likely diagnosis given the history and CXR appearances?

1. A large left-sided pleural effusion.
2. A trace of fl uid remains. In addition, there is extensive
consolidation of the basal segments of the left
upper lobe ( circle Image 3) partly obscuring the left
heart border.
3. Bronchioloalveolar cell carcinoma.

The relatively long history of lethargy and weight loss together with the lack of signs of sepsis suggest malignancy. This degree of consolidation if due to infection would be accompanied by a shorter history and the patient would be clinically septic. CT showed a rind of pleural thickening consistent with pleural metastases explaining her pleural effusion and pleuritic pain ( single arrows Images 4a, b).

This scan was performed following pleural drain insertion, hence the air within the soft tissues. Note the pleural thickening extends along the mediastinal contour ( double arrow Image 4a) and is associated with volume loss, both signs are highly suggestive of malignancy.
In addition, there is posterior bulging of the oblique fi ssure ( arrow Image 4c) which is in favour of
bronchioloalveolar cell carcinoma  . The incidence of bronchioloalveolar cell carcinoma
(a form of adenocarcinoma) is increasing particularly as the incidence of smoking is decreasing. It is the form of lung cancer most commonly seen in nonsmokers. 


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