Grand Rounds- Cannon Ball Secondaries And Pulmonary Metastasis.

Pulmonary Medicine Blog By Dr Deepu.

Lung Cancer incidence is on rise so does the metastasis to the lungs. As the age increases the incidence of lung cancer and also the lung metastasis increases.

An elderly male presented to us with weakness and giddiness associated with chest pain since a month. Clinical examination revealed an enlarged right supraclavicular node. Rest of the clinical findings were normal.
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Before proceeding study this chest X Ray carefully.

Chest X ray shows large , well circumscribed, round pulmonary nodules that are distributed in upper mid and lower lung zones bilaterally, some forming into a mass but most of them are seen concentrated in the lower zones and mostly along the peripheral lung fields. also there is a homogenous mass in the left mid zone just lateral to the descending aorta. The diagnosis could be cannon ball secondaries with unknown primary.

Study the CT images before proceeding

The CT scan above shows multiple nodules of varying sizes, concentrated mostly in the lower lobes and left upper lobe bronchus seems occluded partially by the mass. Here study this mediastinal window and coronal cuts

The mediastinal window shows a few lymph nodes in paratracheal and subcarinal area.

We screened his brain , GIT, bones and Genitourinary system for primary Tumor, the scans were normal , further we considered bronchoscopy and Scopy showed a fungating mass in the left upper lobe, Biopsy reports are awaited. Will update once it becomes available.

Cannonball metastases are large, well circumscribed, round pulmonary metastases that appear, well, like cannonballs. 

 

The French term "envolée de ballons" which translates to "balloons release" is also used to describe this same appearance. 

Causes of Cannon Ball Metastais

Classical- renal cell carcinoma  choriocarcinoma,

                                           

Less commonly - prostate cancer, synovial sarcoma or endometrial carcinoma.

Pulmonary metastases are very common and it is  due to metastatic spread to the lungs from a variety of tumour. It can spread via blood or lymphatics. 

Clinical presentation

Pulmonary metastases are asymptomatic usually,

The constitutional symptoms are related to primary cancerous metastatic condition

Those attributable to the primary tumour dominating. 

Haemoptysis , Chest pain , difficulty in breathing and pneumothorax are sometimes the presenting symptom.

Pathology

Tumour cells reach the lungs via the pulmonary circulation, where they lodge in small distal vessels. 

The most common primaries to result in pulmonary metastases include: 

breast carcinoma

colorectal carcinoma

renal cell carcinoma

uterine leiomyosarcoma

head and neck squamous cell carcinoma

Primaries which most frequently metastasise to lungs (although in themselves much less common tumours) include:

choriocarcinoma

Ewing sarcoma

malignant melanoma

osteosarcoma

testicular tumours

thyroid carcinoma

Radiographic features

Pulmonary metastases characteristically appear as peripheral, rounded nodules of variable size, scattered throughout both lungs . uncommon features include consolidation, cavitation, calcification, haemorrhage and secondary pneumothorax.
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Plain radiograph

Plain films are insensitive, although frequently able to make the diagnosis, as often pulmonary metastases are large and numerous.

CT

CT is excellent at visualising pulmonary nodules. Typically metastases appear of soft tissue attenuation, well circumscribed rounded lesions, more often in the periphery of the lung. They are usually of variable size, a feature which is of some use in distinguishing them from a granuloma.

A prominent pulmonary vessel has frequently been noted heading into a metastasis. This is termed the feeding vessel sign.

Some tumours have a predilection for innumerable small metastases (miliary pattern):

Malignant melanoma

Osteosarcoma

Renal cell carcinoma

Thyroid carcinoma

Trophoblastic disease( choriocarcinoma)

Pulmonary metastasis may be single. Seen most frequently  in colorectal carcinoma.

Other primaries which often present with solitary metastases include:

Malignant melanoma

skeletal sarcoma

adenocarcinomas in general

Adenocarcinoma metastases may rather than displace or destroy adjacent lung parenchyma, cells grow in a lepidic fashion (spread along aleveolar walls) resulting in pneumonia-like consolidation. Air bronchograms may also be visible.

Cavitation is present in ~4% of cases. The most common primary is squamous cell carcinoma, most often from the head and neck or from the lung. Other primaries include adenocarcinomas, and sarcomas.

Calcification, although uncommon and more frequently a feature of benign aetiology (e.g. granuloma or hamartoma) is also seen with metastases, particularly those from papillary thyroid carcinoma and adenocarcinomas. Treated metastases, osteosarcomas and chondrosarcomas may also contain calcific densities.

A halo of ground-glass opacity representing haemorrhage can be seen, particularly surrounding haemorrhagic pulmonary metastases, such as choriocarcinoma and angiosarcoma.

Treatment and prognosis

In general presence of pulmonary metastases is an ominous finding, indicating poor prognosis. The specific prognosis will however depend on the primary tumour.

Complications

Tumours with prominent necrosis located near a pleural surface may result in a pneumothorax. Osteosarcoma is classically described as the pulmonary metastasis that results in pneumothorax. Another cause of pneumothoraces include cystic or cavitatory pulmonary metastases.

Grand Rounds - Opaque hemithorax.

Pulmonary Medicine Blog By Dr Deepu

Grand Rounds:

This patient an elderly lady presented to us with breathlessness and cough eith sputum with increased sputum in right lateral position. Spo2 was 89% 

Examination revealed trachea deviated to left. Apicak impulse felt in left axilla 5th Ics. Breath sounds diminished on left with added crepitations on left side.

This X ray was taken in emergency room.

 CT confirmed fibrosis of left lung.

Complete white out(opacification) of the hemithorax on CXR has a limited number of causes.

 The differential diagnosis can be zeroed on with one simple observation - the position of the trachea. 

Is it central, pulled or pushed from the side of opacification?

• pulled trachea : pneumonectomy, total lung collapse, pulmonary fibrosis,pulmonary agenesis
• central: consolidation, mesothelioma, collapse with effusion. Lung mass 
• pushed: pleural effusion, diaphragmatic hernia.

Radiology- chest X Ray Spotters.

Pulmonary Medicine Blog By Dr Deepu

spotter 1.
A middle Aged male who is HIV+ presents with a cough of 3 months and cachexia. Auscultation reveals crepitations b/l . Differentials???

Clinical Case - Give Your Diagnosis!!!

Pulmonary Medicine Blog By Dr Deepu

An elderly female came to the outpatient department with a history of cough since 2 weeks minimally productive sputum, she also give history of increased breathlessness since 3 weeks, the symptom of breathlessness being present since three years, she also complains of decreased sleep due to productive cough, and a known hypertensive since 5 years.
  Clinical examination reveals pitting pedal edema and bilateral basal crepitations and no other significant clinical findings were present.
Investigations revealed a total count of 13000 and this chest x ray. EKG was normal. What could be the differential diagnosis????

Spotter : Identify the radiological sign in chest X ray.

Spotter for you: What is your Diagnosis?? What are the differentials and source of such condition.