Case and content by Lauren Brown, MD
Expert radiology interpretation by David Godwin, MD
- Differentiate an intrapulmonary mass from a mediastinal mass.
- Identify signs of volume loss.
65 yo woman with 30 pack-year tobacco smoking history presents to clinic with an intermittent, but worsening non-productive cough over the last year. She had one episode of scant hemoptysis. She denies fevers, chills, and night sweats.
Vital signs and physical examination is normal. She has lost 15lbs since over the past year.
Right hilar pulmonary mass with right upper lobe volume loss suggesting at least partial bronchial obstruction centrally.
How can you differentiate an intrapulmonary mass from a mediastinal mass?
Red arrows point to the right hilar mass. This can be identified as intra-pulmonary because of its ill-defined margins; intrapulmonary processes grow into the lung, creating a gradual and thus ill-defined margin. Processes outside of the lung abut the pleura, creating a crisp margin.
CT Chest confirms the intrapulmonary location of the mass:
What signs indicate volume loss, raising the question of central bronchial obstruction?
There is partial upper lobe collapse from compression of the R bronchus. Signs of volume loss include upward displacement of the minor fissure (red arrow, with the broken line indicating usual position), “peaking” of the right hemidiaphragm (yellow arrow), and rightward displacement of the trachea (blue arrow). The remaining right upper lobe remains lucent, so there is not complete upper lobar collapse.
DIAGNOSIS AND OUTCOME
Right hilar squamous cell lung cancer.
Bronchoscopy revealed the presence of an endobronchial lesion partially occluding the right mainstem bronchus orifice; biopsy confirmed squamous cell carcinoma. A positive biopsy of a right supraclavicular lymph node diagnosed Stage IV disease. She had progression of disease on multiple therapies and returned to her home state for hospice care.
TAKE HOME POINTS
- Intrapulmonary masses will have ill-defined margins, whereas extrapulmonary masses (i.e. mediastinal or pleural masses) abut the pleura which creates sharp margins.
- Signs of volume loss include displacement of fissures, tracheal deviation, and peaking of the ipsilateral hemidiaphragm.