British Journal of Radiology 74 (2001),563-564 © 2001 The British Institute of Radiology
A right upper zone chest mass in a smoker
R Hopkins, MRCP, FRCR,
J Virjee, FRCR and
M P Callaway, MRCP, FRCR
Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK
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Introduction
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A 61-year-old man presented with a history of breathlessness and weight loss, as well as right-sided chest and right shoulder pain radiating down the arm. He smoked 20 cigarettes a day. 9 months previously he had undergone total gastrectomy for an undifferentiated adenocarcinoma of the stomach. Staging CT prior to surgery had been normal and had not shown any nodes or distant metastases. Physical examination showed evidence of weight loss, bronchial breathing at the right apex and signs of superior vena cava obstruction. A chest radiograph (Figure 1
) and contrast enhanced CT (Figure 2) are shown. What is the likely diagnosis?
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Figure 2. CT scan of the chest at the same level as Figure 1 , now demonstrating a large apical mass lesion invading the mediastinum.
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Answer
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The chest radiograph (Figure 1) shows a large (9.5 cm) right-sided apical mass lesion. No bony erosion or additional lesions are present. Contrast enhanced CT (Figure 2) confirms the presence of an extensive right apical mass, as well as demonstrating extension into the mediastinum with compression of the superior vena cava (SVC). No additional lesions were otherwise demonstrated on CT. Pancoast type symptoms, mediastinal involvement and SVC compression are highly suggestive of a primary bronchogenic tumour, particularly in a smoker. Fine needle aspiration was performed and the cytology confirmed a poorly differentiated adenocarcinoma. However, the cellular morphology was very similar to the stomach tumour removed 9 months previously. The chest lesion is a single large metastasis. The staging CT performed prior to the operation 9 months previously is normal, even in retrospect (Figure 3), illustrating the rapid growth rate of this lesion. The solitary nature of this very large pulmonary metastasis is very unusual.
Gastric carcinoma can be staged using CT to detect local disease and distant metastases, with complimentary local staging using endoscopic ultrasound [1]. The feature best correlated with patient survival continues to be tumour staging at the time of diagnosis [2]. The lungs are among the most prominent target organs for metastatic disease.
Pulmonary metastases occur most commonly from tumours of the breast, kidney, head and neck, and gastrointestinal tract, as well as testicular tumours and sarcomas [3]. Metastases may be solitary, but are more commonly multiple (75%) and generally of varying sizes. The majority are subpleural. Metastases can be complicated by pneumothorax, especially in paediatric bone tumours such as osteosarcoma. Cavitation is rare but is most commonly seen in cases of squamous cell carcinoma [4]. Solitary metastasis may also be the presenting feature of an undiagnosed primary malignancy.
Currently, spiral CT is the most sensitive imaging technique for the detection of metastases. Volume acquisition as an examination technique is important as it overcomes the theoretical risk of missing nodules between slices owing to variable breath-holding. The specificity of CT remains poor, and only 2–3% of solitary nodules identified in asymptomatic patients will be malignant [5]. This can present a difficult diagnostic dilemma. MRI may offer increased specificity of tissue characterization in the future, but currently the role of radiology in obtaining cytological proof of malignancy remains important.
Received for publication September 12, 2000.
Accepted for publication September 25, 2000.
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References
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Miller FH, Kochman ML, Talamonti MS, Ghahremani GG, Gore RM. Gastric cancer. Radiologic staging. Radiol Clin North Am 1997;35:331–49.[Medline]
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Kirkwood KS, Khitin LM, Barwick KW. Prognostic indicators for cancer. Gastric cancer. Surg Oncol Clin N Am 1997;6:495–514.[Medline]
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Coppage L, Shaw C, Curtis AM. Metastatic disease of the chest in patients with extrathoracic malignancy. J Thorac Imaging 1987;2:24–37.[Medline]
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Dodd GD, Boyle JS. Excavating pulmonary metastases. AJR 1961;85:277–93.
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Grainger RG, Allison DJ. Diagnostic radiology. Edinburgh, UK: Churchill Livingstone, 1997:394.
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