An Interesting Chest X-ray

A 78 year old lady presents with a fall after feeling pre-syncopal. She has a 24 hour history of vomiting and abdominal pain. She is complaining of right sided chest pain, and thinks she must have injured herself during the fall.

On examination she has a heart rate of 100 and a blood pressure of 110/60, with a postural drop to 85/40. Chest examination is clear with no reproducible musculoskeletal chest wall tenderness. Her abdomen is distended, soft and non tender, with obstructive bowel sounds. Her only past medical history is breast cancer. Her abdominal examination shows bowel obstruction, and a nasogastric tube is inserted. This is her Chest X-ray :

1. List at least 3 abnormalities of this Chest X-ray.2. What is the likely diagnosis?3. What additional questions are important to ask this lady?4. How would you investigate this?

1. This Chest X-ray shows a pleural based opacity projected over the right upper lobe. This could represent a localised pleural effusion or empyema, an asbestos plaque, mesothelioma or metastatic carcinoma. Closer inspection reveals destruction

Anna Paes, October 2012.

of the underlying rib, making it more likely that this is a sinister lesion. Furthermore there are lytic lesions throughout the right sided ribs. She has had a left mastectomy. There is oxygen tubing, and a nasogastric tube with its tip in the stomach.

2. The most likely diagnosis would be metastatic carcinoma from her previous breast cancer. It could be mesothelioma, but there is no other evidence of asbestos exposure on the X-ray. Her small bowel obstruction could be incidental, or she could have a colonic carcinoma also.

3. Additional questions should inquire about possible symptoms from these Chest X-ray findings. How long has she had this chest pain for, does it relate to the fall or has it been there for longer? Has she had a cough, dyspnoea, haemoptysis or any weight loss? Does she know about any previous asbestos exposure? In terms of bowel obstruction, you should ask about change in bowel habit, previous abdominal surgery and hernias.

It is also important to enquire about other possible metastatic spread or other primary carcinoma. Has she had any confusion, visual disturbances, headache, nausea or vomiting, or seizures? Is she a smoker or ex-smoker? Is there any other history of cancer?

4. This lady needs a staging CT chest, abdomen and pelvis to assess the extent of spread. A percutaneous biopsy of the lesion will result in a tissue diagnosis. With these results, her case should be discussed at a Multidisciplinary Meeting to decide on the best management for her.

Anna Paes, October 2012.