Thursday, May 19, 2005

Cannonballs



22 Y/O F with 6 month H/O LLQ abdominal pain and low back pain. Over last 2-3 months. Also c/o progressive dyspnea, subjective fevers, sweats, 22 lb wt loss over last 6 months. W/U @ OSH (over the last 4 months) revealed left adnexal mass and pulmonary nodules. Pt underwent FNA of pulmonary lesion which was reportedly "inconclusive." Pt was told by PCP that no further w/u was indicated at this point.
She was seen by gynecology this week who did a transvaginal ultrasound revealing 1 cm periadnexal mass, that did not look particularly suspicious for malignancy according to their notes.
She did not bring any outside records or films.

What do you think she has and how would you proceed?
Posted by Hello

9 comments - CLICK HERE to read & add your own!:

Jeff H said...

Very young for a carcinoma, but we can not exclude metastatic ovarian CA. Any fever's? Any h/o IV drug use? They don't look cavitary, but septic emboli from a right side endocarditis can do this. Possibly a metastatic sarcoma. Other infectious causes-TB, fungal etiologies are possible but also seem unlikely.

I'd obtain her CT scan (or get a new one), and give her pain I'd get a bone scan, or CT of her spine. I'd biopsy any suspicious bony lesions or do a CT guided core as these things look pretty peripheral. If non-diagnostic, and no other extra-thoracic sites are identified, I'd do a surgical biopsy. I'd also, along with all of this, do blood cultures and an echo.

Jennings said...

They are very well defined. Nonetheless, cancer is to be considered:
1. Renal cell ("cannonball"
2. ovarian goes to lung and can be we marginated.
3. colon not in her age group and rare if liver's not involved.
4. You didn't show a lateral but I assume these are lung, not pleural based. If they were all pleural based I would think of ovarian adenomas and Meig's syndrome-related stuff.
5. Infection less likely. They look too solid and well defined.

I would start with a ct scan so we can see the lesions and look at the mediastinum. Might eventually need abd-pelvic CT as well.

Baleeiro said...

Even at this young age I'd be concerned about renal cell Ca (the back pain could be part of it). CT scan of chest/abd/pelvis would be nice.

DKeena said...

She's had intermitent subjective fevers, no history of IVDA. She was HIV (-) @ OSH

She brought in her scans CT CAP and MRI of brain (hard copy) and outside biopsy reports today.
The chest CT shows some symmetric mediastinal LAD but, its not terribly impressive and there's not much to Wang. The lesions are dense with no air bronchograms, some are peripheral and some are more central. The abdominal CT (quick look) showed an enlarged granular textured liver (radiologist said it looked like infiltrative liver Dz)
and a left adnexal mass. I didn't see anything striking in the brain.

The FNA reportedly showed multinucleated giant cells with non-caseating granulomas and negative stains for organisms.

CBC, chem 10 showed elevated LFT's AST/ALT 140's alk phos 140 o/w normal. AFP, CEA normal, CA125 65 (normal 30)

H. Krayem said...

Lymphoma of the lung is a consideration. I am thinking benign metastasizing leiomyomatosis (BML) is also a consideration, but certainly not on top of the ddx list. The answer may be in the liver.....

Jennings said...

When you see "giant cells" and "noncaseating granulomas" in the same sentence, you think of metals. Things like berryllium (but usually you get hilar with that), also aluminum and cobalt I think. Probably some others, I can't remember. I wonder if silicotic nodules would show that pathology? You might want to get a bigger biopsy so you can look at the surrounding architecture.
Anything on history in terms of exposures?

Jennings said...

Actually I like the lymphoma comment. That would be consistent with the pathologic findings as well actually. And she's a 22 y/o and with abdominal/pelvic complaints, so that does fit pretty well.

H. Krayem said...

I would also get HIV serology if not done yet, especially that lymphoma is a consideration.

DKeena said...

She lives at home with her mom and worked in retail sales (now off work), so no exposures, and no travel outside of Detroit metro area either.

I reviewed the films with radiology yesterday.

Radiologist (LQ's)comments: "The symmetry of the mediastinal LAD, favors a more systemic process than hematogenous metastasis." In light of the biopsy findings I favor a diagnosis of macronodular sarcoid and recommend a bronchoscopy".

I think that lymphoma is a strong possibility and that a much larger tissue sample will be needed to diagnose/exclude malignancy. The subcarinal node is too deep for a bronchoscopic core Bx.

I've been going back and forth as to whether to do a CT guided core Bx or just send her for a surgical Bx. I'm not sure that anything less than a surgical Bx will convince me this is benign. As there's a reasonable chance I can get an answer with a less invasive core BX I'm planning to do that 1st.