Wednesday, October 26, 2005

Radiograph of the day

87 year old man with no PMH presented to his PCP with mild SOB. No cough. No constitutional symptoms. He is a non-smoker.

The CXR is shown:

Answer below with discussion.

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

Jennings said...

Did he have TB many years ago? Does this represent a pre-INH surgical intervention for TB? It looks like soemthing foreign placed into the thoracic cavity. I seem to recall that this would be an alternative to artificial pneumothorax for the treatment of TB.

Jeff H said...

There is no history of any thoracic infection or surgery.

Baleeiro said...

Wow! Very smooth and large posterior mediastinal mass. Neuro-endocrine tumors (Schwannomas and neuroblastomas) are a big possibility. Is he a smoker?

Jeff H said...

Non-smoker.

Baleeiro said...

You mean non-smoker as stated very clearly on the history and I still didn't see it?

Baleeiro said...

He seems too old for a germ-cell tumor and this would be an unusual presentation for lymphoma. Any odd occupational exposures or travel Hx?

Jeff H said...

No travel. No occupational exposures.

Jennings said...

Oh i thought that was in the lung; I hadn't cosidered it to be mediastinal. If it was lung I would have offered up non-smoking related tumors such as carcinoid, harmatoma, adenomas, but if it is indeed posterior mediastinal, the the ones baleeiro discussed...

akadar said...

Any history of thalassemia? It's unusual, but with enough strain on the marrow you can develop a posterior rounded mass due to extramedullary hematopoiesis.

Arenberg said...

I like Carlos' idea of a neurogenic origin, as this thing appears to be sprtouting out of the posterior mediastinum, and that would be the most common entity to come from there. I will say a neurofibroma, or a fibrous histiocytoma for my left field guess.

DKeena said...

Sarcoma can result in a large, asymptomatic, well circumscribed lesion, if you buy it could be coming from the chest wall.

Jeff H said...

All good comments. As it turns out, this is a schwannoma (first thing mentioned by Baleeiro). This is not my patient, but thought the film was great. It has been followed for at least 6 years and has been slowly growing. The patient has no neurologic symptoms and, at 87 years old, has been refusing surgery for several years.

Baleeiro said...

Smart patient. At 87 there would be little to gain from surgery unless he was truly symptomatic. Most schwannomas are benign and this one is behaving so far. Any FHx of neourofibromatosis?

Jeff H said...

No family history. He has done well for several years--I wouldn't want the surgery either.