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Here we have a lung cancer screening CT

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of a 57-year-old woman who's seeing a new PCP

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after not having one for some time.

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She has a more than 25 pack year history

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of cigarette smoking and continues to use cigarettes.

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If we look at her screening ct, we see just a little bit

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of very, very mild upper lung predominant central lobular

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emphysema, those little low density holes without walls.

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A little bit of breathing motion artifact on the right lung.

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You can see kinda that star artifact of vessels moving

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as the, as we use.

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He scanning parameters for volumetric acquisition

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and she's definitely got a lot of small airway disease.

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These are markedly thickened small airways,

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mostly lower lobe predominant

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and in the right lower lobe where there's even more than

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that, we have areas of septal thickening

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and they're not perfectly smooth thickened septal like we

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see in interstitial edema.

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They're a little bit lumpy

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or nodular in the right lower lobe,

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but it's very asymmetric.

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We don't see it in the other side,

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but we see this irregular reticular, nodular thickening

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of the interlobular septa together

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with this bronchial wall thickening

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that's much more severe in the right lower

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lobe than the left.

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As we follow some of these airways up, like these two uh,

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segmental airways as they come together,

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the bronchus is completely occluded there,

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so likely some secretions which we

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can see right, right here.

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So there's evidence of small airway disease

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with maybe chronic bronchitis with mucus and secretions,

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but that doesn't really explain the abnormally thickened

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SEPTA and these bands of soft tissue thickening here.

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Let's take a look at the soft tissue windows.

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But before we do that, this is the ASCO esophageal recess

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and normally it's indented.

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You have the esophagus

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and the ascus vein which sit right in front of the spine

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and normally the right lung interdigitates into the

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mediastinum at this location.

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They call that portion of the lung La Krista terminology

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for those of you who like your anatomy terminology.

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But it should never be in this direction of convexity

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where instead of being concave it is convex.

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And then of course I think we can probably see

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through the lung windows into something going

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on in the mediastinum.

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So if we look at the soft tissue windows,

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there are extensive mediastinal lymph nodes up here in the

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right parit tracheal region becoming larger, more confluent

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and inseparable from the SVC

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and the asthe aorta contiguous with the trachea.

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And as we come down to the SubCal region,

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we have a large mass.

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We can see it looks like direct tumor invasion

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into the bronchus intermedius

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and the fact that the bronchus intermedius is so narrow

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and if not occluded,

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This location explains why there's probably secretions

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getting trapped behind it

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and explains some of what's going on in the right.

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Lower lobe is potentially related to lymphic tumor spread.

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We can look at this in different planes.

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If we look at it even without any oral

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or IV contrast, we can see this large SubCal mass

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deviating the esophagus

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and it's got a little bit of smudgy calcification in it.

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Don't know what to make of that.

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Some adenocarcinomas can have calcification,

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but this would be a very atypical presentation

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for a pulmonary adenocarcinoma

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with the predominant abnormality being in the chest.

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So if you were trying to think about small cell cancer

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versus non-small cell cancer, small cell lung cancer tends

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to present with bulky masses, often large mediastinal masses

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and you don't really see the primary in the lung as much.

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This patient underwent a PET ct, whereas you can see all

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of the lymph nodes were intensely FDG AVID mapping

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with where we see the tumor.

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So if we had to think about small cell cancer versus

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non-small cell lung cancer, we'd be favoring this

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as small cell cancer.

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Lung cancer screening was developed really to detect

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any lung cancer, but most specifically

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non-small cell lung cancer, most

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of which is most commonly adenocarcinomas.

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But we will occasionally find limited stage small cell lung

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cancer in a pulmonary nodule

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or we'll see extensive stage small cell carcinoma like this.

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So this patient was referred to pulmonary medicine

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on some really careful questioning.

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The patient revealed that she'd had a chronic cough

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for the last six months sometimes with a lot of secretions.

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She delayed her biopsy for one month.

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There were some family issues.

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She was a caregiver both to her father as well

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as her grandson and to a friend.

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And the ability to get

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to medical care was really compromised due

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to her responsibilities and probably also concerns

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and fear about the diagnosis.

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During her assessment, she had a bronchoscopy, uh,

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with pineal aspiration, which confirmed small cell cancer

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and her cancer stage revealed

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that she had a single brain mentalis.

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She underwent chemotherapy, radiation treatment,

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and uh, some surgical treatments

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and sadly died approximately two years from her um,

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screening CT from her small cell lung cancer.

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So this is a category four x.

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The predominance of the findings are extra pulmonary,

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although clearly there's some involvement of the airway

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and the right lower lobe lung parenchyma as well.

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And then if we juxtapose the non-contrast screening CT to

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a contrast enhanced stage ct,

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we can more clearly see the definition of the tumor relative

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to the adjacent structures

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and she later developed a pleural effusion.

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This was closer to the time that she was able

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to come in for her biopsy.

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So long ran four x primarily due to extra pulmonary findings

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with bulky mediastinal lymph node enlargement

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and a diagnosis of small cell lung cancer.