0:00

Let's take a look at this chest CT

0:02

and a 56-year-old man with a 35 pack year history of smoking

0:06

who still actively remains a cigarette user.

0:09

This patient has severe COPD

0:11

and has been on oxygen therapy with frequent exacerbations

0:15

of their COPD requiring hospitalizations.

0:19

If we look at the ct, we can see from the very beginning

0:22

that there's an asymmetric appearance to the lung apices

0:26

with a central mass, the left upper lobe apex.

0:29

It has a broad surface of contact

0:31

with the overlying pleural surface

0:33

and there are areas of irregular nodularity

0:37

and thickening extending into the adjacent left upper lobe

0:40

parenchyma consistent with local lymphic tumor spreads.

0:43

If we look at it on the soft tissue windows, we can see

0:46

that the nodule is inseparable from the mediastinum,

0:51

and we have a high degree of concern

0:52

for mediastinal invasion as we have no normal fat

0:56

between the mass and the mediastinal structures.

0:59

There are even areas

1:00

where it looks like there's interdigitation

1:03

of the soft tissue into the mediastinal fat

1:05

here posteriorly.

1:07

So a high degree of suspicion for lung cancer.

1:09

There are a few tiny areas of calcification within it.

1:13

None of these calcifications meet the criteria for

1:17

specifically benign calcifications.

1:19

For calcifications to be considered specifically benign,

1:22

we look at an entire nodule being solidly calcified.

1:26

We look for concentric rings of calcification

1:29

and we look for a large central calcification,

1:33

but excentric, stipple calcification,

1:36

or amorphous calcification are not specific signs

1:39

of a benign lesion.

1:41

As we continue to look at this,

1:42

we can see the extensive severe upper lobe

1:45

predominant emphysema.

1:47

There's very little normal

1:49

intervening lung tissue at all in this patient's upper

1:51

lobes, very severe emphysema in the mid lung

1:56

and starting to get a little bit better.

1:58

As we get towards the basis.

2:00

We can categorize

2:02

and look at the patient's emphysema

2:04

using some quantitative imaging tools

2:07

that can calculate the amount of emphysema

2:09

and the lung volume.

2:11

So if we look at this tool, we can see that

2:14

by a density threshold of minus 950, hence units of lower

2:18

as the threshold for emphysema.

2:19

About 37% of the lung printable would map to emphysema.

2:23

If we were to drop that threshold down to minus nine 30

2:26

or minus 900, I would expect that over 50%

2:29

of this patient's lung tissue would be

2:31

categorized as emphysema.

2:33

We can also see the total lung volume at 6.8 liters.

2:36

The patient is certainly hyperinflated,

2:39

but getting back to the lung nodule

2:41

or the lung mass,

2:42

which we use when something hits 30 millimeters

2:45

or bigger in size, this is just under 30 millimeters in mean

2:49

diameter, but as a speculated mass with suspicion

2:52

for mediastinal eva, this is more

2:55

concerning than a four B nodule because of the

2:58

Features along the mediastinum

3:00

and the extensive local lymphatic tumor

3:02

spread in the left upper lobe.

3:04

So this becomes a category four X lesion.

3:08

While it would have the same management recommendation

3:10

of A four B, these other features like concern

3:13

for mediastinal ovation make this a particularly

3:15

concerning lesion with a very high risk of lung cancer.

3:20

Now we can look back at a prior CT of this patient

3:23

and the exam on the right is from just over four years ago,

3:28

and we could see the only thing at the apex at

3:30

that time was an area of linear scar that had been there

3:33

for several years beforehand and had not changed.

3:37

Uh, people talk about the entity that's known

3:39

as scar carcinoma

3:41

or adenocarcinomas that develop in areas

3:43

of lung parenchymal scar

3:45

and that may very well be at play in this patient

3:47

where this nodule

3:48

or mass is centered on this area of parenchymal scar.

3:53

This patient was not a surgical candidate due

3:57

to their severe COPD

3:58

and more recent, UM, COPD exacerbations.

4:02

A PET CT was done to look for metastases elsewhere,

4:05

perhaps finding an area that might be more accessible

4:08

to tissue sampling or biopsy from a diagnostic standpoint,

4:12

there were no other areas on the PET CT concerning

4:16

for metastasis, nothing.

4:17

For example, in a cervical lymph node,

4:20

a mediastinal lymph node, an upper abdominal organ

4:23

where lung cancer tends to go the liver

4:25

and the adrenal glands.

4:27

Because of the location of this,

4:29

it would be very difficult lesion to get

4:31

to this bi bronchoscopy.

4:32

So they ended up doing a CT guided biopsy which demonstrated

4:36

adenocarcinoma with signet ring cell features,

4:40

which may be associated with scar carcinoma,

4:42

and the patient underwent local radiation treatment

4:46

despite the size of the tumor.

4:48

Its location concern for medias evasion coupled

4:50

with severe findings of COPD after radiation treatment.

4:55

This patient did well

4:56

and is with no evidence

4:58

of recurrent lung cancer nearly three years from the

5:03

diagnosis of lung cancer

5:04

through lung cancer screening at the

5:06

time of this examination.

5:08

So lung round four B, due to the findings

5:11

of mediastinal invasion, lymphotic tumor spread becomes a

5:14

four x.