History
A 73-year-old man presents to his GP with a 3-day history of haemoptysis. He has had a dry cough for the last 3 weeks. He denies breathlessness or chest pain. On further probing, he reports unintentional weight loss of 10 kg in the last six months, loose stools for several weeks and feels ‘bloated’. He has a history of hypertension which is well controlled with amlodipine. He has never smoked and was previously employed as a mechanic.
Examination
On examination, he is cachectic and his finger nails are clubbed. He is afebrile, heart rate 84 per minute, blood pressure (BP) 125/85 mmHg, respiratory rate 16 per minute, oxygen saturations 95 per cent on room air. There is a hard enlarged lymph node in the left supraclavicular region. His chest is clear on auscultation and heart sounds are normal with no peripheral oedema. His abdomen is mildly distended with no palpable masses or organomegaly and bowel sounds are present. Digital rectal examination is unremarkable and urine dipstick is normal.
Investigations
Reference range
Haemoglobin 11.5 g/dL 13.5–18.0 g/dL
White blood cell count 5.6 × 109/L 4.0–11.0 × 109/L
Platelets 256 × 109/L 150–450 × 109/L
Mean corpuscular volume (MCV) 70 fL 76–100 fL
Sodium 136 mmol/L 135–146 mmol/L
Potassium 4.1 mmol/L 3.2–5.1 mmol/L
Urea 7.8 mmol/L 1.7–8.3 mmol/L
Creatinine 96 μmol/L 62–106 μmol/L
C-reactive protein (CRP) 22 mg/L <5 mg/L
Total protein 88 g/L 66–87 g/L
Albumin 26 g/L 34–48 g/L
Bilirubin 4 μmol/L <21 μmol/L
Alanine aminotransferase (ALT) 86 Up to 41 IU/L Aspartate aminotransferase (AST) 98 Up to 40 IU/L Alkaline phosphatase (ALP) 159 40–129 IU/L International normalized ratio (INR) 1.3 0.8–1.2
K16954.indb 167 13/05/13 8:42 PM
168 Section 2: Radiology
A chest x-ray is performed (Figure 35.1).
Figure 35.1
QUESTIONS
1. What does the chest x-ray show?
2. What is the differential diagnosis?
3. What do the blood tests suggest?
4. Which further investigations would you request?
K16954.indb 169 13/05/13 8:42 PM
170 Section 2: Radiology
ANSwERS
1. There are multiple nodular opacities of varying sizes throughout both lung fields, heart size normal, no overt bone destruction. These nodules are ill-defined, and no cavitation or associated calcification is present.
2. The most likely diagnosis is pulmonary metastases (from a non-lung primary or lung primary). Other differentials would include Wegener’s granulomatosis, rheu-matoid nodules, fungal infection (e.g. aspergillus), tuberculosis and sarcoidosis.
Wegener’s granulomatosis, although uncommon, may mimic pulmonary metastases in clinical presentation and radiological findings. It commonly affects the upper airways; renal impairment (haematuria/protein on urine dipstick) is found in 80 per cent of patients at presentation and cytoplasmic neutrophil cytoplasmic anti-bodies (c-ANCA) are a relatively sensitive test (positive in 90 per cent of Wegener’s granulomatosis cases). The most likely diagnosis given the history and examination is pulmonary metastases from a primary in the gastrointestinal tract.
3. The patient has a microcytic anaemia and mildly deranged liver function. In the context of the clinical picture this is likely to suggest occult blood loss from the gastrointestinal tract with metastases to the liver.
4. In light of the chest x-ray findings, computed tomography imaging of the chest, abdomen and pelvis to enable further characterization of the nodules and identify the extent of disease and locate the primary tumour would be appropriate at this stage. Contrast-enhanced computed tomography (CT) scan is generally preferred for radiological staging as it improves the identification of vascular anatomy, particu-larly of the liver, and may improve visualization of nodal disease.
Further tests which may be useful include tumour markers, which are non-specific, but may assist in the diagnosis. Carcinoembryonic antigen (CEA) is non-specific for bowel cancer and may be raised in non-malignant disease, such as Crohn’s, chronic obstructive pulmonary disease, pancreatitis and in smokers. However, if raised, it can be a useful marker of disease pre- and post-treatment.
The patient underwent a contrast-enhanced CT of the chest, abdomen and pelvis.
An axial lung windowed image of the CT of the chest is shown in Figure 35.2.
Throughout both lungs, there are multiple nodular opacities (A) of variable sizes with a pleural lesion also demonstrated on the right. CT of the sigmoid colon revealed a stricture with thickened colonic wall consistent with a possible primary malignancy, and further large ill-defined lesions throughout the liver. Colonoscopy confirmed the diagnosis of sigmoid carcinoma. The oesophagus (B) and descending thoracic aorta (C) are also shown in figure 35.2.
Malignant tumours commonly metastasize to the lungs via haematogenous or lym-phatic spread. Those which commonly metastasize to the lungs are breast, gastro-intestinal (GI) tract and renal cell carcinomas, as well as head and neck, soft tissue sarcomas and melanoma. Less common malignancies which may metastasize to the lungs include thyroid and testicular tumours.
Case 35: Man with a bloody cough 171
Colorectal cancer is the third most common cancer in the UK, around 65 per cent of these are in the left side of the colon. Most cases arise from adenomatous polyps.
Ninety-five per cent of colorectal cancers are adenocarcinomas with the remainder being squamous cell carcinoma, carcinoid tumour, sarcoma and lymphoma. The most common sites for metastases are the liver and lymph nodes, but metastatic spread to the lungs, as well as peritoneum, pelvis and adrenals also occurs. Only one third of colorectal cancer is diagnosed in the early stages (Duke’s stages A and B).
It is associated with advancing age, with more than 80 per cent of those diagnosed being over the age of 60 years, a high fat and low fibre diet, inflammatory bowel disease (ulcerative colitis) and a hereditary predisposition, the two major forms of which are familial adenomatous polyposis (FAP) and hereditary non-polyposis colon cancer (HNPCC).
The most common presenting symptoms depend on the site of the lesion within the colon and rectum and are often non-specific, but include change of bowel habit, rectal bleeding, tenesmus, abdominal pain and weight loss. Patients with a lesion in the left side of the colon are more likely to present with bowel obstruction, whereas lesions on the right, where the lumen diameter is larger and stool is more fluid, tend to present later as an iron-deficiency anaemia. Severe anaemia may cause symptoms of breathlessness and fatigue. Patients may, however, present with symp-toms related to metastatic disease, the most common of which is cough and haem-optysis, but also pneumonia, pleuritic chest pain and dyspnoea.
There are two staging systems used for colorectal cancer in the UK; the TNM (tumour, node, metastasis) system is more commonly used, but staging may also be
K16954.indb 171 13/05/13 8:42 PM
172 Section 2: Radiology
referred to by Duke’s classification. ‘T’ describes how far the tumour has infiltrated the wall of the intestine and spread to local areas. ‘N’ is the extent of spread to regional lymph nodes and ‘M’ is the extent of metastatic spread to other areas of the body.