SET T0037 -
GP Referrals -
Chest Radiographs

A large mass obscures the left heart border - ie the mass is arising in the left upper lobe . . . or it is originating in the mediastinum and is invading or compressing the left upper lobe.

Bones unremarkable.

~~~~~~~~~~~~~~

See the CT. The mass is mediastinal. Some pleural fluid is also present

Histology: lymphoma.

Ill defined shadow in the left lower zone (LLZ). Left heart border not obscured.

Impression: The shadowing is situated in the left lower lobe. Given the history this is consistent with a left lower lobe pneumonia.

Findings: Abnormal CXR.

Interstitial shadows are present. Nodular. In both midzones. The nodules are small and fairly discrete; almost miliary.

Elsewhere . . .  the mediastinum, hila, and bones appear normal.

Most likely causes: Sarcoid is a strong possibility. Tuberculosis (miliary) deserves consideration - but given the clinical history, TB is a much less likely diagnosis . . . and furthermore, the nodules are not wholly convincing as being "miliary" on the CXR.

~~~~~~~~~~~~

See the CT section. Nodules confirmed.

Proven sarcoid.

Observations: 

• Faint shadowing over the lungs at several sites - suggestive of pleural or extra-pleural soft tissue.
• Mediastinum and hila are within norml limits.
• Bones are very abnormal. Several ribs are missing (in part). In particular, the right clavicle is grossly abnormal with multiple lucent/lytic areas within it.

Impression:

The main finding is that the bones are very abnormal. The abnormalities are destructive.

The differential diagnosis lies between Multiple Myeloma and disseminated skeletal metastases.

The soft tissue shadows will represent tumour extending from the bone lesions into the soft tissues of the chest wall and causing these extra-pleural shadows.

~~~~~~~~~~

Proven diagnosis: Multiple Myeloma.