Case history

This 72 year old retired engineer, a former smoker, presented to his GP complaining of a recent onset cough, productive of sputum and containing "spots" of fresh blood. He also said that he had recently been more breathless than normal on walking to collect his morning newspaper.

On examination the left apex was dull to percussion and there were increased breath sounds over this area. There was also a reduction in chest expansion on the left side. His left eyelid was slightly droopy and the pupil seemed smaller on that side.

Lateral chest radiograph

Questions

1. What preliminary investigations would you request given the above clinical
   features?
   The posteroanterior (PA) and lateral chest radiographs requested are shown below.
2. What abnormalities are apparent on these films?
3. What further imaging investigations may be required in the management of this condition?
4. What are the main histological types of this condition?
5. What is your diagnosis and what are the characteristic features of the associated syndrome?

Answers

1. The following first line investigations would be necessary given the symptoms in a former smoker in his 70s: a posteroanterior (PA) chest radiograph, sputum cytology, full blood count, urea and electrolytes, liver function tests. A lateral radiograph can help in localising a lesion within the lung.
2. The PA chest radiograph shows a large, poorly defined radio-opaque area in the right upper lobe of the lung extending into the apex. This is further shown on the lateral radiograph.

   Sternal wiring indicates a previous median sternotomy, with surgical clips projected over the heart consistent with a left internal mammary artery (LIMA) to left anterior descending (LAD) coronary graft. Such a medical history may be related to his smoking history.

3. Thoracic computed tomography (CT) is appropriate to assess and stage the full extent of the lesion. This may precede or follow bronchoscopy with biopsies/brushings. CT imaging of the liver and adrenals is routinely undertaken in the patient with carcinoma of the lung to exclude intra-abdominal metastases.

   Thoracic CT can also be useful in confirming that the lesion's features are consistent with bronchial malignancy. If alkaline phosphatase (from the above biochemical tests) is markedly raised or if "bony" pain is a further patient complaint a radioisotope bone scan should be considered to identify any metastatic bone disease. Clearly, this would further influence management.

4. Bronchial carcinomas are typically divided into small cell lung cancers and non-small cell lung cancers because the histology determines the management and prognosis. Non-small cell lung cancers are further divided into large cell carcinoma, adenocarcinoma, and squamous cell carcinoma. Squamous cell carcinoma is the commonest bronchial carcinoma overall and is the one most associated with Pancoast's tumour.
5. The diagnosis is an apical bronchial carcinoma, specifically a Pancoast's tumour. This is an apical bronchial carcinoma associated with ipsilateral Horner's syndrome. This is characterised by ptosis, miosis, enophthalmos, and ipsilateral anhydrosis. This is due to the invasion of the cervical sympathetic plexus by the encroaching tumour.

Barry Kelly consultant radiologist, Royal Victoria Hospital, Belfast

Further reading

Dicks E. Chest x rays made easy. studentBMJ 2001;9:10-2.(February 2001.)

Henry Khumrath Pancoast, 1875-1939, professor of radiology, University of Pennsylvania, Philadelphia.

Johann Horner, 1831-83, professor of ophthalmology, Zurich. He first described his syndrome in 1869.