Chest X-ray - Scenario 7
Answers to scenario questions

Answers to scenario questions

Question 1 - (referring to image 2)

What is this imaging examination and why do you think this was requested?

• CT of the thorax and upper abdomen performed for staging purposes

Question 2 - (referring to image 2)

What precautions would you take prior to requesting this investigation?

• You would be expected to know that intravenous contrast material is nephrotoxic and so you should ensure that renal function is normal
• It is also necessary to check that there is no history of previous allergic reaction to intravenous contrast

Question 3

What is the differential diagnosis of the findings on the X-ray?

• A differential diagnosis of cavitating lung lesions...
• Infection - including Staphylococcus aureus, mycobacterium species, Klebsiella pneumoniae, hydatid cyst, and fungal disease such as aspergillosis
• Malignancy - primary or secondary (squamous cell carcinoma often cavitates - as in this case), and lymphoma
• Other causes of cavitating lung lesions include vasculitis, rheumatoid nodules, congenital cysts, septic emboli, cystic bronchiectasis

Question 4

Given the clinical history, what is the most likely diagnosis?

• There are no features to suggest acute lower respiratory tract infection. The lack of travel history makes some infective causes less likely
• The history is much more suggestive of cancer

Question 5

What are the options for imaging-guided tissue sampling in this patient?

• If there are lymph nodes which are clinically palpable, or superficial lymph nodes seen on the CT scan, then ultrasound-guided sampling may be an option
• Sampling of the lung lesion using percutaneous imaging-guided techniques would carry high risk of complications, such as pneumothorax
• The liver could be more easily biopsied under ultrasound guidance

Question 6

What are the common sites of metastatic spread from bronchogenic carcinomas?

• Ipsilateral and contralateral lung***
• Hilar, mediastinal and distant lymph nodes***
• Adrenal glands
• Liver
• Brain
• Bone
• *** These sites of spread are often forgotten