1. MedPix Medical Image Database COW - Case of the Week Case Contributor: Jason Blitz Affiliation: Uniformed Services University

2. MedPix No: 9835 - History Pt Demographics: Age = 42 y.o. Gender = man Chief complaint:47 y/o male presented in Nov 2005 with pain in right anterior thigh. X-ray revealed a mass in the femur and adjacent soft tissue. Partial surgical resection of mass revealed adenocarcinoma. Subsequent PET scan indicated increased uptake at several locations in the right lung.Patient had a history of pulmonary nodules dating to 2003/2004. However a PET conducted in August of 2004 was negative except for minimal uptake in one pulmonary nodule. Serial X-rays showed no changes in these nodules through mid 2005.Patient was diagnosed with metastatic adenocarcinoma of the right lung and referred to oncology for radiation and chemotherapy.PMX: Nephrolithiasis HyperlipidemiaPSHX: Right neck lymph node resection (benign) at 22 yo Cholestectomy in 2004SocHx: >1PPD for 20 years No ETOHFMHX: Sister (smoker) died of lung cancer in 1979 Sister (non-smoker) died of lunger cancer at 40 yo Sister (non-smoker) died of lung cancer at 62 yo Brother (smoker) diagnosed with head and neck cancer 2006Meds: PercocetAllergies: Aspirin - upset stomach Downloaded by (-1)

3. MedPix No: 9835 - EXAM & LABS Not applicable

4. 13 April 06 Chest CT 13 April 06 Chest CT demonstrating normal right pulmonary arterial flow. Downloaded by (-1)

5. 16 August Chest CT 16 August Chest CT demonstrating decreased right pulmonary arterial flow due to compression from cancerous tissue. Downloaded by (-1)

6. 13 April Abdominal CT 13 April Abdominal CT demonstrating normal adrenal glands. Downloaded by (-1)

7. 16 August Abdominal CT 16 August Abdominal CT demonstrating metastatic spread to bilateral adrenal glands. Downloaded by (-1)

8. 13 April Abdominal CT 13 April Abdominal CT demonstrating bilateral normal gluteal soft tissue. Downloaded by (-1)

9. 16 August 06 Abdom CT 16 August 06 Abdom CT demonstrating metastatic spread to right gluteal soft tissue. Downloaded by (-1)

10. FINDINGS Chest and abdominal CT on 13 April 2006 revealed the following in comparison with an August 2004 chest and abdominal CT: Progression of right hilar adenopathy and enlargement of the pleural-based soft tissue mass along the posteromedial aspect of the right lower lobe. Pulmonary parenchyma demonstrates enlargement of multipleright lower lobe pulmonary nodules. The pancreas, spleen, adrenal glands, and kidneys are normal. Soft tissue in the bilateral gluteal regions are normal.Chest and abdomal CT on 16 August 2006 after 4 months of chemotherapy and radiation revealed the following in comparison with the 13 April 2006 study: Subcarinal lymphadenopathy is demonstrated and increased from previous study. Associated rib destruction is demonstrated. Associated endobronchial narrowing is demonstrated extending to the right lower lobe. No pulmonary nodules are seen in the left lung. Interval development of bilateral adrenal masses. Soft tissue masses are demonstrated within the mesentery. Interval development of right gluteal mass

11. DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? Metastatic Adenocarcinoma of the Lung - Metastatic Small Cell Cancer of the Lung - Metastatic Squamous Cell Cancer of the Lung - Other Metastatic Cancer

12. Diagnosis: Metastatic Adenocarcinoma of the Lung Dx Confirmed by: Pathology

13. DISCUSSION Aggressive spread of adenocarcinoma of the lung to thoracic, abdominal and soft tissues.