1. MedPix Medical Image Database COW - Case of the Week Case Contributor: Paul J Cunningham Affiliation: Madigan Army Medical Center

2. MedPix No: 2656 - History Pt Demographics: Age = 58 y.o. Gender = man A 58-y.o. man presents with increasing dysphagia over the past month and a half. The patient was noted to have tonsilar enlargement about 45 days ago and was subsequently treated with two separate courses of antibiotic therapy by an outside provider - without clinical improvement. The patient denies odynophagia and describes dysphagia that has progressed now to inability to swallow his own salivary secretions. Downloaded by (-1)

3. MedPix No: 2656 - EXAM & LABS Cachexia. Left tonsilar enlargement. Cervical lymphdenopathy.

4. Spindle cell carcinoma There is a right upper lobe nodule, seen superimposed on the shadow of the anterior part of the second rib. - - Right paratracheal and right hilar masses suspicious for adenopathy are seen as well. - - Midline anterior abdominal wall sutures are seen in the upper abdomen. Surgical clips are seen near the gastroesophageal junction. Downloaded by (-1)

5. Spindle cell carcinoma There is a right upper lobe nodule, seen superimposed on the shadow of the anterior part of the second rib. - - Right paratracheal and right hilar masses suspicious for adenopathy are seen as well. - - Midline anterior abdominal wall sutures are seen in the upper abdomen. Surgical clips are seen near the gastroesophageal junction. Downloaded by (-1)

6. FINDINGS Right upper lobe nodule. Right hilar and right paratracheal mediastinal adenopathy.

7. DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? Malignancy: primary lung, metastatic, or lymphoma. - Infectious: tuberculosis or endemic mycoses. - Inflammatory: sarcoidosis. - - By far the most likely is a primary lung tumor. Bulky adenopathy in the presence of a small peripheral mass is a pattern often seen with small cell carcinoma. - - In this case, the presence of the tonsillar mass makes the mediastinal findings more likely to be due to metastasis from a primary head-and-neck tumor, probably a squamous cell carcinoma. If that is the case, the right upper lobe mass may be a metastasis or a synchronous primary lung tumor.

8. Diagnosis: Non-Small Cell Lung Carcinoma with metastases Dx Confirmed by: Mediastinal biopsy

9. DISCUSSION DIAGNOSIS: spindle cell carcinoma lung cancer