Thread by @RyanChristieMD

#Wetread Case 18

Hx: Chest Pain

Professionally appropriate gif responses only please. No spoilers! wetread.org #FOAMrad #FOAMed #radres #errad #chestrad #CXRarehard

#Wetread Case 18

So hopefully everyone saw this pleural based opacity in the RUL. But does anyone see the other finding? 🤔 #CXRarehard #chestrad

#Wetread Case 18

Turns out pt had some pain radiating to their neck so they got this C-spine X-ray. Perhaps one of the rare times a non-trauma C-spine X-ray is helpful? 😁

#Wetread Case 18 Answer: Pancoast tumor (aka superior sulcus tumor)

RUL Pleural density is a rib met from the destructive tumor in the R pulmonary apex. Where is R C7 TP?😮

Very difficult to 👀 so you have to examine the apices closely! #FOAMed #radres #chestrad #CXRarehard

Pancoast tumor:

-varying tumor types (NSCLC m/c)
-classic hx is Pancoast Syndome (chest pain, C8-T2 radiculopathy, Horner's syndrome) but only ~25% have all 3
-often involves brachial plexus and subcl vessels to trt is radx/chemo +/- resection
-poor 5yr survival

In review, our pt did have upper chest/neck/shoulder pain, c/w partial Pancoast syndrome (no Horner). Understandably easily overlooked in a busy ER, but a reminder to clinicians and Rads to narrow symptoms down as detailed and specific as possible.

Pancoast Tumor (Imaging)

CXR: soft tissue mass pulm apex, 👀 bone destruction!
CT: improved resolution over CXR
MRI: 👀 nerve/vessel involvement (if >C8 nerve involvement may be inoperable)
PET/CT: nodal, distant mets

My rec is to always examine and re-examine the lung apices, with mag🔍!

👀 for:
-⬆️Soft tissue density (scarring v mass)
-bone destruction
-nodules
-PTX!!

⭐️you often get a better look at the apices on the coned down C-spine CT than on the full FOV Chest CT #ryanradrecs 😁