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Case 32

Adenocarcinoma, unknown primary

Female, 60 yrs, with breathlessness and weight loss

This 60 year old lady presented with breathlessness and weight loss. This CT scan was obtained during follow up of her treatment.

Findings

There is extensive lobular thickening of the pleura on the left, which encases the left lung, and involves the mediastinum also. There is possible chest wall invasion on image b.

A hickman catheter has been inserted for chemotherapy, and the tip is visible in the right atrium. This is a contrast enhanced scan, but a low attenuation mass is seen adjacent to the catheter tip in the right atrium. This is thrombus adherent to the catheter tip - there was a recent history of difficulty flushing the catheter. This was confirmed on injection of contrast down the catheter and was promptly treated by intra catheter thrombolysis with rTPA, due to the risk of pulmonary embolus.

Diagnosis

Adenocarcinoma, unknown primary

Discussion

Metastatic adenocarcinoma often spreads through the pleural cavity in this fashion, and the mediastinal involvement and lobular appearance should suggest malignancy. Mesothelioma secondary to asbestos exposure also produces this appearance, but no history of exposure was obtained in this case, and there were no features of asbestos exposure (eg calcified plaques) on the images. Adenocarcinoma was confirmed on biopsy of enlarged cervical nodes.

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