Pulmonary Fibrosis- CXR

76 yr old compalints of shortness of breath with history of COPD with decreased oxygen saturation with no definite occupational history relating to toxins/pollutants. There is extensive, ill defined reticular hard shadowing  in all zones  with suggestion of Rt CP angle blunting and rt diaphragmatic, possible calcium with no significant Rt ventricular enlargement  on this film.

Best  described as Dirty lung fields.

Teaching points

-Hard reticular shadows with some subpleural nodules  with at places loss of  tissue interfaces

-Rt pleural thickening along with plaque diaphragmatic region

-Questionable mediastinal adenopathy

-Few areas of focal hyper inflation

-Heart not conformity to  COPD with pulmonary conus not full

Xray diagnosis could suggest Pulmonary fibrosis - needs compariosn with old Xrays/ HRCT evaluation

Pulmonary fibrosis

Definition: literally scarring andreplacemnt of lung tisue with fibrous tisue

Classification: at the most confusing and rapidly changing as the etiology and types are broad progresses rapidly after 40s and 50 s, presents with shortness of breath and dry cough, typically misdiagnosed initially in view of clinical mimic to infection/embolism/COPD/ heart failure /Asthma etc. Xray chest could be normal adding to the misdiagnosis

Restrictive lung disease suggested by maintained FEV1/Fvital capacity  , though the latter is decreased  depending on the etiology radiolgical features vary idiopathic may show usual interstitial patern(UIP)  

More on this will be presented with HRCT picture -look out for it.

Adenosquamous Carcinoma Lung-CT

50 year male with cough and CT showed a large well defined regular, heterogeneously enhancing , peripheral , broadbased , noncalcifying, nonnecrotised SOL with no defintie bronchus cutoff. The medial and proximal lung of upper lobe displays airbronchogram. Mediastinal lymphadenopathy of moderate size is suggested in paratracheal and precarinal region with possible involvement of ipsilateral hilum. Ribcage, pleuralmargin, soft tissues, rest of the lung fields and adrenal glands are normal along with supraclavicular regions. CT value suggests solid lesion consistent with mass lesion

CT guide FNAC suggested adenosquamous carcinoma

AdenoSquamous carcinoma is unusual and rare pulmonary malignancy with two distinct cell types. Constitutes only 0.4 to 4% of all pulmonary malignancies.

Etiology: can arise from damaged parenchyma posibly from pneumoconiosis, and radiaiton fibrosis

Histology was defined by WHO in 1982 , modified by japanese lung society recently with suggestion of atleast 10% of microscopic appearance from both adeno and squmous components This can arise by collison of two adjacent tumours and yet distinct tumours , or as some consider as high grade mucoepidermoid ca with high squamous content or adenoca with squamous metaplasia

Studies-Mass Gen Hosp reports them to be peripheral in 83%, right lung involv in 63%,size varying from 7 to 65 mm with presence of cavitation in only 14%. It has been recently reported in chest journal presenting as multiple cavitating nodules mimicking infections . Prognosis is generaly considered poor with nagasaka et al reporting 6.2%survival at 5 yrs compared to appx 42% each for adeno and squamous varieties amongst review involving 1400 cases.

Case Submitted by – Dr Sudheer , Dr Krishnamohan and Dr MGK Murthy