PMC4049498_01
Chest X-ray. A. Pneumonitis or pulmonary tuberculosis in both upper lobes. A lung mass lesion in the right upper lobe was ruled out. B. Pneumoconiosis such as silicosis with progressive massive fibrosis (PMF). Slightly decreased densities around PMF were present since January 2012. A differential diagnosis for lung cancer, which is rarely considered, was performed. C. Pneumothorax, right. Underlying complicated pneumoconiosis, progressive massive fibrosis. HRCT. D. PMF, subpleural, and centrilobular silicotic nodules (arrows) are seen at both lung and pseudoplaque formation (arrow at pleural area) in the right lung.
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Chest images: In the plain chest x-ray, potential pneumonitis or pulmonary tuberculosis was found bilaterally in the upper lobes of the lungs (discernment of a lung tumor on the right upper lobe was required) (Figure 1-A). Chest images: Small opacities were observed throughout the whole lung in plain chest radiographic images, and a large opacity was observed in the right upper lung, interpreted to be pneumoconiosis (ILO classification u/u, 2/3, A) (Figure 1-B). Nodules characteristic of silicosis were observed in the centrilobular and subpleural parts of the lung in the chest high resolution CT (HRCT) (Figure 1-D). Images: In the chest X-ray images, pneumothorax on the right side and pneumoconiosis were observed (Figure 1-C). In the chest CT, pneumothorax on the right side, localized pulmonary edema in various sites, complicated pneumoconiosis accompanied by progressive massive fibrosis, and mediastinal reactive lymph nodes were observed.
Thyroid and neck sonography. Enlargement of multiple lymph nodes appears like metastases at both neck levels IV and VI and the supraclavicular level. CT with enhancement. Lymph node enlargement about 2 cm in size at the left supraclavicular area. Abbreviation (arrows): A, common carotid artery. V, jugular vein. LN, supraclavicular lymph node.
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There were no abnormal findings in the thyroid. The cervical level IV and VI lymph nodes and supraclavicular lymph nodes on both sides were enlarged, which raised a suspicion of cancer metastasis (Figure 2).
Bronchoscopy. Fibrosing stenosis at the apical, posterior, anterior segmental branch of the right upper lobe, lateral segmental branch of the right middle lobe, and apicoposterior segmental branch of the left upper lobe. Abbreviations. MC: main carina, LMB: left main bronchus, RMB: right main bronchus, LUL: left upper lobe, LLL: left lower lobe, RUL: right upper lobe, RML: right middle lobe, RLL: right lower lobe, RBI: right bronchus intermedius, Lat: lateral segmental branch, B1: apical, B2: posterior, B3 anterior, UDB: upper division bronchus (apicoposterior + anterior), LDB: lower division bronchus (lingular).
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