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ROENTGENOGRAM OF THE MONTH
ROf)';'] GE).;OC,RAM OF TIlE MO:'\TH
BARRETr BoLTON, M.D.* M.O.* AND AND PAUL PAUL H. GUILFOIL, M.D., F F.C.C.P.** B m n H. BOLTON, GUILPOIL, M.D., .c.c.P.**
Dayton, Ohio
T T
HIS 48-YEAR-OLD WHITE MAN WAS mADHIS 48-YEAR-OLD WHITE MAN
mitted 8, 1964, com1964, cornmined on September 8, plaining of right lower quadrant abdominal
Staff Research, Veterans *-AJsociate h i a t e Chief of S u B for , Veterans
Clinical Assistant Administration Center and Cluuul Profeaor of Medicine. Medicine, Ohio State Univenity State Uniwnity Pmfemr College Medicine. College of Medicine. --Assistant Chief, Chief, Surgical mce, Service, Ve&Veterans AdAdministration Center Center and and C Clinical Assistant ministration hicd h n i r m t ProPro. fessor of rT Thoracic Surgery, Ohio Sate State Univerf ~ of hodc S -, Ohio UNVWsity College of Medicine. Medicine. ity C d e g e of
pain. Physical Physical examination examination and elaborate elaborate roentgen work-up, including chest films, roentgen films, were negative, and the patient was disnegative, discharged on September September 26, 1964. 1964. He was readmitted hospital on mdmined to to the hospital September 13, 1965, complaining of left 13, of left several days' duration. A chest chest pain of several duration. roentgenogram was mentgenogram was obtained obtained (Fig. 1). 1 ).
FIGURE
315
1
Diseases of tM Chest
SOLTON AND GUILFOIL METASTASES Diagnosis: LYMPHANGmC L Y M P H ~ GMETASTASES ~C TO LUNG LUNG FROM ADENOCARWOMA ADENOCARCINOMA OF THE THE PROSTATE PROSTATE OF
prominent linFigure 1 shows extensive prominat fonnear shadows radiating from the hila, formstreaks with a somewhat reticular ing heavy streaks pattern fading periphery. The upper pattcm fading at the periphery. lung fields fields show a more ~~like string-like appearance, while the basal infiltrate appears changes are diffuse diffuse and more nodular. The chanp appearance of a fibmnodular fibronodular progive the appearance
cess. CCLPI.
On October 15, 15, 1965, the patient underwent open biopsy of the right middle lobe, showed metastatic adenocarcinoma, adenocarcinoma, which showed gland. probably originating in the prostate gland. emboli w were blood v& vesTumor emboli m located in Mood sels lymphatics, with infiltration into sds and lymphatics, into alveoli, bronchial walls and supporting supporting ~truetures (Fig. 2). Needle biopsy of the structures adenocarcinoma. prostate gland revealed adenocarcinoma.
The radiographic appearance metasThe radiographic appearance of metasstreaked tatic pulmonary tumors as diffuse diffuse streaked or stringy radiating from the hilum stringy densities densities radiating and resembling diffuse fibrosis diffuse pulmonary fibmis has Iymphangitic carhas been rreferred e f d to as as Iymphangitic type of metastatic cinomatosis. This type metastatic spread cinomatosis. This found in about (19 of 314) was found about 6 per cent (19 of cases of pulmonary metastases Minor. J caws pulmonary maastaPor by Minor.' Only one of his cases Iymphangitic cases of lymphangitic ~read had a primary source source in the prostate. spmad results in raProstatic adenocarcinoma adenocarcinoma raulb diologically evident pulmonary metastases dialogically evident pulmonary metastass in 4.9 per cent to 10 10 per cent of the cases.' caws.' In a recent series of 17 patients with such series 17 patienn such metastases, only one roentgen apme*utases, one had the rocntgcn ap pearance of lymphangitic Iymphangitic spread. The othpearancc ers had discrete discrete nodular lesions. em I&ons.' 4 Besides k i d = being distributed in clumps throughout the lymphatics lymphatics of the entire lung, in t this fonn of spread, spread, tumor is also his form also found infiltrating bronchial m mucosa, found infiltrating u m , arterial artvial walls and the alveoli. alveoli. The involvement of the deep deep intrapulmonary lymphatic system, intrapuhwary lymphatic system, and the diffuse diiuse extension of tumor with minimal fonnation large nodules is conmiotnal formation of large eonsidered responsible for the characteristic s i d e d responsible roentgen appearance. roentgen REFERENCES Ra?s~Ncs.
I M~NOR, MrNOR, G. clinical radiologic .tudy 1 C. R.: "A d i n i d and &I&c smdy or metaatuic metastatic oulmonary neoplum:' neoplasm," I J. .T Tho,.". of h . Sur,., 34, 1950. Sure.. 20: 20:34. C., Ja.: or the 2 BUMPUS, Buvpus H. C. Jm.: "Carcinoma "Carcinoma of I& prostate; c~inicd'smdy clinical .tudy or Sur,. pmute; of 1,000 1,000 cues," sure. Cynte. and Cynrc. n d Obst., Oblt. 43: 150, 150 1926. 3 AALYEA, P. .AND HENDERSON, 3 L m . E E. . P ~ H . ~ ~ . oA.~ F.: A ."Car'carF . : cinoma or prostate; mnwdmc immediate resPOnle of the pmatc; rclponr to bilateral clinicali md and X-RI x-ray evib i b * orchiectomy; orchicetomy; d Mdence," 1099, 1942. dence lAMA, I A M A 120: 120:1099 1942. B., H:: H.: "Pulmonary metaatues rrom B O L ~ NB. vttlmomlmomuy meI4 BoLTON, carcinoma prostate; incidence incidence m and m i n o n u or of the pmute; d cue report remission," I J. .Urol., 73, repon or of aa long long mnkhn," Uml., 94: 94:73, 1965. MUELLER, H. SNIFFEN, "Roent5M m ~ u n H. , P. P. AND S ~ R R NR. . C.: C.: "Romtgenologic a p v and and pathology thdow or of intrainm~ n o k i cappearance lymphatic metaatatic canpulmonary 1 phtle spread s p d oorf metuutic oncer," Am. ]. Romig. tmd RtUlium TI&.rtlh, ar," jp)~ornl#. n d Radium TIrne)r, 53: 109, 109, 1945. BENJAlIIN FEL80N, B t%~~*w Pusoa, m M.D., Editor HAROLD H m o w SPITZ, SPITZ,M.D., Co-Editor Co-Ediior reprintl, p please Dr. Bolton. Bolton, VA HOIFor reprints, l u r write: Dr. Horpital, 4100 Weat Dayton, Ohio pitll, 4100 W a Third Street, Dayton, Ohio 45428.
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FIOUD
Readers a~ to b dnr u . iinYitcd & m yow to h BmjamiD p ur ccase ar m i&
2
submit articla for for the tM lRomtamo,ram of & tM Month. Month. P Pl"ase submit aa brief brid abstract rubdc .rtida r-am ol h s e submit abstraa of el f"lson. M M.D.•Dc:partment of IladiolOftT. Cincinnati GcfIual Hospital. Fdnn. . D . . D r p m t of Cinri-1s Getma1 H a p i d . Cincinnati. tirrinnati. Ohio. Ohio.
bdiolw.
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BARRETr BoLTON, M.D.* M.O.* AND AND PAUL PAUL H. GUILFOIL, M.D., F F.C.C.P.** B m n H. BOLTON, GUILPOIL, M.D., .c.c.P.**
Dayton, Ohio
T T
HIS 48-YEAR-OLD WHITE MAN WAS mADHIS 48-YEAR-OLD WHITE MAN
mitted 8, 1964, com1964, cornmined on September 8, plaining of right lower quadrant abdominal
Staff Research, Veterans *-AJsociate h i a t e Chief of S u B for , Veterans
Clinical Assistant Administration Center and Cluuul Profeaor of Medicine. Medicine, Ohio State Univenity State Uniwnity Pmfemr College Medicine. College of Medicine. --Assistant Chief, Chief, Surgical mce, Service, Ve&Veterans AdAdministration Center Center and and C Clinical Assistant ministration hicd h n i r m t ProPro. fessor of rT Thoracic Surgery, Ohio Sate State Univerf ~ of hodc S -, Ohio UNVWsity College of Medicine. Medicine. ity C d e g e of
pain. Physical Physical examination examination and elaborate elaborate roentgen work-up, including chest films, roentgen films, were negative, and the patient was disnegative, discharged on September September 26, 1964. 1964. He was readmitted hospital on mdmined to to the hospital September 13, 1965, complaining of left 13, of left several days' duration. A chest chest pain of several duration. roentgenogram was mentgenogram was obtained obtained (Fig. 1). 1 ).
FIGURE
315
1
Diseases of tM Chest
SOLTON AND GUILFOIL METASTASES Diagnosis: LYMPHANGmC L Y M P H ~ GMETASTASES ~C TO LUNG LUNG FROM ADENOCARWOMA ADENOCARCINOMA OF THE THE PROSTATE PROSTATE OF
prominent linFigure 1 shows extensive prominat fonnear shadows radiating from the hila, formstreaks with a somewhat reticular ing heavy streaks pattern fading periphery. The upper pattcm fading at the periphery. lung fields fields show a more ~~like string-like appearance, while the basal infiltrate appears changes are diffuse diffuse and more nodular. The chanp appearance of a fibmnodular fibronodular progive the appearance
cess. CCLPI.
On October 15, 15, 1965, the patient underwent open biopsy of the right middle lobe, showed metastatic adenocarcinoma, adenocarcinoma, which showed gland. probably originating in the prostate gland. emboli w were blood v& vesTumor emboli m located in Mood sels lymphatics, with infiltration into sds and lymphatics, into alveoli, bronchial walls and supporting supporting ~truetures (Fig. 2). Needle biopsy of the structures adenocarcinoma. prostate gland revealed adenocarcinoma.
The radiographic appearance metasThe radiographic appearance of metasstreaked tatic pulmonary tumors as diffuse diffuse streaked or stringy radiating from the hilum stringy densities densities radiating and resembling diffuse fibrosis diffuse pulmonary fibmis has Iymphangitic carhas been rreferred e f d to as as Iymphangitic type of metastatic cinomatosis. This type metastatic spread cinomatosis. This found in about (19 of 314) was found about 6 per cent (19 of cases of pulmonary metastases Minor. J caws pulmonary maastaPor by Minor.' Only one of his cases Iymphangitic cases of lymphangitic ~read had a primary source source in the prostate. spmad results in raProstatic adenocarcinoma adenocarcinoma raulb diologically evident pulmonary metastases dialogically evident pulmonary metastass in 4.9 per cent to 10 10 per cent of the cases.' caws.' In a recent series of 17 patients with such series 17 patienn such metastases, only one roentgen apme*utases, one had the rocntgcn ap pearance of lymphangitic Iymphangitic spread. The othpearancc ers had discrete discrete nodular lesions. em I&ons.' 4 Besides k i d = being distributed in clumps throughout the lymphatics lymphatics of the entire lung, in t this fonn of spread, spread, tumor is also his form also found infiltrating bronchial m mucosa, found infiltrating u m , arterial artvial walls and the alveoli. alveoli. The involvement of the deep deep intrapulmonary lymphatic system, intrapuhwary lymphatic system, and the diffuse diiuse extension of tumor with minimal fonnation large nodules is conmiotnal formation of large eonsidered responsible for the characteristic s i d e d responsible roentgen appearance. roentgen REFERENCES Ra?s~Ncs.
I M~NOR, MrNOR, G. clinical radiologic .tudy 1 C. R.: "A d i n i d and &I&c smdy or metaatuic metastatic oulmonary neoplum:' neoplasm," I J. .T Tho,.". of h . Sur,., 34, 1950. Sure.. 20: 20:34. C., Ja.: or the 2 BUMPUS, Buvpus H. C. Jm.: "Carcinoma "Carcinoma of I& prostate; c~inicd'smdy clinical .tudy or Sur,. pmute; of 1,000 1,000 cues," sure. Cynte. and Cynrc. n d Obst., Oblt. 43: 150, 150 1926. 3 AALYEA, P. .AND HENDERSON, 3 L m . E E. . P ~ H . ~ ~ . oA.~ F.: A ."Car'carF . : cinoma or prostate; mnwdmc immediate resPOnle of the pmatc; rclponr to bilateral clinicali md and X-RI x-ray evib i b * orchiectomy; orchicetomy; d Mdence," 1099, 1942. dence lAMA, I A M A 120: 120:1099 1942. B., H:: H.: "Pulmonary metaatues rrom B O L ~ NB. vttlmomlmomuy meI4 BoLTON, carcinoma prostate; incidence incidence m and m i n o n u or of the pmute; d cue report remission," I J. .Urol., 73, repon or of aa long long mnkhn," Uml., 94: 94:73, 1965. MUELLER, H. SNIFFEN, "Roent5M m ~ u n H. , P. P. AND S ~ R R NR. . C.: C.: "Romtgenologic a p v and and pathology thdow or of intrainm~ n o k i cappearance lymphatic metaatatic canpulmonary 1 phtle spread s p d oorf metuutic oncer," Am. ]. Romig. tmd RtUlium TI&.rtlh, ar," jp)~ornl#. n d Radium TIrne)r, 53: 109, 109, 1945. BENJAlIIN FEL80N, B t%~~*w Pusoa, m M.D., Editor HAROLD H m o w SPITZ, SPITZ,M.D., Co-Editor Co-Ediior reprintl, p please Dr. Bolton. Bolton, VA HOIFor reprints, l u r write: Dr. Horpital, 4100 Weat Dayton, Ohio pitll, 4100 W a Third Street, Dayton, Ohio 45428.
-."
.-.
FIOUD
Readers a~ to b dnr u . iinYitcd & m yow to h BmjamiD p ur ccase ar m i&
2
submit articla for for the tM lRomtamo,ram of & tM Month. Month. P Pl"ase submit aa brief brid abstract rubdc .rtida r-am ol h s e submit abstraa of el f"lson. M M.D.•Dc:partment of IladiolOftT. Cincinnati GcfIual Hospital. Fdnn. . D . . D r p m t of Cinri-1s Getma1 H a p i d . Cincinnati. tirrinnati. Ohio. Ohio.
bdiolw.
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