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Weekly Chest CasesImaging Conference Cases

Case No : 1

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  • Age/Sex 20 / M
  • Case Title A 20-year-old man presented with weight gain and dyspnea. He had been admitted several times to evaluate and treat an underlying disease. Can you guess the underlying disease and two current problems of the patient from the three-year interval chest radiographs and CT scans? Describe the current problems of the patient. Fig 1. Chest PA (96. 6) Fig 2. Chest PA (99. 7) Fig 3-5. Chest CT (99. 7)
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Diagnosis With Brief Discussion

Courtesy
S
Chief Complaint
A 20-year-old man presented with weight gain and dyspnea.
He had been admitted several times to evaluate and treat an underlying disease. Can you guess the underlying disease and two current problems of the patient from the three-year interval chest radiographs and CT scans? Describe the current problems of the patient.
Fig 1. Chest PA (96. 6)
Fig 2. Chest PA (99. 7)
Fig 3-5. Chest CT (99. 7)
Imaging Findings
Three years ago, there was no discernible abnormality on chest radiograph (Fig. 1).
At that time, osteosarcoma of the left fibula was found.

He had been treated with chemotherapeutic agents including adriamycin. Total accumulative dose of adriamycin was 566 mg per square meter of body surface area.

He had suffered from dyspnea since 1997. Echocardiography demonstrated decreased left ventricular ejection fraction (31%), dilated left ventricle and both atria.

Chest radiograph shows cardiomegaly and multiple nodules suggesting metastases (Fig. 1).

Chest CT scans also show global enlargement of cardiac chambers and multiple ossified metastatic nodules in both lungs (Figs. 3-5).
Discussion
Adriamycin (doxorubicin) cardiotoxicity causes characteristic histologic changes on endomyocardial biopsy, with vacuolar degeneration and myofibrillar loss.
Potential mechanisms of cardiotoxicity include free radical formation, release of histamines and catecholamines, and effects on mitochondrial function and nucleic acid synthesis.
Between 5 and 10% of patients receiving at least 500 mg per square meter of body surface area develop overt heart failure, but more than half of patients receiving multiple courses have 10% decline in resting ejection fraction.
Patients with higher doses and lower baseline ejection fraction have higher risk for clinical heart failure.
The dysfunction may continue to progress, with 63% of pediatric patients who have received at least 500 mg per square meter having some cardiac dysfunction detected after 10 years.
Clinical status may improve with supportive hemodynamic therapy, but chronic cardiac function rarely improves.
Use of slower, less frequent infusion appears to decrease toxicity, but may not be as effective against some tumors.
Cardiomegaly is the hallmark of dilated myocardiopathy.
Although all cardiac chambers may be affected, the left ventricle usually is the most dilated with decreased ventricular ejection fraction.
Reference
1. Stevenson LW. Diseases of the myocardium. In Bennett JC, Plum F. Cecil textbook of medicine. 20th ed. Philadelphia: W.B. Saunders company, 1996:327-336.
Keywords
Multiple organ, Lung, Malignant tumor, metastasis,
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