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Weekly Chest CasesArchive of Old Cases

Case No : 75 Date 1999-04-03

  • Courtesy of Ki-Nam Lee, MD / Dong-A University Hospital, Pusan, Korea
  • Age/Sex 59 / M
  • Chief ComplaintA 59-year-old man presented with chest pain for 2 months, who had been intermittently treated with anti-tuberculous therapy for 25 years.
  • Figure 1
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Chest PA

Diagnosis With Brief Discussion

Diagnosis
Diffuse B-cell malignant lymphoma associated with chronic pleural empyema
Radiologic Findings
Chest radiograph shows band-like soft tissue density with pleural calcification along the inner chest wall of the left hemithorax. A bulging soft tissue density is also noted in the left chest wall. Enhanced CT scan demonstrates irregular parietal pleural thickening and medial displacement of the calcified pleura due to enhancing nodular mass, lateral to the parietal pleura. Extrapleural fat is also thickened. The extrapleural mass extends into the chest wall through the intercostal space.
Brief Review
The association of malignancy with long-standing pleuritis or empyema, especially tuberculous empyema, is occasional. The range of neoplasms is wide and includes non-Hodgkin lymphoma, squamous cell carcinoma, mesothelioma, and rarely sarcoma (1). As for non-Hodgkin lymphoma (NHL), Iuchi et al (2) reported that it occurred in 2.2% of patients with chronic empyema. Almost malignant lymphomas were B-cell NHL. Detection of malignancy near the empyema cavity is difficult in most cases. Early detection of malignancy associated with chronic empyema by means of plain chest radiographs alone is still more difficult because the tumor shadows are hidden by broad radiopaque areas of empyema cavities in most cases. However, several findings, such as increase in extent of radiopaque areas in the thoracic cavity, soft tissue bulgings and/or unsharpness of the fat planes in the chest wall, destruction of bone near the empyema, and extensive medial displacement of the calcified pleurae, especially of the parietal pleura, suggest the diagnosis (3). New recurrence of an air-fluid level in the empyema cavity is also another important finding. When patients with longstanding empyema complain of symptoms or their chest radiographs reveal some changes in abnormal findings, CT is essential. CT can demonstrate an abnormal mass with soft tissue attenuation around the empyema and usually shows contrast enhancement in the mass. The most important differential diagnosis is exacerbation of empyema, especially formation of empyema necessitatis. To differentiate the malignancy from exacerbation of the empyema, it is important to examine the shape of a mass with soft tissue attenuation, irregularity of the thickeness of the wall, and existence of projections in the cavity. The pathogenesis of this entity has been the subject of many hypotheses but is still undetermined.
References
1. Minami M, Kawauchi N, Yoshikawa K, et al. Malignancy associated with chronic empyema: radiologic assessment. Radiology 1991;178:417-423
2. Iuchi K, Ichimiya A, Akachi A, et al. Non-Hodgkin lymphoma of the pleural cavity developing from long-standing pyothorax. Cancer 1987;60:1771-1775
3. Park KS, Lee Y, Chung SY, et al. T-cell non-Hodgkin lymphoma associated with chronic tuberculous empyema: case report. J Korean Radiol Soc 1993;29:738-741
Keywords
Pleura, Chest wall, Lymphproliferative disorder, Lymphoma,

No. of Applicants : 21

▶ Correct Answer : 10/21,  47.6%
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▶ Semi-Correct Answer : 8/21,  38.1%
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  • - Sir H N Hospital, Mumbai, India Dr. Bhavin Jankharia
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