Clinical:

History – This 64 year old female had a nephrectomy for renal cell carcinoma 1 year ago.  She was lost to follow-up.  She was seeing her primary physician for mild chest pain, shortness of breath, and fatigue.

Symptoms – Mild, dull, chest pain.  Weight loss (7 kg in 3 months). Fatigue.

Physical – Nephrectomy scar was seen.  Nil else.

DDx:

Infection, Pneumonia

Malignancy

Imaging Recommendation

Chest X-ray

Imaging Assessment

Findings:

There were multiple nodules in both lungs of varying sizes.  They were round and well marginated.  No evidence of central necrosis. No evidence of lymphadenopathy. No other findings.

Interpretation:

Embolic infection

Embolic malignancy

Diagnosis:

Metastatic Disease – Renal Cell Carcinoma

Discussion:

Multiple nodules in the lung are most often metastatic lesions that have traveled through the bloodstream from a distant primary (hematogenous spread).  Hematogenous spread of infection may also be possible. Multiple metastatic nodules are usually of differing sizes, varying from micronodular to “cannonball” masses, indicating tumour embolization that occurred at different times. They are frequently sharply marginated.

Possible Primary Tumours that may result in Lung Metastases, by Gender

Attributions

Figure 9.25 Chest x-ray displaying multiple lung nodules by Dr. Brent Burbridge MD, FRCPC, University Medical Imaging Consultants, College of Medicine, University of Saskatchewan is used under a CC-BY-NC-SA 4.0 license.