Drs. Escobar, Pikus, and Blackwell’s CMC X-Ray Mastery Project: January Cases

Adult Chest X-Rays Of The Month
Daniel Escobar, MD1, Angela Pikus, MD1,
Alex Blackwell, MD1, Lauren Ramsey, PA-C2
1Department of Emergency Medicine
2Sanger Heart & Vascular Institute
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD - Faculty Editor
CMC Imaging Mastery Project
January 2022

Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Imaging Presentations And Much More!

Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

A 54-Year-Old
Female With A
History Of
Hypertension And
Asthma Presents
To The ED With
Two Weeks Of
Dyspnea,
Intermittent
Palpitations And
Leg Swelling.
T:99.8, HR:87, RR:17,
BP:117/81, SpO2 99%

Left Atrial Mass
Maximal Diameter 62.6 x 43.3 mm
A Chest CT Is Obtained

The Patient Is Admitted And An Echocardiogram Is Obtained
LVOT
LV
LA
MV
Ao
LVOT = Left Ventricular Outflow Tract, LV = Left Ventricle, LA = Left Atrium, MV = Mitral Valve, Ao = Aorta
Atrial Mass
Key Findings:
• Left Atrial Enlargement
• A Large Left Atrial Mass

The Patient Undergoes Surgical Excision Of A Large Left Atrial Myxoma
Surgical Resection: 7.0 x 4.6 cm
Stalk
Surgical Images Curtesy Of Lauren Ramsey PA-C

Let’s Go Back And Look At Our
Patient’s Initial ED Diagnostic Studies

Our Patient Normal CXR
Notice The Differences In Contour Of The Left Heart Boarder

Fullness And
Straightening Of
The Left Heart
Boarder.
Rightward
Tracheal
Deviation
Chest X-Ray Findings Suggestive Of Left Atrial Enlargement

You May See Similar CXR Findings In Patient With
Left Atrial Enlargement Due To Mitral Stenosis

Our Patient’s ECG Also Demonstrates Left Atrial Enlargement

Cardiac Myxoma
• Myxomas are the most common primary cardiac tumors in adults
• Rhabdomyomas are the most common pediatric cardiac tumor
• 80% originate in the left atrium
• Cytologically non-malignant
• Higher incidence in females
• Symptoms related to anatomic tumor location, size, and mobility

Cardiac Myxoma
Left Atrial Tumors
• Outflow obstruction
• Left heart failure
• Mitral valve dysfunction
• Systemic emboli
• Pulmonary hypertension
Right Atrial Tumors
• Outflow obstruction
• Right heart failure
• Tricuspid valve dysfunction
• Pulmonary emboli

Recent Case Reports Describe A Wide Range Of Clinical Presentations
JACC 2013; 61:81.
JAMA IM 2021; 181:1650.
JACC 2019; 73:2354.
JACC 2019; 73:2840.
JACC 2019; 73:2282.
JAMA Card 2021; 6:271.

A 47-Year-Old Woman Presented With 6 Months Of Worsening Exertional Dyspnea, Fatigue And Orthopnea. Exam
Was Notable For Tachycardia, An Abnormal Heart Sound And Bilateral Leg Edema. Chest X-Ray Revealed Pulmonary
Venous Congestion. A TEE Revealed A Left Atrial Mass Attached To the Septum That Partially Prolapsed Into The Left
Ventricle. A 5.7 x 4.3 x 5.0 cm Left Atrial Myxoma Was Excised And The Patient Recovered Uneventfully.
A Very Similar Presentation To Our Patient!

77-Year-Old Male
Presenting To The
Emergency
Department With
Chest Pain That
Began This
Morning.
T:99.8, HR:87, RR:17,
BP:117/81, SpO2 99%

77-Year-Old Male Presenting With Chest Pain.
Current CXR CXR 1-Year Ago

Cardiac Mass
“Irregular Lobulated Mass Invading The
Left Atrium And Pericardial Space.”
*
*
A Chest CT Is Obtained

77-Year-Old Male Presenting With Chest Pain.
Cardiac MRI
“There is a large invasive intracardiac and
pericardial mass within the right atrium
measuring 7.3 x 6.4 x 8.2 cm along the right
atrial anterior/lateral wall with direct
extension into the anterior pericardial space
with prolapsing into the RV and IVC.”
Given the extent of the mass, the patient
underwent a cervical lymph node biopsy
that revealed a high-grade lymphoma.
Because of the extent of disease, the
patient was transitioned to Hospice Care.

Cardiac Lymphoma
• Very rare malignancy of the non-Hodgkin type
• Primary cardiac lymphoma account for about 1% of the primary
cardiac tumors and 0.5% of the extra-nodal lymphomas
• Patient can be asymptomatic, but could also have symptoms of mass
effect

Please See Additional Slides Related
To This Topic in APPENDIX 1 At The
End Of This Slide Presentation.

Cardiac Tumors
In general, cardiac tumors may present in 1 of 3 ways:
Systemic Constitutional (fever, arthralgias, weight loss, fatigue) and paraneoplastic
syndrome (primary cardiac tumors)
Cardiac Mass effect interfering with myocardial function or blood flow, resultant
arrhythmias, interference with heart valves causing regurgitation, or pericardial
effusion with or without tamponade, or syncope
Embolic Pulmonary or systemic thromboembolic phenomena from the tumor

51-Year-Old Male
Presents To The ED with
Confusion Following Two
Seizures.
T-98.4, BP- 136/80, HR- 150,
SpO2- 80% On RA & 90% On
Nasal Cannula Oxygen.
Physical Exam: Ill-
Appearing And Confused
With A GCS 12, Coarse
Rhonchi On The Left.

Airway: Midline trachea. The lungs show
multifocal opacities consistent with
pulmonary nodules (blue arrows)
Bones: Normal
Cardiac: Normal heart size with borders
obscured by scattered pulmonary nodules
Diaphragm: Normal
Effusion: None
Foreign Body: Tunneled right internal
jugular catheter that terminates within the
right atrium (red arrow). Telemetry wires
scattered throughout (yellow arrow)
Gastric: Appropriate gastric bubble
.
Hilum: Increased vascularity and
nodularity/perihilar pulmonary nodules
present

This Multinodular
Appearance has A Very
Broad Differential!
Fortunately, We Already Have A Clue!
However, This Is NOT
An Exhaustive List!
He Has A Port-a-Cath
(Infusion Catheter)

Top Left Image: Scattered pulmonary nodules that appear
hyperdense. Notice they have poorly defined borders and
some with a spiculated appearance most with irregular
borders. Notice lesions involve the superior lobes and multiple
lesions found throughout the entire lung fields bilaterally.
Bottom Right Image: reveals a lucency within the left parietal
bone consistent with a metastatic lesion.
DIAGNOSIS:
Small Cell Lung
Cancer

*Focus in the Emergency Department is evaluation and identification, presumptive diagnosis,
initial treatment/intervention of paraneoplastic syndromes and of other urgent pathologies,
and consultation as necessary with Medicine, Surgical, and particularly Hematology/Oncology.

Chest. 2013 May; 143(5 Suppl): e93S–e120S.
doi: 10.1378/chest.12-2351

doi: 10.1378/chest.12-2351
*Solid Nodules measuring > 8 mm in diameter
require further investigation
Decision Making Based on Solid Nodule Size

doi: 10.1378/chest.12-2351
Characteristic Tendencies of Benign vs Malignant Nodules
Am Fam Physician. 2015 Dec 15;92(12):1084-1091A.
*Subsolid nodules (Includes Non-Solid (pure ground glass) or Part Solid
(containing solid component but >50% ground glass) have shown to have a
higher risk for malignancy than purely Solid nodules. These require further
investigation.

StatPearls
publishing,
January 2022
Small Cell Lung Cancer (SCLC) is the 2nd most common lung cancer
It is the LEADING cause of cancer death in BOTH men and women accounting for ~25% of all cancer deaths!
Smoking has a strong association with SCLC
Presents with metastasis in ~60%+ on diagnosis and is associated with a poor prognosis which is why focus is on
screening and prevention
Most common site of distant metastasis occur in the bone, brain, liver, and adrenal glands
Associated with paraneoplastic syndromes such as SIADH, Cushing syndrome (ectopic ACTH), Lambert-Eaton
Syndrome
Has the potential to cause Superior Vena Cava Syndrome from local lung tumor growth
Lung Cancer Screening (USPSTF Grade B Recommendation)
Ages 50-80 with 20 pack-year smoking history who currently smoke or quit in the past 15
Annual Low Dose Chest CT
No screening necessary if no smoking in past 15 years or has a limited life expectancy due to health problems or if
unwilling to have curative lung surgery

39-Year-Old-Female
With A History Of
Cervical Squamous Cell
Carcinoma Presents To
the ED In Respiratory
Distress.
T-99.1, BP- 148/90, HR- 108,
SpO2- 86% NRB
Physical exam In
Tripod Position
Gasping For Air With
Bilateral Course Breath
Sounds. Switched To
High-Flow Cannula.

Make sure not to miss anything by going
through your ABCs.
Airway (red arrows): The trachea is slightly
deviated to the right - it is related to slight
rotation and a possibly mass effect. There are
bilateral upper lobe paratracheal opacities, and
scattered pulmonary nodules
Bones: Normal
Cardiac: Borderline enlarged without clearly
defined cardiac borders that appear to be
obscured by scattered pulmonary
opacities/nodules
Diaphragm: (purple arrow) Right elevation.
Effusion: (blue arrows) Bilateral effusions.
Foreign Body: (green arrows) High flow nasal
cannula tubing. Horizontal telemetry wire.
Gastric: Appropriate gastric bubble present
Hilum: (yellow arrow) Increased vascularity
and nodularity

Arrows pointing to large superior lobe masses and pulmonary
nodules.
Also noted a right upper lobe mass compressing the right
pulmonary artery visualized by a paucity of contrast dye!
The patient was transitioned to Hospice care.
A Chest CT
Demonstrates
Metastatic Cervical
Squamous Cell
Carcinoma.

ACE AME Case
Reports, 2: 23,
May 2018
Cervical Cancer is the 3rd most common cancer diagnosed in women
At least 70% of cervical cancers are squamous cell in origin
Within 2 years, metastasis and/or recurrence is typical and is associated with a poor prognosis
Most common site of distant metastasis occur in the lungs and paraaortic lymph nodes
Human Papilloma Virus(HPV) is the leading cause of cervical cancer and up to 8 in 10 in the USA come
into contact with this virus in their lifetime
The HPV vaccine is one of Medicine’s modern marvels. It can protect against infection that leads to
~90% of cervical cancers
Cervical Cancer Screening is also important (USPSTF Recommendations)
Begins at Ages 21-29: Cytology q3 years
Ages 30-65: Cytology + HPV testing q5 years
No screening necessary before age 21 and >65 if adequate negative prior screening

33-Year-Old Male
Presenting To The
ED With Chest pain
And Shortness Of
Breath Since A
Physical
Altercation 2 days
Ago
Vital signs:
T: 99.2, HR: 68, RR: 20,
BP: 178/98, SpO2: 100%

After Zooming In
On The Right Side
Of The Chest X-Ray
You See That Lung
Markings Do Not
Extend Out To The
Edge Of The
Thoracic Cavity.

33-Year-Old Male
With A Right Sided
Pneumothorax.

On The Initial
Chest X-Ray, You
Can Also See
Subcutaneous
Emphysema As
Indicated By The
Arrow Above The
Right Clavicle.
Clinically This May
Manifest As
Palpable Crepitus
Over The Involved
Areas.

Subcutaneous Emphysema
• Occurs when air is trapped
under the skin
• Physical exam may reveal
crepitus, often described as
“Rice Krispies”
• Treatment focuses on the
primary cause

33-Year-Old Male
With A Right-Sided
Pneumothorax.
Pigtail
Catheter
Drainage

33-Year-Old Male
With A Right-Sided
Pneumothorax.
CXR 2 Days Later:
Lung Re-Expanded
And SQ Emphysema
Resolved.

www.EMguidewire.com April 2020

Primary Spontaneous Pneumothorax
Although technically occurring in the absence of clinical lung disease, much more
common in smokers (including marijuana smokers). Also more common in tall men.
Secondary Spontaneous Pneumothorax
Most frequently due to COPD (57%); other causes include asthma, PJP pneumonia,
cystic fibrosis, malignancy, or TB.

Primary Spontaneous Pneumothorax:
Stable, small PNTX Observe 4-6 hours, repeat CXR, consider discharge with close F/U
Stable, large PNTX Needle or catheter aspiration or pigtail or chest tube insertion
Unstable patient Immediate pigtail/chest tube, if delayed needle or finger thoracostomy
Secondary Spontaneous Pneumothorax:
Stable, small PNTX Admit for observation with treatment(s) based on progression
Stable, large PNTX Pigtail or chest tube insertion
Unstable patient Immediate pigtail/chest tube, if delayed needle or finger thoracostomy
Steven A. Sahn, MD, FCCP; for theACCP Pneumothorax Consensus Group†
ovide explicit expert-bas
ed cons
ens
usrecommendationsfor the management of adultswith
econdarys
pontaneouspneumothoracesinanemergencydepartment andinpatient hos
pital
s
e of opinion wasmade explicit by employing a s
tructured ques
tionnaire, appropriatenes
s
ons
ens
us s
cores with a Delphi technique. The guideline was des
igned to be relevant to
o make management decis
ionsfor the care of patientswith pneumothorax.
isions for observation, chest tube placement, surgical interventions, and radiographic
fectivenessof pneumothorax resolution, duration of and patient tolerance of care, and
x recurrence.
erature review from 1967 to January 1999 and Delphi questionnaire submitted in three
a multidisciplinary physician panel.
guideline development group determined by consensus the relevant outcomes to be
developing the Delphi questionnaire.
ms, and costs:The type and magnitude of benefits, harms, and costsexpected for patients
e implementation.
ions: Management decisions vary between patients with primary or secondary pneu-
with observation of small pneumothoracesbeing appropriate only for primary pneumo-
level of consensusvariesregarding the specific interventionsindicated, but agreement
general principles of care.
ecommendations were peer reviewed by physician experts and were reviewed by the
lege of Chest Physicians (ACCP) Health and Science Policy Committee.
on: The guideline recommendations will be published in printed and electronic form
ion of synopsesfor patientsand health care providers. Contentsof the guideline will be
into continuing medical education programs.
e ACCP. (CHEST 2001; 119:590–602)

• Multicenter, randomized, non-inferiority trial evaluating the management of
moderate-to-large primary spontaneous pneumothorax
• 316 patients were randomized to either interventional treatment (n=154) or
conservative treatment (n=162)
• Primary outcome: complete radiographic resolution within 8 weeks

Interventional Treatment:
• Small-bore pigtail catheter (≤12 F) inserted & placed to water seal
• Repeat CXR at 1 hr. If resolved, catheter clamped & patient observed x 4 hrs
• If patient stable and repeat CXR without recurrence, the catheter was removed
and the was patient discharged
• If not resolved on initial CXR or if recurrence of PNTX, patient admitted for
further care
• Conservative Treatment:
• Observed for 4 hours; discharged if stable & not requiring O2 + tolerating ambulation

Main Results:
• Conservative treatment was not inferior to interventional treatment
and had a lower risk of adverse event
• Of interest, the conservative group also had a lower risk of recurrence
of pneumothorax

Annals Emergency Medicine 2020: 0(0), 1-15.
https://doi.org/10.1016/j.annemergmed.2020.01.009.

Comparing Management Strategies
• Systematic review of meta-analysis of 12 RCTs (n=781) comparing:
• Needle aspiration
• Small-bore (≤14 F) chest thoracostomy
• Large-bore (≥14 F) chest thoracostomy
• 1° Outcome: “immediate success” of the intervention
• 2° Outcome: length of stay, complications

A Resolution of symptoms and radiographic resolution, sustained for
6-24 h in the needle aspiration group
B Radiographic resolution, no air leak, and chest tube removal in < 7
days in either size chest tube groups
C Ability to discharge patient from the ED in the needle aspiration
and small-bore chest tube group
Immediate Success:

• No difference in immediate success between large-bore chest tube,
small-bore chest tube, or needle aspiration
• Needle aspiration had similar rate of complications as small-bore
chest tube; significantly lower odds of complications seen with needle
aspiration than large-bore chest tube
• Small-bore chest tube most likely to be effective; needle
decompression safest
• No benefit of large-bore chest tube over small-bore chest tubes in the
management of symptomatic spontaneous PNTX

Chest Tube Placement
• Make an incision between the
4th and 5th intercostal space at
the mid-axillary line and dissect
to reach the intrathoracic space.
• Guide the tube through the rib
space in the cephalad direction
to reach the apex of the lung.
• Attach the tube to suction to
enable lung re-expansion.

Carolinas Medical Center
Spontaneous Pneumothorax Case Studies

18-Year-Old With
Acute Pleuritic
Chest Pain.

Spontaneous Pneumothorax
18-Year-Old With
Acute Pleuritic
Chest Pain.

Young Healthy
Patient Presents
With Pleuritic
Chest Pain.

Left Spontaneous Pneumothorax
Young Healthy
Patient Presents
With Pleuritic
Chest Pain.

After Drainage
Young Healthy
Patient Presents
With Pleuritic
Chest Pain.

Healthy Young
Female With
Sudden Onset
Right-Sided
Pleuritic Chest
Pain.

Spontaneous Pneumothorax
Healthy Young
Female With
Sudden Onset
Right-Sided
Pleuritic Chest
Pain.

20-Year-Old Male
Presents With
Sharp Chest Pain
And Shortness Of
Breath.

After Drainage
Healthy Male
Presents With
Sharp Chest Pain
And Shortness Of
Breath.

Healthy Male
Presents With
Sharp Chest Pain.

Healthy Male
Presents With
Sharp Chest Pain.
Right Spontaneous Pneumothorax

Healthy Male
Presents With
Sharp Chest Pain.
After Drainage

Young, Healthy
Male Experiences
Acute Left-Sided
Chest Pain While
Running.

Summary Of Diagnoses This Month
 Atrial Myxoma
 Cardiac Lymphoma
 Small Cell Lung Cancer
 Metastatic Cervical Squamous Carcinoma
 Spontaneous pneumothorax

Drs. Escobar, Pikus, and Blackwell’s CMC X-Ray Mastery Project: January Cases

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Editor's Notes