Not only are small or medium-sized pleural effusions often misidentified as lung opacities, [4] thoracic cage lesions such as rib fractures or osteochondroma may also mimic lung lesions. The WHO manual of diagnostic imaging (2006) Radiographic anatomy and interpretation of the chest and the pulmonary system.

ABSTRACT:- Disseminated malignancies have unusual pattern of spread from site of origin to other sites, similarly malignancy from other sites in body may present as multiple diffuse fluffy opacity or mass lesion on chest roentgenogram canon ball opacity. On chest radiographs, pulmonary metastases typically appear bilaterally as peripheral rounded nodules of variable sizes [3]. We herein report three cases with cannonball metastases at initial presentation. Chest xray 1. By continuing you agree to the use of cookies. Lippincott Williams & Wilkins.

In order to avoid pitfalls on plain films, pattern-recognition is key in differentiating pulmonary from non-pulmonary opacities. Awareness of such presentation and linking it to past medical history, which proved to have a significant weight in diagnosis, is essential in order to guide treatment and avoid unwarranted further investigations. We use cookies to help provide and enhance our service and tailor content and ads. Seaton A (2000) Other pulmonary neoplasm and related conditions. ISBN: 0397515324. Radiological investigations revealed numerous bilateral pulmonary nodules of variable size (cannonball appearance) (figure 1), …

Cannonball metastases. Initial Coronal CT image demonstrating multiple sclerotic ribs with periosteal bone formation, Figure 3. The most likely diagnosis was Cushing’s syndrome-associated spontaneous rib fractures. Several terms are used interchangeably for spontaneous rib fractures including pathological, fragility, compression and insufficiency fractures. Figure 1. Spontaneous fractures may occur in the ribs or pelvis and less commonly in long bones. MRI T1 coronal image of pituitary fossa demonstrating normal appearances of the pituitary gland, Figure 5. Lippincott Williams & Wilkins. Occasionally it can be seen in endometrial cancer, prostate cancer and transitional cell carcinoma of the bladder – this patient had a history of bladder TCC. DOI: 10.15761/MCRR.1000132, Consultant Interventional Radiologist, Radiology Clinical Tutor and Specialty lead, The Pennine Acute Hospitals Trust, Northern Care Alliance Manchester, UK, E-mail : [email protected]. Multiple pulmonary nodules on the chest X-ray have multiple causes, including, metastases (cannon-ball secondaries), various infections, immunological diseases, and arteriovenous malformations. Crofton and Douglas's Respiratory Diseases. Sagittal CT image of chest and abdomen demonstrating the normal vertebral height and alignment of vertebral spine with no evidence of osteoporotic fractures. Vrbanić TS, Novak S, Sestan B, Tudor A, Gulan G (2008) A case of pathological rib fractures: focal osteolysis or osteoporosis. Examination revealed room air oxygen saturation of 91% with diffuse chest crackles, gynaecomastia and hepatosplenomegaly. In addition, they may arise from fungal, parasitic infections, hydatid disease, rheumatoid nodules, wegener's granulomatosis and pulmonary tuberculosis [1,2]. Cannonball metastases refer to large, well circumscribed, round pulmonary metastases that appear, well, like cannonballs. The French term "envolée de ballons" which translates to "balloons release" is also used to describe this same appearance.Metastases with such an appearance are classically secondary to: renal cell carcinoma; choriocarcinoma; Or less common primary tumours: Contemporaneously acquired conventional radiolographs showed parenchymal nodules that demonstrated the classic “cannon ball” appearance of pulmonary metastases. Pulmonary metastasis from an endometrial primary is a rare event, as are the presence of … © 2019 Copyright OAT. Multiple pulmonary nodules of cannonball appearance are associated with colorectal cancer and sarcoma. Not only does it act as a comparative study following treatment, bone scan may also reveal multifocal uptake in the ribs and reflect the extent of bony involvement; an appearance that may potentially resolve following treatment. Copyright © 2016 Turkish Society of Medical Oncology. Naidich DP, Srichai MB, Krinsky GA (2007) Computed tomography and magnetic resonance of the thorax. Seo JB, Im JG, Goo JM, Chung MJ, Kim MY (2001) Atypical pulmonary metastases: spectrum of radiologic findings. Initial axial CT image demonstrating multiple sclerotic ribs with periosteal bone formation, Figure 4. Figure 2. Skeletal metastases commonly manifests with osteolytic rib lesions on plain chest radiographs and hot spots on bone scan [13]. 2006 Mar. Past medical history included cushing’s syndrome. No destructive bony lesion or fractures were found elsewhere within the visualised skeleton (Figure 4) and pituitary gland appeared normal (Figure 5). Wang K, Allen L, Fung E, Chan CC, Chan JC, et al. Lee HJ, Je JH, Seo JH, Na YJ, Yoo HJ (2014) Mutiple Spontaneous Rib Fractures in Patient with Cushing's Syndrome. Spontaneous rib fractures are likely to be misinterpreted as metastatic lung lesions, particularly in young patients with Cushing’s syndrome. A subsequent contrast enhanced computer tomogram (Figure 2, 3, 6) of the thorax, abdomen and pelvis revealed multiple sclerotic ribs with periosteal bone formation. This is an uncommon finding, and is typically seen in patients with a history of renal cell carcinoma and choriocarcinoma. cannon ball lung opacities; multiple pulmonary lesions; spontaneous rib fractures. Cannonball metastases refer to well-defined spherical nodules scattered over both lungs, being a classical presentation of hematogenous tumor spreading. This is an uncommon finding, and is typically seen in patients with a history of renal cell carcinoma and choriocarcinoma. 3D reconstruction demonstrating multiple bilateral posterior rib fractures, Figure 6. Prof. Hamid Yahya Husain Article. Cannonball-like lung opacities are often the classic presentation of haematogenous dissemination of malignancy to the lungs; therefore, indicating advanced stage of the disease with a very grim prospective cure or survival [10].
Accepted date: June 05, 2019 Chest X-ray showed well-defined opacities overlying the ribs in the right middle and left upper zones and right fifth posterior rib fracture. [8] MRI, albeit not routinely used, may potentially be as sensitive as CT in spotting pulmonary metastases [9].

This 83 year old woman presented with shortness of breath. Approximately one-third of patient would develop vertebral fractures especially at the thoracic and lumbar levels [11]. Kitazono MT, Lau CT, Parada AN, Renjen P, Miller WT Jr. (2010) Differentiation of pleural effusions from parenchymal opacities: accuracy of bedside chest radiography. Contemporaneously acquired conventional radiolographs showed parenchymal nodules that demonstrated the classic “cannon ball ” appearance of pulmonary metastases. Geneva: World Health Organization. In order to avoid pitfalls on plain films, pattern-recognition is key in differentiating pulmonary from non-pulmonary opacities. In this case, the primarily diagnosed cushing’s syndrome may have possibly led to secondary osteoporosis, which may have given the described findings. Bisphosphonates-associated adverse outcomes are a rare cause [12]. The treatment for acutely symptomatic spontaneous rib fractures is analgesia, orally administered bisphosphonate, with supplemental calcium and vitamin D. This regimen is well-tolerated with unremarkable gastrointestinal side effects [14].

All rights reserved. Wolfgang Dahnert (2011) Radiology Review Manual, [7th Edn] ISBN-10: 1609139437. The patient was managed conservatively then discharged. Cannonball metastases. We aim to bring about a change in modern scholarly communications through the effective use of editorial and publishing polices. Lippincott Williams & Wilkins. Patients with Cushing’s syndrome often require definitive intervention for hypercortisolism by either adrenalectomy or pituitary adenomectomy, with subsequent disappearance of the multiple hot spots found on bone scan [11]. Pulmonary metastasis is seen in 20-54% of the extrathoracic malignancies. Pulmonary metastasis from an endometrial primary is a rare event, as are the presence of … Furthermore, multiple spontaneously-distributed foci of increased radionuclide uptake in ribs, mimicking osseous metastases, have been reported in post-traumatic conditions, extreme altitudes, tuberculosis, brucellosis, coccidiomycosis and Cushing's syndromes [14]. Lass RB, Norton KI, Mitre SA, Kang E (2002) Pediatric ribs: a spectrum of abnormalities. 129 (3):738-45. . Figure 2 – A and B, Multiple brown-reddish angiomatous lesions on the trunk (A) and face (B). OA Text’s journals are led by prominent researchers, each embracing the concept that basic knowledge can foster sustainable solutions for society. Collins J, Stern EJ (2007) Chest radiology, the essentials. [5] Additionally, a vascular thoracic lesion may well be confused for a pulmonary neoplasm [6].

©2019 Alfahad A. This 83 year old woman presented with shortness of breath. Chest X ray shows large , well circumscribed, round pulmonary nodules that are distributed in upper mid and lower lung zones bilaterally, some forming into a mass but most of them are seen concentrated in the lower zones and mostly along the peripheral lung fields.
The goal of this presentation is to raise awareness of ectopic hCG expression in patients presenting with similar astonishing scenarios. Cannon ball appearance on radiology in a middle-aged diabetic female. A chest radiograph, which was performed to exclude pneumothorax, showed a right fifth posterior rib fracture and well-defined opacities overlying the ribs in the right middle and left upper zones (Figure 1). Radiograph and CT of the chest at presentation (A & B) revealed multiple bilateral cannon-ball opacities in both lungs and a 6-cm mass in the anterior mediastinum (white arrow). also there is a homogenous mass in the left mid zone just lateral to the descending aorta. C, A 10-cm soft hemangiomatous lesion located in …