A 63-year-old woman is transferred to your facility for evaluation of acute lower extremity paralysis. She has had ongoing back pain for the past several months.

Yesterday, she noticed her legs were dragging; last night, she was unable to walk, which prompted her trip to the local emergency department. She says she had “some sort of scan” there and was told that she had a tumor on her spine. 

She denies any injury or trauma. Her medical history is significant for reflux, hypertension, and extensive tobacco use. She is in no obvious distress, and her vital signs are normal.

Physical exam demonstrates extreme weakness in both lower extremities, from the hips down and worse on the left side. She has decreased sensation and reflexes as well. 

As you review the rest of her transfer paperwork and try to find any imaging studies or reports, the radiology technician collects the patient for a chest radiograph (the result of which is shown). What is your impression?

ANSWER

The radiograph demonstrates a fairly large mass on the medial aspect of the left upper lobe. Such findings are usually associated with bronchogenic carcinomas.

Among the documentation from the transferring facility was a copy of a CT scan of the patient’s chest. On that study, the mass is seen; it appears to extend to the posterior chest wall, with extensive involvement and destruction of the ribs and posterior elements of T4 and T5. There is also evidence of some spinal cord compression, which would explain the patient’s presenting complaint.

Subsequent CT-guided biopsy demonstrated the lesion to be a non–small cell carcinoma. Due to the already extensive involvement, surgery was not an option, and the patient was referred for palliative radiation therapy.