A 61-year-old man presents to your urgent care center for evaluation of “chest pain” he has been experiencing for almost four weeks. He denies any injury or trauma.  He describes the pain as “sharp” and “stabbing” and says occasionally it is associated with breathing, localized primarily to the left side. There is no radiation of the pain. He denies fever, nausea, weight loss, night sweats, and hemoptysis.

He has smoked a half-pack of cigarettes daily for more than 40 years. His medical history is otherwise unremarkable, except that he was told he had “high blood pressure” and he had his sternum repaired several years ago, following fracture in an accident.

Vital signs are as follows: temperature, 36.4°C; blood pressure, 174/100 mm Hg; ventricular rate, 88 beats/min; respiratory rate, 20 breaths/min; and O₂ saturation, 100% on room air. He appears to be in no obvious distress. Lung sounds are normal, as is the rest of the physical examination.

You obtain a chest radiograph. What is your impression?

ANSWER
The radiograph demonstrates evidence of previous surgery on the sternum. There also is evidence of scarring or discoid atelectasis along the left mid lung.

Of note, though, is a soft tissue mass (about 5 to 6 cm) within the left pulmonary apex. This lesion could represent a rounded infiltrate, an atypical infection such as a mycetoma, or possibly a pulmonary neoplasm.

Since the patient was stable, he was placed on antibiotics with instructions to follow up with his primary care provider for further work-up on the mass. The patient did follow up; the lesion persisted and subsequent biopsy confirmed carcinoma.