Case 63

Michael P. D'Alessandro, M.D.
Peer Review Status: Internally Peer Reviewed

Clinical History:
The patient was a 12 year old male who presented initially with back pain and was diagnosed with a paraspinal Ewing sarcoma. At the time of presentation, the patient was noted to have a single metastatic lesion in the right lower lobe. The patient was treated with chemotherapy and radiation therapy and the lung lesion cleared 2 months after it was initially diagnosed. On a surveillance chest CT exam performed 11 months after the initial presentation, new lung lesions were noted.

Clinical Physical Exam:
Unremarkable

Clinical Labs:
Non-contributory

Clinical Differential Diagnosis:
Recurrent metastatic disease

Imaging Findings:
On a surveillance chest CT exam performed 11 months after the initial presentation, new lung lesions were noted. A short interval follow-up scan was performed 2 weeks later, showing further new lesions.

Images 1, 2, and 3

Images 4 , 5, 6, and 7

Imaging Differential Diagnosis:
Opportunistic infection, metastases, septic emboli

Operative Findings:
A CT guided biopsy of the largest lesion performed two days after the last chest CT exam was non-diagnostic. One week later, a thoracoscopic biopsy of the nodule in the left lower lobe was performed.

Pathological Findings:
Pathological examination of the biopsy specimen revealed bronchiolitis obliterans with organizing pneumonia.

Image 8

Final Diagnosis:
Bronchiolitis Obliterans with Organizing Pneumonia

Follow-up and Prognosis:
The patient had an uncomplicated post-operative course. A chest CT exam performed 3 weeks after the thoracoscopic biopsy showed all the lung nodules to be resolving.

Images 9 and 10

Similar Cases:
Case 11, Case 62

References:

• International Thoracic Teaching Resource - http://www.vh.org/adult/provider/radiology/ITTR/BOOP/BOOP.html

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