Cannonballs

By Peter Galvin, MD

Recently I came across a case study in “The New England Journal of Medicine” that I thought I would share with you. It has both a curious name and startling images. The case is from the University of Iowa Hospitals and Clinics in Iowa City. A 54-year-old man with a history of mild, intermittent asthma presented to the emergency department with a two-month history of worsening shortness of breath and cough. His vital signs (blood pressure, temperature, heart rate, oxygen saturation, and respiratory rate) were normal as was his physical examination. A chest X ray showed innumerable round opacities in both lungs (see panel A). A CT scan of his chest (see panel B) showed many well-circumscribed, solid nodules of various sizes in both lungs – this finding is known as “cannonball” pulmonary lesions. Cannonball lung nodules usually indicate the hematogenous (via the bloodstream) spread of cancer to the lungs. This radiologic finding may be less commonly seen in infectious or autoimmune conditions.

His bloodwork was notable for a lactate dehydrogenase (LDH) level of 5492 (reference range 125 to 220), a beta human chorionic gonadotropin (beta HCG) level of 607 (reference range <4.99), and a normal alpha-fetoprotein level. LDH is contained in every cell in our body and is released when cells are damaged or destroyed, so an elevated LDH level is very nonspecific. However, an elevated beta HCG level in a man is startling because beta HCG is the hormone for maternal recognition of pregnancy, obviously in a woman, not a man. Alpha-fetoprotein is a marker for liver cancer.

An ultrasound of his scrotum revealed a mass in his right testicle, and a bronchoscopy with transbronchial needle biopsy was performed. Based on the pathology results, a diagnosis of metastatic embryonal carcinoma was made. This is a rather rare type of nonseminomatous germ-cell tumor. We all have residual embryonic tissue in us, left over and undeveloped since birth. Rarely, this embryonic tissue can develop into a tumor, known as a germ cell tumor. These tumors, that can occur in the ovaries or testes, can produce both beta HCG and alpha-fetoprotein.

The patient was given chemotherapy and is awaiting stem cell transplantation.

Please direct questions or comments to editor@rockawaytimes.com