CME INDIA Case Presentation by Dr. Nishith Kumar, MD, FAPSR, Consultant Department of Pulmonary Medicine, OMC, Ranchi.

CME INDIA Case Study

How Presented?

Physical findings/Lab tests

  • O/E – B/L basal crepts.
  • CBC, LFT – WNL.
  • S. Creatinine – 1.6.
  • CXR-PA View.
  • Echocardiography
  • Normal Cardiac Chamber Dimension.
  • LVEF – 55%.
  • No RWMA, Mod Severe MR.
  • Mild AR.
  • Grade I, Diastolic Dysfunction.
  • CT Scan of Thorax
  • CT images revealed Localized interlobar pleural effusion mimicking SPN/Mass lesion.

After diagnosis, what happened?

  • CXR post 5 days of treatment with diuretic, Valsartan and fluid intake reduction resulted in complete resolution of the observed round/oval tumor-like image on the control CXR and remarkable improvement in patient’s symptom.

CME INDIA Discussion

Dr. P R Parthasarathy, Chest Physician, Chennai:

  • Plain x-ray doesn’t give a clue to the diagnosis.

Dr. Arun Kedia, Diabetologist, Raipur:

  • Looks like a coin lesion. Cud be malignancy, hydatid cyst, fungal infection.

Dr. G B Sattur, Sr. Diabetologist Physician, Hubli:

  • D/D
  • Metastasis.
  • Hydatid cyst.

Dr. Devi Jyoti Dash, Pulmonologist, Raipur:

  • Slight cardiomegaly can be seen. 
  • With Orthopnoea as history, can be phantom tumor.

Dr. N K Singh:

  • Did you not think of doing FNAC/CYTOLOGY?
  • Very nice case. But, any idea of malignant pathology, your thought?

Dr. Rajan Chaudhary, Sr Radiologist, Patna:

  • Too smooth and rounded for malignancy.

Dr. Nishith Kumar

  • Saw the CXR, CT Thorax images and gave him diuretics. On CXR, suspicion of malignancy, as it revealed a spherical homogeneous opacity in Right Lower Zone, but CT Thorax clenched the diagnosis.
  • Accumulation of Pleural fluid in inter lobar spaces should always raise the suspicion of Phantom tumor in a patient whose clinical feature is consistent with that of Heart Failure.

Final Diagnosis

(Dr. Nishith Kumar)

  • This was a case of Phantom tumor of the lung in a patient with preserved left ventricular systolic function.
  • Although phantom tumor is generally believed-to occur in patients with systolic dysfunction, in this case, its appearance was secondary to diastolic dysfunction.
  • Phantom tumor of the lung refers to the accumulation of fluid in the interlobar spaces as a result of congestive heart failure, giving the radiological appearance of a neoplasm.
  • Rapid radiological improvement in response to treatment for heart failure is a classical feature of this clinical entity. Phantom tumor is also known as “pseudo tumor” or “vanishing tumor.”

CME INDIA Learning Points

  • Phantom or vanishing tumor is well known entity and stands for a localized transudative interlobar pleural fluid collection in congestive heart failure.
  • The origin of the name is due to  its frequent resemblance to a tumor on the CXR and from its tendency to vanish after appropriate management of heart failure.
  • Pathogenesis:
  • Adhesions and obliteration of the pleural space around the edge of the fissure due to pleuritis.
  • In such setting, phantom tumors arise whenever the transudation from the pulmonary vascular space exceeds resorptive ability of the pleural lymphatics.
  • Atypical intrafissural distribution of pleural effusions can also be explained by local increase in elastic recoil by adjacent, partially atelectatic lung that yields a “suction cup” effect and favors loculation of liquid even in the absence of pleural adhesions.
  • The right-sided predilection of phantom tumor has been described.
  • It can be(Right sided predilection)  best explained by the greater hydrostatic pressure existing on this side in comparison with left in congestive heart failure. It results in impaired venous and lymphatic drainage causing loculation of fluid.
  • The differential diagnosis of loculated pleural effusions within the fissure
Transudates due to the left ventricular failure or renal failure
Exudates (parapneumonic pleural effusions, malignant pleural effusions, and benign asbestos-related pleural effusions)
Hemothorax
Chylothorax
Fibrous tumors originating from the visceral pleura of the interlobar fissure
  • Peculiarities
  • Phantom tumors predominantly occur in men.
  • Usually in the right hemithorax.
  • Three-quarters of the reported cases within the right transverse fissure.
  • Less frequently within the oblique fissure.
  • Simultaneous occurrences in both fissures were reported in about one-fifth of cases.
  • Left hemithorax – only sporadically.

CME INDIA Tail Piece

  • In 1928, Dr. Stewart was the first one to report this entity as “interlobar hydrothorax.”

References

  1. D. E. Bedford and J. L. Lovibond, “Hydrothorax in heart failure,” British Heart Journal, vol. 3, no. 2, pp. 93–111, 1941.
  2. K. P. Buch and R. S. Morehead, “Multiple left-sided vanishing tumors,” Chest, vol. 118, no. 5, pp. 1486–1489, 2000.
  3. B. M. Haus, P. Stark, S. L. Shofer, and W. G. Kuschner, “Massive pulmonary pseudotumor,” Chest, vol. 124, no. 2, pp. 758–760, 2003.


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