R Nagaraja, R Sandhyav
cannon ball metastases., lung secondaries, metastases
R Nagaraja, R Sandhyav. CANNON BALL SECONDARIES?. The Internet Journal of Surgery. 2008 Volume 21 Number 1.
Multiple pulmonary nodules on chest x-ray, known commonly as cannon ball secondaries, are the classical presentation of haematogenous dissemination of a malignant tumor to the lungs. This almost always indicates advanced stage of the disease with a very grim outlook in terms of cure or survival. But there are numerous causes for multiple pulmonary nodules and their interpretation as cannon ball metastases should be viewed with caution. Here we present one such instance of “
A-37-year old male, chronic alcoholic and smoker, with no previous medical comorbidities, presented to us with a ruptured liver abscess and generalised peritonitis. The patient was taken up for emergency laparotomy after resuscitation. Intraoperative findings were: purulent peritoneal fluid, a large abscess cavity in segment 4-5 of the liver and an inflamed gallbladder. After thorough peritoneal lavage and drainage of peritoneum and abscess cavity, the abdomen was closed. Post-operatively, there was persistent drainage of blood-stained fluid from the abscess cavity drain and the patient developed productive cough with haemoptysis. A chest x-ray was taken (figure 1) and revealed multiple pulmonary nodules and obliteration of the costo-phrenic angles bilaterally.
Culture of both peritoneal fluid and sputum revealed growth of
Multiple pulmonary nodules seen on plain chest x-ray have a multitude of causes, starting from metastases (cannon ball secondaries), various infections, immunological diseases to arterio-venous malformations 1 .
Pulmonary metastases in adults are usually from breast, kidney, gut, testes, head-neck tumors and a variety of sarcomas. The basic sign of haematogenous pulmonary metastases is one or more discrete pulmonary nodules. The nodules are usually spherical and well-defined, but they may be almost of any shape and can occasionally have a very irregular edge, especially in adenocarcinoma 2 . Calcification is very unusual except in osteo/chondrosarcoma. Secondary deposits can also present as miliary mottling throughout the lung fields or with extensive perihilar spread (lymphangitis carcinomatosa) 3 .
Septicemic infections by
Finally, a word on tumor rupture in hepatocellular carcinoma (HCC): Tumor rupture in HCC presents as an acute abdomen as a result of haemoperitoneum. Such presentation occurs in 5% of patients with HCC 5 .
The aim of this presentation is to emphasise that, although metastases are an important and common cause of multiple pulmonary nodules on plain chest film, the diagnosis should be made with caution taking into consideration all the relevant data available about the patient and the various differential diagnoses for multiple pulmonary nodules, mainly the infective causes.