Case contribution: Dr Radhiana Hassan
Clinical:
- A 70 years old male
- Active smoker since teenagers
- History of cholecystectomy for gallbladder stone about 20 years ago
- Presented with incomplete voiding and occasional hematuria for one month
- Also had loss of appetite and loss of weight
X-ray findings:
- Multiple rounded well-defined lesions are seen in both lung fields.
- These lesions are of varying sizes involving all zones of the lung.
- No cavitation or calcification within these lesions.
- No obvious bone lesion is seen in the visualized bones. No bone destruction.
- Abdominal radiograph shows previous surgical clips, otherwise no significant finding.
Ultrasound findings:
- Both kidneys are normal in position and echogenicity.
- There is moderate to gross bilateral hydronephrosis.
- The ureters are also dilated.
- The urinary bladder is empty with Foley’s balloon catheter in situ.
- There is diffuse thickening of urinary bladder wall.
CT scan findings:
- The urinary bladder wall is grossly and irregularly thickened, which is better seen on delayed images (yellow arrows).
- Both VUJ and distal ureters are obliterated by the mass.
- Marked perivesical fat stranding is seen.
- Normal prostate and seminal vesicles are not visualised likely involved.
- Bilateral nephrostomy tubes are in situ.
- Liver is enlarged with multiple hypodense liver lesions within.
- Portal vein is patent.
- An ill-defined irregular non enhancing hypodense lesion is seen in uncinate process of the pancreas . This lesion abuts the medial wall of D2 segment of the duodenum. The rest of the pancreas is normal.
- Both adrenal glands, spleen and bowel loops are normal.
- Multiple aorto-caval and paraaortic nodes are observed.
- Multiple irregular heterogeneous masses are scattered in both lungs. The largest lesion is seen in the posterior basal segment of the right lower lobe .
Progress of patient:
- CE: huge tumour in the bladder
- TURBT: HPE shows high grade carcinoma
- Bilateral nephrostomy and internalization of both ureters done
- His condition worsened, had AKI secondary to obstructive uropathy
- Family opted for palliative treatment
Diagnosis: Cannonball lung metastases from high grade urinary bladder tumour
Discussion:
- Cannonball lung metastases refers to multiple large, well-circumscribed, round pulmonary metastases like cannonballs
- Metastases with such appearance are classically secondary to renal carcinoma and choriocarcinoma. Other primary include carcinoma of prostate, endometrium, synovium and adrenal.
- Other differential diagnosis for cannonball pulmonary lesion include various infection (septic emboli, multiple abscesses, tuberculosis, nocardia, histoplasmosis, coccidioidomycosis and hydatid cysts), rheumatological disease (Wagener granulomatosis, rheumatoid nodules) and arteriovenous malformations
