1. Right shoulder and chest pain Kate Rubey November 2013

2. Patient is a 70 year old male with PMH of HTN and hyperlipidemia who presents with constant substernal chest pain for 2 weeks and new onset R shoulder pain Patient has history of similar substernal chest pain, most recently in February when he had a negative NM cardiac stress test Notes cough exacerbates shoulder pain Patient denied abdominal pain at presentation Clinical History 2

3. Vitals BP: 141/84 Pulse: 80 Temp: 98.1 °F Resp: 22 SpO2: 98 % Exam Unremarkable with exception of RUQ tenderness to palpation Physical Exam 3

4. Concern for pulmonary embolism vs. ACS vs. gallbladder pathology Wells PE criteria low risk, so D-dimer indicated before chest CT How should we evaluate the gallbladder? Work-up 4

5. ACR Appropriateness Criteria 5

6. Normal Liver Ultrasound long

7. Abdomen - Liver Ultrasound long 5420719

8. Liver ultrasound revealed multiple large hypoechoic, but not cystic, mass lesions seen throughout the liver, measuring up to 7.6-cm., with very little normal intervening liver parenchyma. Differential includes: – hepatic hemangiomas: usually hyperechoic lesions – idiopathic noncirrhotic portal hypertension: generally isoechoic and poorly visualized on ultrasound – hepatocellular carcinoma: usually with poorly-defined margins and coarse, irregular internal echoes – metastatic disease: variable appearance, almost always multiple lesions, may be hypoechoic Differential 8

9. Liver metastases are concerning for GI, GU, and lung cancer Patient had colonoscopy 4/13 without evidence of GI malignancy Patient had CT of the chest, abdomen, and pelvis to look for primary malignancy and characterize liver lesions – For lesions found on US highly suspicious for malignancy: CT abdomen with contrast is rated an 8 (usually appropriate) Suspected Liver Metastases 9

10. Abdomen CT – axial, 5 minutes post contrast

11. Abdomen – Liver hemangioma Contrast CT – axial

12. Abdomen – Hepatocellular carcinoma Contrast CT – axial

13. Abdomen – Liver metastases Contrast CT – axial

14. Abdomen CT - axial 5420893

15. Abdomen CT - axial

16. Abdomen CT – axial 5420893

17. CT chest showed a R hilar mass associated with subcarinal and paratracheal lymph nodes, concerning for neoplasm Patient underwent ultrasound guided biopsy of one of the liver lesions by IR Results of the biopsy showed “Poorly differentiated carcinoma. Immunophenotype (CK7+ and TTF-1+) is consistent with lung primary.” 17