A 43-year old previously healthy woman visited her doctor due to exercise-induced pain in her right knee, which showed up to be a spontaneously transient symptom. Otherwise, she was completely asymptomatic, had never had tuberculosis or had episodes of erythema nodosum, arthralgias, eye pain or fatigue. The lung function and all blood test were normal. She had been smoking corresponding to 15 pack years. Two years earlier (2016) bilateral breast implants placed of cosmetic reasons had been removed since leak was demonstrated by breast magnetic resonance imaging (MRI) and ultrasound, which also revealed enlarged silicone-containing right axillary lymph nodes. The patient was referred for a routine chest X ray (no symptoms but former smoker) that lead to CT of the chest. This showed non-calcified asymmetrical lymphadenopathy of stations 2R, 7, 10R and 11R (short axis diameter: 10-15 mm), and multiple bilateral lung nodules (diameter 5-10 mm) with no pleural, subpleural or perivascular preference. Furhermore, a prosthesis residue was demonstrated laterally in the right breast. C-reactive protein, renal function tests and ionized calcium were all normal. The patient was referred to our unit for workup of suspected malignancy. PET-CT revealed increased metabolic activity in the lymph nodes and lung nodules mentioned (Fig. 1, Fig. 2). We performed bronchoscopy (bronchial wash for cytology and culture) and endobronchial ultrasound with real-time guided transbronchial needle aspiration (EBUS-TBNA). The patient had difficulties cooperating during the first procedure performed under conscious sedation because she was coughing. To ensure sufficient biopsies from as many lymph nodes as possible, we performed a second procedure under general anesthesia.
At 12-month follow up, she was consistently asymptomatic, but the patient refused the planned chest CT due to fear of long-term consequences of irradiation.
CT (2018) showed bilateral pulmonary infiltrates and enlarged lymph nodes in all mediastinal stations.