CASE CONFERENCE

The Expert Clinician

Section Editors: Peter Clardy, M.D., and Charlie B. Strange III, M.D.

Occam’s Razor versus Hickam’s Dictum

Thomas A. Newman1, Julie E. Takasugi2, Gustavo Matute-Bello3,4, Jeffrey B. Virgin5, Leah M. Backhus6,7, and
Rosemary Adamson3,4
1
Department of Internal Medicine and 4Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle,
Washington; 2Department of Radiology, 3Department of Pulmonary and Critical Care Medicine, and 5Department of Pathology,
VA Puget Sound Health Care System, Seattle, Washington; 6Division of Thoracic Surgery, VA Palo Alto Health Care System, Palo Alto,
California; and 7Department of Cardiothoracic Surgery, Stanford University, Palo Alto, California
ORCID IDs: 0000-0003-2878-5682 (T.A.N.); 0000-0001-6174-4466 (R.A.).

Case Vignette

A 76-year-old man was referred to the

pulmonary clinic with symptoms of cough
and sputum production of 2 months’
duration. He denied fevers, chills,
hemoptysis, and weight loss. He had an
approximately 100–pack-year smoking
history and had handled asbestos without
wearing a respirator for approximately
25 years while working as a plumber.
The results of a physical examination
were unremarkable. The results of basic Figure 1. (A) Coronal computed tomography (CT) of the chest demonstrating left lower lobe mass
laboratory tests, including a complete blood abutting diaphragm and pleural plaque. (B) CT of the chest demonstrating endobronchial nodule
(black arrow) in the orifice of the superior segmental bronchus of the right lower lobe and one of the
count and a basic metabolic panel, were
pleural plaques (white arrow) on the left.
normal. A chest radiograph showed a
large left lower lobe opacity. Computed
tomographic (CT) imaging of the chest
showed a 6-cm left lower lobe mass, several
noncalcified pleural nodules on the left, and
an endobronchial nodule in the orifice of the
right lower lobe superior segment (Figure 1).
Positron emission tomographic (PET)-CT
imaging demonstrated fluorodeoxyglucose
(FDG) avidity in both the right endobronchial
nodule (standardized uptake value, 10.3) and
left lower lobe mass (standardized uptake
value, 2.6) (Figure 2).
On flexible bronchoscopy, the
endobronchial nodule in the right lower lobe
superior segment was the only airway Figure 2. (A) Fused positron emission tomographic–computed tomographic (PET-CT) image
abnormality found. Endobronchial biopsies showing the 18F-fluorodeoxyglucose–avid right endobronchial nodule (arrow). (B) Fused PET-CT
taken from this nodule were diagnostic of image showing the left lower lobe mass (arrow).

(Received in original form January 30, 2017; accepted in final form June 19, 2017 )
Correspondence and requests for reprints should be addressed to Rosemary Adamson, M.B.B.S., Department of Pulmonary and Critical Care Medicine, VA
Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108-1597. E-mail: [email protected]
Ann Am Thorac Soc Vol 14, No 11, pp 1709–1713, Nov 2017
Copyright © 2017 by the American Thoracic Society
DOI: 10.1513/AnnalsATS.201701-087CC
Internet address: www.atsjournals.org

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non–small cell lung cancer (NSCLC).

Transbronchial biopsies taken from the
left lower lobe mass under fluoroscopic
guidance showed no diagnostic alteration.
The case was reviewed by a
multidisciplinary tumor board. It was
imperative to definitively diagnose the left-
sided lesions because left-sided malignancy
would be a contraindication to the otherwise
appropriate surgical resection of the right
NSCLC. Therefore, the board recommended
video-assisted thoracoscopic surgery for
biopsies of the left lung mass and pleural
nodules. The patient underwent left video-
assisted thoracoscopic surgery, and, given the
size of the lung lesion, a core needle biopsy
rather than wedge resection was performed
of the left lower lobe mass. Excisional
biopsies were taken from the pleural lesions.

Questions

1. What is the most likely cause of the left

lower lobe lesion?
2. What is the most likely cause of the
pleural-based lesions?
[Continue onto next page for answers]

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 CASE CONFERENCE

Clinical Reasoning clinical findings. In fact, the patient’s Discussion

and Management multiple intrathoracic abnormalities could
all be explained as sequelae of asbestos Although the histology of the patient’s
This patient was found to have a right-sided exposure. The patient’s left lower lobe mass endobronchial, left lower lobe, and pleural
endobronchial NSCLC, a large contralateral appeared most consistent with rounded lesions revealed three distinct
lung mass, and several pleural-based atelectasis on CT imaging, which is often pathophysiologic processes, namely
nodules by CT imaging. When confronted associated with asbestos exposure. In squamous cell lung cancer, rounded
simultaneously with multiple focal combination with his tobacco use history, atelectasis, and asbestos-related pleural
intrathoracic lesions, an astute diagnostician asbestos exposure markedly increased plaques, they are all potential sequelae
might approach the differential diagnosis his risk for developing his known of asbestos exposure, an interesting
by applying Occam’s razor, the principle primary lung cancer. Finally, given his compromise between Occam’s razor and
that the simplest answer to a problem history, asbestos-related pleural plaques Hickam’s dictum. Rounded atelectasis, one
is often the correct one. These lesions are the likely explanation for his pleural of the most dramatic and frequently
could all represent lung cancer, presenting lesions. misdiagnosed types of asbestos-related
as a single primary lesion, or multiple The intraoperative findings were lung disease, was a key feature of this case,
synchronous primary lesions, with consistent with a gross appearance of benign which illustrates important characteristics
metastases to the pleura. Indeed, the FDG pleural plaques and rounded atelectasis of its clinical presentation. Rounded
avidity of the left lower lobe mass and (Figure 3). The histologic specimen from atelectasis is a peripheral focus of
the presence of unilateral pleural nodules the left lower lobe mass demonstrated mild collapsed lung tissue that is usually
in a patient with known NSCLC were emphysema with associated interstitial discovered incidentally on chest imaging.
fibrosis and no evidence of neoplasia Patients may present with pulmonary
concerning for synchronous cancers or
(Figure 4). The histologic specimen from symptoms, but many patients found
metastatic disease.
the pleural plaque showed a dense fibrous to have rounded atelectasis are
Patients, however, do not always adhere
plaque and no evidence of neoplasia asymptomatic despite often impressive
to Occam’s razor. The counterargument is
(Figure 5). On the basis of the benign radiologic findings (1, 2). Common risk
sometimes referred to as Hickam’s dictum:
results, bilobectomy of the right middle and factors for the development of rounded
A patient can have as many diseases as
lower lobes and mediastinal lymph node atelectasis, particularly exposure to
he or she pleases. Although the left lower
dissection were performed as definitive asbestos, are also risk factors for lung and
lobe mass demonstrated FDG avidity on
treatment for the clinical early-stage lung pleural malignancies, so distinguishing this
PET-CT scans, the uptake was much less
cancer. Pathology revealed a papillary benign pulmonary abnormality from
intense than the known right-sided squamous bronchial carcinoma with
malignant lesion, and the pleural lesions malignancy is important when deciding
minimal invasion into the bronchus wall whether to pursue invasive diagnostic
did not show significant FDG avidity. (Figure 6) and no involvement of the
What’s more, contralateral and pleural testing.
sampled parabronchial and mediastinal Although the pathogenesis of rounded
metastases seemed less likely, given the lymph nodes.
absence of mediastinal lymphadenopathy. atelectasis is not well understood, the two
Primary lung cancer presenting with a most common theories implicate pleural
large mass and associated metastases often Diagnoses inflammation and pleural effusion,
causes more symptoms, such as weight loss Stage IA bronchial squamous cell carcinoma, respectively, as the first step in its
and pain, than were seen in this patient. pleural plaques, and rounded atelectasis development. The first theory holds that
Finally, some features of the left lower
lobe mass were consistent with rounded
atelectasis, a type of focal peripheral lung
collapse that appears as a mass on CT
imaging.
Our differential diagnosis for the
patient’s pleural lesions also expands if we
apply Hickam’s dictum. In addition to
metastatic primary lung cancer, other
malignant causes for his pleural nodules
include malignant mesothelioma,
lymphoma, metastatic thyroid cancer,
and metastatic thymoma. Other
nonmalignant causes could include
fibrous pleural tumors and asbestos-related
pleural plaques.
The patient’s asbestos exposure was a
key piece of history in this case and brings
us back to Occam’s razor in evaluating his Figure 3. Intraoperative photograph showing diaphragmatic pleural plaque and left lower lobe mass.

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usually fibrotic, whereas the underlying

elastic layer of the pleura is folded with
invagination into the underlying lung
parenchyma, a feature that distinguishes
rounded atelectasis from typical
pleural fibrosis (8). The pleural fibrosis
of rounded atelectasis is usually associated
with mild chronic inflammation,
but without a significant cellular
infiltrate (8).
Although often discovered on chest
radiographs, rounded atelectasis usually
appears as a pulmonary opacity resembling
a pulmonary neoplasm and requires CT
imaging for further evaluation. There is no
single diagnostic feature of rounded
atelectasis on CT imaging, but there are
several characteristic findings to evaluate
Figure 4. Photomicrograph (340 original magnification) of the left lower lobe biopsy showing mild
when considering the diagnosis. Rounded
emphysema and associated interstitial fibrosis.
atelectasis is located peripherally,
abutting and forming an acute angle
localized pleural inflammation leads to that form between abutting pleura with the pleura (9). It is typically associated
pleural fibrosis, with eventual contraction within the folded lung, even with pleural thickening, which may be
of the fibrotic visceral pleura causing after the effusion resolves (1). This located adjacent to the lesion and/or
pleural folding and collapse of the “folding” theory for the pathogenesis of elsewhere in the chest (9). Often there
underlying lung tissue (3). Rounded rounded atelectasis has been criticized are features indicative of ipsilateral volume
atelectasis has been associated with because of a lack of preexisting pleural loss (6). The presence of an indistinct
various causes of pleurisy and asbestos effusion in many cases (6), though central margin where bronchovascular
exposure that can lead to localized rounded atelectasis developing in the markings converge on the lesion is
areas of pleural inflammation and presence of pleural effusions without typical (10), as illustrated in Figure 1A.
pleural thickening, which supports this prior asbestos exposure is well The most useful CT feature of rounded
“fibrosing” theory for its pathogenesis described (7). atelectasis is the so-called comet tail
(4, 5). The second theory proposes that Histologic features of rounded sign, which is the convergence of
the presence of a pleural effusion atelectasis include thickened, fibrotic bronchovascular markings on the lesion.
causes compressive atelectasis pleura overlying sections of collapsed but This feature was 83% sensitive and 92%
and folding of the lung tissue; this otherwise normal parenchymal lung specific in identifying rounded atelectasis
distortion is maintained by adhesions tissue (8). The superficial pleura is in one series, with a positive likelihood
ratio of 10 and a negative likelihood
ratio of 0.18 (10). Although rounded
atelectasis has been reported to be
metabolically inactive on FDG-PET
imaging (11), there have been cases of
rounded atelectasis that exhibit FDG
avidity (12), though at lower intensity
than malignant lesions, as seen in the
present case.
For asymptomatic patients found to
have pulmonary lesions that fit the
above criteria, including the convergence
of bronchovascular markings, it is
reasonable to forgo invasive diagnostic
testing in favor of a conservative
monitoring approach (10, 13). CT
imaging is not a perfect tool for the
diagnosis of rounded atelectasis, and
patients found to have this abnormality
are often at high risk for developing a
Figure 5. Photomicrograph (340 original magnification) from the pleural biopsy showing a dense pulmonary malignancy, so repeat imaging
fibrous plaque. to monitor for stability of the lesion is

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Follow-up
The patient has done well since his surgery
and has had no evidence of cancer
recurrence on surveillance CT chest
imaging.

Insights
d Most patients with rounded atelectasis
are asymptomatic despite significant
pulmonary abnormalities on CT
imaging.
d Rounded atelectasis is associated with
a variety of causes of pleural
inflammation and pleural effusion,
Figure 6. Photomicrograph (340 original magnification) from the right lower lobe endobronchial
which likely contribute to its
lesion showing invasive squamous cell carcinoma with tumor giant cell reaction.
pathogenesis.
d The “comet tail sign” is the most
warranted. In the presented case, specific radiologic feature of rounded
Answers atelectasis.
suspected rounded atelectasis was
found in a patient with known lung d Asymptomatic patients with typical
1. What is the most likely cause of the left
cancer and pleural lesions, prompting a features of rounded atelectasis on
lower lobe lesion?
more invasive approach to rule out CT imaging do not require invasive
synchronous cancer or metastatic disease. Rounded atelectasis. diagnostic testing but should have
For patients with atypical radiologic repeat imaging to monitor for
features or concerning concomitant
2. What is the most likely cause of the stability. n
pleural-based lesions?
findings, such as in the present case,
further evaluation to rule out malignancy Pleural plaques related to asbestos Author disclosures are available with the text
should be pursued. exposure. of this article at www.atsjournals.org.

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