A 20-yr-old Caucasian male construction worker had a previous history of a road traffic accident 3 yrs before presentation. A computed tomography (CT) scan of the thoracic spine was carried out to exclude vertebral damage. No evidence of vertebral bone damage or other lesions was seen, and the patient recovered without sequelae.A week before presentation, he noticed a stabbing pain in his right hemithorax, without dyspnoea. The pain persisted, and the patient was referred, by his general practitioner, for a chest radiograph ( fig. 1). Based on these results, the patient was referred to a general hospital for further diagnostic tests. A CT scan of thorax and abdomen (not shown) revealed a large mass, which was interpreted to arise in the right upper abdomen, probably originating from the liver. A malignant tumour, or a metastatic lesion, was suspected and the patient was referred to University Medical Center Groningen (Groningen, The Netherlands).The patient did not suffer from dyspnoea, cough or haemoptysis and there was no history of fever, weight loss, fatigue or excessive sweating. There were no neurological or gastrointestinal complaints. The patient was a nonsmoker, and did not use any medication.On physical examination, a healthy appearing, haemodynamically stable young male, of normal posture was seen. On percussion, a dull sound was found in the right lower zone of the chest. Auscultation revealed normal cardiac sounds without murmurs, and normal breathing sounds on the left side and upper right side of the chest. Abdominal examination revealed no palpable masses or other abnormalities. No palpable lymph nodes were present. Additional physical examination revealed no other abnormalities.Laboratory tests only showed a slightly elevated serum alkaline phosphatase of 174 U?L -1 (normal value: 13-120 U?L -1 ). Serum lactate dehydrogenase, a-fetoprotein and b-human chorionic gonadotropin values were all normal; therefore, an extra-gonadal germ cell tumour was unlikely.On revision of the CT scan, there was doubt regarding the hepatic origin of the mass. Therefore, abdominal ultrasonography was performed. No focal lesions in the liver parenchyma were observed, and the liver blood flow appeared intact. In the right thoracic region, a mass was seen with variable echogenicity and rich vascularisation. Due to the high degree of vascularisation observed on the abdominal ultrasonography, no percutaneous biopsy was performed. A CT angiography was performed: first, to narrow the differential diagnosis, and, secondly, to provide the thoracic surgeon with more detailed information about vascularisation ( fig. 2). At bronchoscopy, no endobronchial abnormalities were seen. Cytological examination of the bronchial lavage showed no signs of malignancy. A bone scan was normal.Exploratory thoracotomy revealed a tumour originating from the right dorsal region, lateral from the vertebral column. A surgeon was able to remove the tumour (figs 3 and 4). Eur Respir J 2005; 26: 740-743
