Corresponding Author: Elisabete Dulce da Cunha Mendes, Internal Medicine Resident, Medical Degree, Department of Internal Medicine, Unidade Local de Saúde do Norte Alentejano, Hospital de Portalegre, Portalegre, Portugal, Email: vitoria.cantim@gmail.com ; ORCID: http://orcid.org/0000-0002-1994-7849.

Citation: Elisabete Dulce da Cunha Mendes, Sara Lourenço Tereso, Rita Afonso Diz (2026). The Real Culprit Behind the Cannonball Pattern. Euro J Case Rep Clin Imag. 2026; August, e22,1-3.

Copyrights: © Elisabete Dulce da Cunha Mendes, 2026, et al., This article is licensed under the Creative Commons Attribution-Non Commercial-4.0-International-License-(CCBY-NC) (https://europeanjournalofcasereports.com/blogpage/copyright-policy). Usage and distribution for commercial purposes require written permission.

Image Case Presentation:

The “cannonball” pattern describes the radiological appearance of multiple, well-defined, rounded pulmonary nodules of variable size. It is a characteristic manifestation of haematogenous pulmonary metastases, although the differential diagnosis includes infectious, inflammatory and vascular conditions [1]. Renal cell carcinoma is classically associated with this appearance, while colorectal and other solid malignancies may also present with multiple “cannonball” metastases [1–3].

We present an 87-year-old woman with colon adenocarcinoma who presented to the emergency department with worsening dyspnoea and several days of disorientation. Chest radiography revealed multiple bilateral pulmonary nodules in a diffuse “cannonball” pattern (Figure 1). Remarkably, these findings were absent on a chest radiograph obtained less than one year earlier (Figure 2), highlighting the rapid progression of the disease. Brain computed tomography demonstrated a 2.8-cm rounded, heterogeneous lesion in the deep left temporoparietal region, adjacent to the ventricular system, suspicious for a neoplastic lesion. Further investigation confirmed pulmonary and cerebral metastases from colon adenocarcinoma.

This case highlights the importance of recognising the “cannonball” pattern as a radiological clue to metastatic disease, particularly in patients with a known malignancy. Comparison with previous imaging may provide an important clue to disease progression and help guide further diagnostic evaluation and management.

Keywords: Pulmonary Metastases, Pulmonary Nodules, Chest Radiography, Cannonball Pattern.