Cáceres’ Corner Case 248 – SOLVED

Dear Friends,

today I am showing preop radiographs for knee surgery of a 71-year-old man.
What do you see?

More images will be shown on Wednesday.

Click here to see new images

Dear friends, showing additional images of the sternum taken six years earlier, in 2014.
What do you think?

Click here to see the answer

Findings: PA chest is unremarkable (A). The lateral radiograph shows an expanding lytic lesion in the sternal manubrium (B, circle).

Cone down view shows the lesion better (C, arrows). Sagittal, coronal and axial unenhanced CT taken six years earlier (2014) demonstrate that the cortical bone is broken in several places, suggesting an aggressive process (D-F, arrows). A soft-tissue mass is not visible.

No other skeletal lesions were found. Biopsy of the sternum confirmed the diagnosis of solitary myeloma (plasmocytoma), that was subsequently treated. The patient remained asymptomatic.
 
Final diagnosis: Plasmocytoma of the sternum
 
Congratulations to Priyanka Chhabra and Olena, who made the correct diagnosis. And kudos to all of you who saw the lesion in the lateral chest radiograph.
 
Teaching point: Remember that a lytic lesion of the sternum in an adult is malignant until proven otherwise. Main etiologies are primary tumors (chondrosarcoma) and metastases.

Reviewing the literature, I found a case report with similar findings: Solitary plasmacytoma of the sternum with a spiculated periosteal reaction: A case report. ONCOLOGY LETTERS 9: 191-194, 2015

Dr. Pepe’s Diploma Casebook 163 – SOLVED

Dear Friends,
I am back with a new Diploma case. Miss Piggy sends her regards😍 and has helped to choose the case.
Chest radiographs belong to a 74-year-old man with a cough and pain in the chest.

What do you see?

Click here to see the answer

Findings: PA radiograph shows a bulge in the left paraspinal line (A, arrow), suggestive of a posterior mediastinal mass. A rounded posterior opacity is seen in the lateral view (B, arrow).

Unenhanced coronal and sagittal CT show large osteophytes displacing the paraspinal line (C, circle) pushing the aorta forward in the sagittal view(D, circle). Incidental gas is visible in the intervertebral disk.

Final diagnosis: large osteophytes simulating a pulmonary/mediastinal mass

The aim of this Diploma is to discuss chest imaging in the elderly. As patients get older the appearance of their chest radiographs changes in comparison with young persons. I intend to discuss changes associated to aging as well as the most common pathologies in the old.

I have divided the presentation into three separate chapters:

1- Bony structures of the chest
2- Heart and mediastinum
3- Lungs and diaphragm

Today I will comment on the main manifestations of aging in the chest skeleton, discussing variations that may simulate disease, followed by the most common bone pathologies in the elderly.

NORMAL VARIANTS IN THE AGED

Degenerative changes are the hallmark of the aging skeleton.Vertebral osteophytes are common and large ones should not be confused with pulmonary nodules (Fig 1) or mediastinal masses (Fig 2), as shown in the initial case. The diagnosis is easily made with chest CT.

Fig 1. 67-year-old male without significant symptoms. PA radiograph (A) is unremarkable. Lateral view shows a posterior nodule that could be intrapulmonary (B, arrow).

Coronal and sagittal unenhanced CT show that the nodule represents a large osteophyte (C-D, arrows). The absence of other osteophytes makes it difficult to suspect this diagnosis in the plain film.
Fig 2. 65-year-old man in whom a posterior mediastinal mass was discovered (A-B. arrows). The mass was unchanged in comparison with a previous examination. CT was recommended because a neurogenic tumor could not be excluded.
Unenhanced coronal and sagittal CT demonstrates that the mass represents a single large osteophyte (C-D, arrows)

Calcification of the first costal cartilage may happen in the young but it is more common in the elderly. When asymmetrical, it may be confused with a pulmonary nodule (Fig 3). Exuberant cartilage calcification may simulate an upper lobe infiltrate (Fig 4).

Fig 3. 70-year-old man with a large pleural effusion, suspected to be malignant because of a possible nodule in the LUL (A, arrow). Cone down view shows that the nodule es calcified and corresponds to the first costal cartilage (B, arrow). Post-pneumonic empyema.
Fig 4. 69-year-old woman with fever. Exuberant calcification of the first right costal cartilage was initially diagnosed as pneumonia (A, circle). Comparison with a radiograph taken four years earlier did not show any change (B-C, arrows).

Aging causes brittle bones and explains the increased incidence of costal fractures in the elderly. The callus of a healed fracture should not be confused with a pulmonary nodule (Fig. 6).

Fig 6. 74-year-old woman in whom a RUL nodule appeared one year after cardiac surgery (A, arrow).
A 3-D reconstruction shows that the nodule represents a healed fracture of the second rib (B, circle). Ribs fractures after cardiac surgery are not uncommon

Resuscitation maneuvers, not uncommon in advanced age, may cause bilateral rib fractures, that should be recognized as such (fig 7).

Fig 7. 63-year-old man with prostate carcinoma, complaining of chest pain. PA radiograph shows
sclerotic areas in the lower ribs (A, arrows), not present in previous films. My initial impression was metastatic disease, until I learned that the patient has had resuscitation maneuvers a few months earlier. Axial and coronal CT confirms symmetrical healed fractures of the anterior lower ribs (B-C, circles).

SKELETAL PATHOLOGY

The most common bone pathology in the elderly are fractures. Acute rib fractures are common, most of them secondary to falls (Fig 8). Detection is important because they cause respiratory impairment that may end in pneumonia with the subsequent increase of morbidity and mortality.

Fig 8. 78-year-old alcoholic man after a fall. PA radiograph shows displaced rib fractures (A, circle) as well as pneumothorax (A, red arrow) and subcutaneous emphysema Note the straight air-fluid level of hemothorax at the left base (A, arrow)

Compression fractures of vertebral bodies are related to osteoporosis and common in the elderly. They cause significant pain, leading to inability to perform daily activities. If they are not recognized they cause a decline of the quality of life in elderly patients (Fig 9).

Fig 9. 84-year-old woman with chronic back pain. PA radiograph (A) is unremarkable. Lateral chest shows a severe compression fracture of D9 (B, circle), better seen in the cone down view (C, arrows).

Lytic bone lesions in the elderly are usually related to metastases or multiple myeloma. Sclerotic metastases are common in old males. Given the prevalence of prostate carcinoma this should be our first diagnostic consideration in widespread sclerotic lesions (Fig 10). The differential diagnosis includes myelofibrosis (fig 11) and chronic renal failure (Fig 12).

Fig 10. 71-year-old male with widespread sclerotic lesions of ribs and spine secondary to metastases from prostatic carcinoma.

Myelofibrosis is a myeloproliferative neoplasm which cause osteosclerosis. The association of an enlarged spleen should alert us to this possible diagnosis.

Fig 11. Preoperatory chest film in a 67-year-old woman. Diffuse increased bone density (A), better seen in the cone down view of left shoulder (B). The medially displaced gastric bubble suggests splenic enlargement (A, arrow). Myelofibrosis suspected and confirmed.
Fig 12. 73-year-old woman with chronic renal failure. PA radiograph (A) shows deformity of the rib cage. Lateral view (B) show the rugged-jersey spine, typical of this entity.

Solitary sclerotic lesions of the skeleton raises the possibility of metastasis vs. Paget disease. In the spine, Paget disease usually increases the size of the vertebra whereas metastases do not (Fig 13). In the peripheral skeleton the increase in width of the cortical bone is characteristic of Paget disease (Figs 14-15) .

Fig 13. 68-year-old man who presented with back pain. PA radiograph (A) is unremarkable. Lateral view shows an ivory vertebra (B, circle) that has the same size than the others.
Diagnosis: metastasis from prostatic carcinoma.
Fig 14. Two patients with Paget disease of a rib. Note the increased cortical thickness of the 6th rib in the first patient compared to the other ribs (A, arrow) a hallmark of Paget disease. The second patient has sclerosis of the whole 6th rib which is increased in size
(B, arrow), another characteristic of Paget.
Fig 15. 70-year-old man with prostate carcinoma and metastasis to the anterior third rib (A-B, arrows). Note the difference with the previous cases.


Follow Dr. Pepe’s advice:

1. Osteophytes and healed rib fractures may simulate pulmonary nodules in the elderly

2. It is important to detect rib or vertebral fractures in the elderly because they may be the source of complications

3. Sclerotic bone lesions in the elderly are usually due to prostate metastases or Paget disease

Cáceres’ Corner Case 247 – SOLVED

Dear Friends,

Today´s radiographs belong to a 53-year-old man with abdominal pain.
What do you think?

Dear Friends,

showing today axial and coronal CI images of the abdomen. What do you think?

Click here to see new images

Click here to see the answer

Findings: PA and lateral chest radiographs show a large gastric bubble, with abundant stomach contents (A, arrow). In addition, there is a prominent air-fluid level in the right upper quadrant (A-B, red arrows), A small rounded metallic opacity is projected over it in the lateral view (B, circle).
The findings are suggestive of gastric outlet obstruction. Duodenal obstruction is unlikely because the second air-fluid level is anterior in the lateral projection. The little rounded metallic opacity suggests the possibility of a foreign object.

Coronal and axial CT show a food-filled stomach with a balloon located in the antrum (C-D, arrows).

Upright abdominal radiograph (E), parallels the gastric findings in the coronal CT (F).
(Showing plain film of the abdomen as an homage to Dr Genchi Bari).
 
A gastric balloon for obesity had been placed two weeks earlier.

Final diagnosis: balloon causing stomach outlet obstruction. This complication occurs in less than 1% of cases (*).
 
Congratulations to Olena, who was the only one to see the balloon valve and to Archanereddyt who made the final diagnosis.
 
Teaching point: as stated in case 242, always include iatrogenesis in your differential diagnosis. Reviewing the literature I discover an interesting fact: the saline in the balloons is tinted blue. If the urine becomes blue or green, is a sign of balloon deflation.
 
Incidentally, malicious rumors about the radiographs belonging to Miss Piggy are totally false!
 
(*) Gastric outlet obstruction secondary to orbera intragastric balloon. SA Kook and J Hammond. JSCR 2018; 10: 1-3

Dr. Pepe’s Diploma Casebook 162 – SOLVED

Dear Friends,

taking advantage of Dr Pepe’s absence I am showing today an unproven case (always wanted to do it!). All relevant images are shown, without comment, looking forward to hear your opinions.
I will share my impressions with you next Friday. Hope we will coincide. We have to wait together until we get the final diagnosis (or not).

Chest radiographs belong to a 66-year-old man with abdominal pain and a history of diverticulitis. The round opacity at the left base led to a review of previous examinations, dating back to 2007.

Abdominal CT for diverticulitis in 2007 and 2008 show a cystic lesion in the left costophrenic sinus

The patient had recurrent episodes of diverticulitis and/or abdominal pain. I am offering several axial CTs in different years to document the evolution of the lesion

Occasionally the chest was also examined. Showing three samples of sagittal CTs with pulmonary window over a ten years’ period.

The last abdominal CT was taken on August 30, 2020. I have selected the most relevant axial, coronal and sagittal images.

Have you reached a conclusion after reviewing all the images?

Click here to see the answer

The case starts in 2019 with chest radiographs of a 66-year-old man with abdominal pain and previous history of diverticulitis. A rounded opacity is seen the left lung base (A-B, arrows). This finding led to a review of previous examinations, dating back to 2007.

Abdominal CTs for diverticulitis in 2007 and 2008 show a cystic lesion in the left costophrenic sinus(C-D, circles). The lesion has grown slightly in one year.

Since 2007 the patient had recurrent episodes of diverticulitis and/or abdominal pain. Several abdominal CTs in different years document the evolution of the lesion: the purely cystic lesion in 2008 (E, arrow) has grown in 2013 and fine septa are seen within it (F, circle).
CT in 2015 shows that the septa are thicker and enhance after contrast injection (G, circle). An unenhanced CT in 2018 demonstrates a smaller lesion with a thick peripheral rim of solid tissue (H, arrows).

Sometimes the chest was included in the CT examination. Three samples of sagittal CTs with pulmonary window over a ten years’ period show that the lesion lies within the left major fissure (A-C, arrows). It looks like a pendulum held by the fissure and has an irregular contour in the last image in 2018.

A final unenhanced abdominal CT taken on August 2020 shows that the appearance of the lesion has not changed significantly in the last two years. In the meantime a small punctate calcification has appeared (L and O, arrows).

Conclusion after review of the images:

1- Slow-growing mass over a period of ten years.

2- The initial cystic mass has developed thick septa and thick peripheral rim.

3- Located within the left major fissure.

4- Punctate calcification.

Given all these finding, my best option is a fibrous pleural tumor of the left pleural fissure which is undergoing malignant transformation.

An alternative diagnosis could be a mucinous pleural tumor if such entity exists.
In my opinion, hydatid cyst is very unlikely. It has been practically eradicated from Spain and I have never seen one within a fissure.

The patient is now in the hands of a competent pneumologist. Hope we will get a definitive diagnosis soon. As soon as I get it, I will post it in the blog ( and, if it happens to be a hydatid cyst, I will do penance in a nunnery).

Cáceres’ Corner Case 246 – SOLVED

Dear Friends,

Today I am showing the PA radiograph of an 82-year-old woman. Preoperatory for cataracts.

What do you think about the right hilum?

1. Calcified TB nodes
2. Sarcoidosis
3. Amyloid
4. None of the above

More images will be shown on Wednesday.

Click here to see the images shown on Monday


Dear friends, showing today PA and lateral radiographs taken two years earlier. Hope they help.

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Click here to see the answer

Findings: Initial PA radiograph shows opacities in the right hilum (A, circle), unchanged in comparison with a previous film taken two years earlier (B, circle).

The clue to the diagnosis lies in the density and appearance of the opacities. They are denser than the typical lymph node calcifications, suggesting that they are metallic. In addition, some of them look tubular or branching (C, red arrows). A lateral view taken two years earlier confirms dense lineal and branching opacities in right lung (D, arrows).
The combination of linear and branching metallic opacities suggests that they are either in the bronchi (previous bronchography) or within the pulmonary vessels (embolism after vertebroplasty o treatment of AV malformation). See Diploma # 44.

Lateral view of the lumbar spine shows surgical changes with vertebroplasty of L3 to L5 and leakage of the cement into the epidural veins (E, arrows), better seen in the sagittal CT (F, arrows).

Unenhanced CT confirms multiple cement emboli in the pulmonary arteries (G-J, circles)

Final diagnosis: cement embolization of the lung after vertebroplasty
 
I must mention Olena and Ayudi who suggested amyloid and broncholithiasis but failed to notice the metallic opacity of the findings.
 
Teaching point: Consider previous vertebroplasty when you see metallic opacities in the lungs. It is a common complication.

Dr. Pepe’s Diploma Casebook 161 – Meet the examiner

Dear Friends,

This week’s case follows the pattern of a “Meet the Examiner” presentation, with questions and answers similar to a real examination. Take your time before scrolling down for the answer.

The images belong to a 60-year-old man with moderate cough and dyspnea

What would you recommend?

1. Compare with previous films
2. Chest CT
3. PET-CT
4. None of the above

Click here to see the answer

Findings: PA radiograph shows large bullae in both upper lobes. There is a nodule in the RUL projected over one bulla (A, arrow). Two small calcified granulomas are visible in the periphery of the LUL (A, circle). PA film taken five years earlier (B) does not show any nodule in the RUL. The granulomas in the LUL are unchanged.

Report of the chest : bullous emphysema with a nodule not visible in 2014. Given the relationship between bullous disease and carcinoma, it is imperative to do a chest CT.

Enhanced CT was done the next day. What would you suggest?

1. Antibiotic treatment and CXR in one month
2. PET-CT
3. Antibiotic treatment and CT in one month
4. None of the above

Click here to see the answer

Findings: aside form large bullae in both upper lobes, an irregular nodule is evident in the RUL (A-B, arrows). In my opinion, given the appearance of the nodule I would suspect malignancy and request a PET-CT. However CT was reported as: Pseudonodular opacity in RUL that could be related to an infectious/inflammatory process. A neoplasm cannot be excluded. Recommend control after treatment

Click here to see more images

A chest radiograph was taken one month later.
What would you do?

1. PET-CT
2. CXR in three months
3. CT in three months
4. Control in one year

Click here to see more images

The chest radiograph one month later was reported as unchanged and no further suggestions were made by the radiologist. The clinician took no further action.

The patient came back ten months later, and a new radiograph showed an obvious increase in size of the nodule (B, arrow) when compared to the initial film (A, arrow)

Click here to see more images

Enhanced CT confirms the increase in size of the nodule (A-B, arrows). Surgery discovered a carcinoma in the wall of a bulla.

Final diagnosis: adenocarcinoma of the lung associated to bullous disease.

Lung carcinoma seems to occur more often in bullous disease, although there is not enough evidence compiled at the present time. Despite the lack of evidence, knowing
this association may prevent misdiagnosis.
A lesser known fact is that the cystic space may disappear after the carcinoma develops, as occurred in a second case (see below). Spontaneous regression of a bulla may be due to non-malignant causes, but carcinoma should be excluded with CT because it may take years for the lesion to be visible in the chest radiograph.

I am showing this case because the opinion given in the chest radiograph was unequivocal, whereas the CT report was vapid, giving the impression that the nodule was infectious, and that malignancy was less likely. The follow-up radiograph was disregarded by the radiologist and clinician and this caused a delay in diagnosis of almost one year.

To complete the information, I am showing a second case of carcinoma developing in the wall of a cystic space

Images of the second case were obtained during routine CT screening in a 72-year-old man, heavy smoker.
Apical axial CT image shows a small nodule in the LUL (A, arrow), with increased uptake on PET-CT (C, arrow). There is a cystic airspace in the LLL (B, arrow) with no PET-CT uptake, interpreted as a non-specific cystic airspace lesion.

At surgery a carcinoma of the LUL was found.

It was decided to continue with yearly follow-up studies. The cystic air space (A, arrow) increased in size in 2008 but still had a thin wall (B, arrow). In 2009 it has decreased slightly in size and the wall is thicker than the previous year (C, arrow). A new PET-CT shows increased uptake in the posterior wall (D, arrow).

Malignancy was suspected. The patient refused further surgery or percutaneous biopsy and it was decided to do a follow up study three months later.
Axial CT shows that the cystic airspace has disappeared and in its place, a solid mass has developed (A and B, arrows) with increased overall uptake on PET-CT (C, arrow). At surgery, an adenocarcinoma was found.

Final diagnosis: adenocarcinoma arising in the wall of a cystic airspace, which disappeared as the tumour progressed.


Follow Dr. Pepe’s advice:

1. Bullous emphysema and isolated cystic spaces may be associated with an increased incidence of carcinomas

2. A poorly worded report may cause an unnecessary delay in diagnosis

Musculoskeletal #15 – Flashcard

This is the third and last case of the musculoskeletal series. Check the first one and second one on this blog.

What do you see on the following images?

Click here to see the answer

Osteoblastoma: Osteoblastoma is histologically similar to osteoid osteoma but they are larger (usually accepted more than 1 cm), often involving the posterior column

Cáceres’ Corner Case 245 – SOLVED

Dear friends, Dr Pepe has eloped with Miss Piggy (again) and has let me alone, holding the fort. Hope he will be back in time to give the next webinar.

Today’s radiographs belong to a 60-year-old male with cough and moderate dyspnea.

Diagnosis:

1. Hilar lymphadenopathy
2. Right pulmonary artery aneurysm
3. Mediastinal tumor
4. None of the above

Click here to see the answer

Findings: PA and lateral chest radiographs show a right hilar mass (A-B, arrows). In my opinion, the appearance of the mass and its location in the right hilum in the lateral view rules out a mediastinal mass.
There is a small nodule in the RUL (A, red arrow) that can be overlooked unless we look for it

The nodule is better seen in the cone down view and the axial CT (C-D, red arrows), with high SUV in the PET-CT (E, arrow), accompanied by a metastatic node in the mediastinum (E, circle).

Caudal slices of enhanced CT show multiple lymph nodes in right hilum (F, arrow) and mediastinum (G, circle).

Biopsy of a lymph node returned as metastatic carcinoma.

Final diagnosis: carcinoma of the lung with mediastinal metastases

Congratulations to archanareddyt who was the only one to discover the RUL nodule

Teaching point: this is an interesting case for educational purposes.
1. Knowing the most common causes of unilateral hilar enlargement (lymph nodes vs. enlarged artery) helps the differential diagnosis.
2. We should think of common processes rather than unusual ones (lymph nodes vs. aneurysm).
3.  Suspecting unilateral hilar lymph nodes leads to search for the two more common etiologies (TB or carcinoma) leading to the discovery of the RUL nodule.

Hope the case was useful!