Cáceres’ Corner Case 196 – SOLUTIONS


Dear Friends,

Welcome to 2019! I will start the year with preoperative chest radiographs for meningioma in a 78-year-old woman.
More images will be shown on Wednesday.

What do you see?

Click here to see the images showed on Monday

Dear Friends,

Presenting CT images of the chest. Do they help?

Click here to see more images

Click here to see the solution

Findings: PA radiograph shows a bilobed lesion in the LLL (A, arrow) with ill-defined margins, which makes it intrapulmonary. It is rounded in the lateral view, with ill-defined inferior border (B, arrow).

Enhanced axial CT shows a pulmonary mass with little enhancement (C, arrow). Coronal and sagittal views show distal pulmonary impactions (D-E, arrows), suggesting an intrabronchial location.

Bronchoscopy confirmed an intrabronchial mass in the L10 segmental bronchus. Biopsy returned as atypical carcinoid.
 
Final diagnosis: atypical carcinoid with distal bronchial impaction
 
Congratulations to Ner, who made a good interpretation of the plain film and CT. And saw a finding that I overlooked: increased posterior lucency in the lateral view. I reviewed the original CT and the lucency was not evident, although an expiratory CT was not done.
 
Teaching point: this case complements nicely my recent webinar on endobronchial lesions. Remember that bronchial mucous impaction is an important sign to suspect malignant endobronchial tumors.

18 thoughts on “Cáceres’ Corner Case 196 – SOLUTIONS

  1. rounded mass on the left lower lobe, there is vascular structure running from left hilum toward it.
    no other lung or bony lesions. normal hilar region.
    DDx of solitary pulmonary nodule.

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  2. Hello professor!
    There is increased reticular pattern of both lungs – consistent with fibrosis senilis and probably not important.
    There is a retrocardiac mass, which seems elongated on PA and round-ish on lateral (can’t explain that), but there is also decreased density of upper part of lower lobe (segm 6) which brings to my mind a mass that causes obstruction. My main ddx is – tumor (as always) and mucus impaction (probably due to bronchial atresia?).
    So – either patient has previous films or we’re doing CT.

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      1. So, now with CT I see the mucus impaction, but there’s also a round (probably enhancing a little bit?) mass causing the obstruction. So my answer would be – mucus impaction caused by tumor…
        I’m a bit worried I don’t see low density in segm 6 on CT – I was sure about that on film 😦

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        1. Don’t worry about the increased blackness in the lateral view. It is there and I missed it! Will review the original CT and see if it real. Congratulations!

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  3. Left retrocardiac (posterior basal segment) lobulated mass, possibly associated with the left lower lobe bronchus, which appears to be horizontally cut off just above the mass.
    Trachea appears to be slightly displaced anteriorly, but no air-fluid level is seen to indicate achalasia. The aortic knuckle calcifications are not on its most lateral aspect – mildly suspicious for aortic dissection.
    Small nonspecific dense round nodule with mildly irregular margins overlying the 6th posterior rib on the right, not visible on the lateral view.
    DDx: lung tumor, vascular lesion (either of the lower lobe artery or aorta), other posterior mediastinal lesion (esophageal?)

    Waiting for the CT!

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  4. Good morning!
    There is a an asimetry between the right and left hemithorax. The left main bronchus is verticalized. In the lateral view there is an anterior displacement of the trachea (air trap?)
    There is a posterior mediastinal lesion and an elongated aorta. I think it could be vascular pathology like aneurysm/pseudoaneurysm.

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    1. The aortic outline is not obliterated by the adjacent rounded opacity. This makes it very unlikely that it is arising from the aorta.

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  5. There is an radiodense opacity with ill-defined medial wall noted in the left hemithorax likely mediastinal origin. D/D Focal aneurysm from the descending thoracic aorta.

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  6. Soft tissue density mass lesion seen posterior to the aorta in the lower lobe.
    The mass is seen to abutt the posterior wall of aorta..tubular structure seen inferior aspect of the lesion..mostly dilated bronchus
    No significant enhancement or calcification..

    Mucus inspection with dilated bronchus

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  7. There is well defined soft tissue density lesion in the left lower lobe with tubular structure entering it – pulmonary arteriovenous malformation

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