Cáceres’ Corner Case 197 – SOLVED!

Dear Friends;

Today I am showing a preoperative PA chest radiograph for knee surgery in a 50-year-old woman. More images will be shown on Wednesday.

What do you see?

Click here to see the images published on Monday

Dear Friends,

showing today axial CTs and a cone down view of lesion. Hope they clarify your thoughts.

Click here to see the new images

Click here to see the see the answer

Findings: PA chest radiograph shows a well-defined opacity in the apex of the right lung. There is pleural thickening in the periphery of the opacity (A, arrow) that suggests an extrapulmonary location. There is a chain-like line in the periphery, better seen in the cone down view (A-B, red arrows), which looks like metallic surgical sutures. In addition, an irregular mass is visible in the right upper mediastinum (A-B, yellow arrows).

Discovering metallic sutures raises the possibility of post-surgical changes. It was found that the patient had been treated five years earlier with bullectomy and talc pleurodesis for persistent pneumothorax (C-D, arrows).

Enhanced axial CT at the present time shows a cystic pleural collection surrounded by talc (E, arrow). A caudal paramediastinal clump of talc (F, arrow) explains the right mediastinal mass seen in the plain film.

Final diagnosis: post-operative changes after bullectomy and talc pleurodesis for persistent pneumothorax.
Congratulations to Ner, who gave an excellent discussion and discovered the metallic sutures in the plain film.
Teaching point: Remember to look carefully at the radiographs. A simple finding, such as discovering metallic sutures, may lead to the correct diagnosis before CT.

20 thoughts on “Cáceres’ Corner Case 197 – SOLVED!

  1. Right upper zone soft tissue mass like lesion
    The trachea is central so it’s mild shited by mass like lesion
    ? With patient age put ? Pancost tumor
    CT chest is advisable

  2. Hello,

    1. Right well defined apical opacity without deviation of trachea or hilium displacement, without rib involvement, but with tiny chain-like shadow, which I belive is post-surgical.
    2. A little bit of pleural thickening between III and IV rib on the right which would be consistant with post-op.
    3. Poorly defined opacity between right apical opacity and right hilium. There might be calcified lymph node there, but it also could be something surgery related.
    4. Right heart border blurring, but since patient goes to knee surgery she probably isn’t ill, so I’d go with pectus excavatum.
    5. Little roundish shadow overlaying II left rib that might be in soft tissues.

    I can’t see anything highly suspicious, but I might change my mind if patient’s history doesn’t go along with my imagination. 🙂

  3. ….occorre una laterale per stabilire se l’opacita’…, origina nel collo con estensione nel torace ed in questo caso è anteriore….oppure situata nel mediastino ed allora si proietta posteriormente in LL….stabilita l’origine se ne definisce poi la eventuale patologia….nel mediastino posteriore è di origine nervosa…saluti da BARI—-

  4. Rt hemithorax apex opacity, posterior (cervicothoracic sign). Remodeling of 2nd and 3rd ribs, which points to a slow-growing lesion. I’d go with a neurogenic tumor (neurofibroma or schwannoma).

  5. Boarded base radioopacity with well defined posterior and lateral border and ill-defined upper border – seen in the right upper hemithorax. No deviation of the trachea. The right paraspinal line not well made out – Superior mediastinal mass.

  6. soft shadow right apex with very sharp rounded inferior border.
    cervicothoracic sign =ve
    possible 2 small areas of pleural thickening adjacent rt 4th rib.
    cp angles clear.
    no rib destruction.
    trachea not shifted.
    ct next step.

  7. Hello Dr Pepe

    Well defined soft tissue density lesion projected over the right lung apex. Very sharp lateral and inferior margins without a clearly visible upper border or medial border. Central trachea. Lung volumes preserved. Can’t see any bony destruction.

    Posterior mediastinal or cervical mass (thyroid mass with retrosternal extension).
    I’ll go for a nerve sheath tumour as the most likely diagnosis.
    Compare with previous imaging and advise CT for further assessment.

  8. Good morning!

    Leptosomic habit.

    There is a lineal increased density in the periphery of the apical lesion that remembers to me surgical suture… Any surgery at this level?. I think that the right apical lesion is extrapulmonary, so if sugical history it would be a hematoma…

  9. Greetings,
    right apical pleural-based soft tissue mass with right hilar enlargement, no deviation of the trachea or apparent bone erosion.

    Pancoast tumor with rigth hilar lymphadenopathy.

  10. Greetings,
    the lesion seems to have a fluid-density with a well-defined round margin that seems to show some contrast enhancement and forms acute angles with the lung; with several peripheral dot-like and linear hyperdensities (vessels or calcification), the caudal end of the lesion seems to be located within the lumen of a distended enhancing vessel (azygos vein?).

    Impression: lesion of vascular origin (thrombosed aneurysm azygos vein?..), coronal and sagittal reformation might help.

  11. Surgical bullous history! postsurgical changes with encapsulated liquid in the surgical bed. I think in ligation of the acigos vein with ectasia and partial thrombosis (but really it is more dense than the acigos…)

  12. I’d go for post-surgery changes in upper lobe and maybe postoperative linfocele looking at the density and morfology

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