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