Cáceres Corner Case 199 – SOLVED!

Dear Friends,
Today´s case is provided by my good friend Alberto Villanueva.

PA radiograph belong to a 58-year-old man with cough and weight loss. Gastrectomy for stomach cancer in 2006. A previous film is shown for comparison.

Do you see any abnormality?

More images will be shown on Wednesday

Click here to see the images shown on Monday

Dear Friends,

showing a PA chest radiograph taken three months later.

What do you see?

Click here to see the new image

Click here to see the answer

Findings: PA radiograph taken in February 2018 shows an area of increased opacity in the subcarinal region (A, red arrows), more evident when compared with a previous film of 2014 (B). This finding was not detected.

Three months later the patient returned with increasing dyspnea. PA chest radiograph shows the typical appearance of RLL collapse, evidenced by a basal triangular shadow (C, arrow), downward hilar displacement (C, yellow arrow) and tracheal displacement. The subcarinal mass is now more evident (C, red arrow). Enhanced coronal CT shows the central mass (D, red arrows) as well as the RLL collapse (D, arrow).

Final diagnosis: oat-cell tumor of the lung

Congratulations to Elisa and Krister A, who were the first to detect the subcarinal mass in the initial examination
 
Teaching point: most of you detected the subcarinal mass that was missed in the original reading. This case emphasizes the importance of comparing with previous films to detect subtle findings.

19 thoughts on “Cáceres Corner Case 199 – SOLVED!

    1. The chest x ray taken 3 months later shows right lower lobe collapse (with mediastinal shift towards the right, right hemidiafragm elevation). Extrinsic compresion (pleural tumor/intraparenchimatous tumor) or bronchial invasion should be considered as causes.
      Chest CT strongly advised.

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  1. Right parasagittal retrocardiac opacity at hilar level. Seems to obliterate azygo-oesophageal stripe. CT is highly recommended. Oesophageal origin? Tumor? Bezoar?

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  2. paucity of vascular opacities on the right hilar region. suspicion of a smooth contoured soft tissue opacity on the right side between 5th-6th intercostal space in the 2018 XR??

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  3. Lt copula of diaphragm is not clearly seen Homogenous opacity seen overlying posterior left 11 rib? Sclerosis? Consolidation this opacity increased in comparison to the old x ray

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  4. PA chest radiograph – Compred to previous xray
    1. There is interval appearance of partly well-defined radiodense opacity in the subcarina location causing mild increase in the subcarinal angle.
    2. Pneumomediastinum
    3. Bilateral emphysematous lung fields

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  5. PA CHEST RADIOGRAPH: Comparison made with previous x ray
    1. Interval appearance of partly well defined opacity in the subcarinal region causing mild increase in subcarinal angle.
    2. Pneumomediatinum.
    3. Emphysematous lung fileds.

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  6. …importanza della LL nella radiografia del torace….l’opacita’ toracica a dx, tra la 6-7 costa, è’ intratoracica o extra Toracica?

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    1. ….l’opacita’ a dx era l’iniziale subatetelettasia , polmonare, ….per quanto mi sforzo non trovavo altri segni nel radiogramma AP….ecco perché’ chiedevo una LL dx, per stabilirne la sede intra-extra toracica e la ricerca di altri segniche potessero indirizzare verso una diagnosi…

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  7. PA CHEST RADIOGRAPHY: Comparison made with previous x-ray
    – Interval appearance of Right lower lobe collapse due to right bronchial lesion, less likely subcarinal mass

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  8. Good morning!! Loss of volume of the right hemithorax. Lower lobe atelectasis with an amputated right bronchus and elevated left one, so hiliar/mediastinal tumoral lesion.

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  9. A new x ray may 2018
    Opacity in the right hilum with Lower lobar collapse
    Retrospective the density and size of the opacity in the right hilum increased metastic hilar node or metastatic lung nodule with lower lobe collapse

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