Cáceres’ Corner Case 204 – SOLVED

Dear Friends,

Today’s radiographs belong to a 54-year-old man with chest pain.

More images will be shown on Wednesday.

What do you see?

Click here to see the images

Dear Friends,

Showing new images of the thoracic cage. 

What do you think?

Click here to see the new images


Click here to see the answer

Findings: PA radiograph shows an extrapulmonary lesion in the left hemithorax (A, arrow). The 3rd left rib is broadened (A, red arrows) and the distal segment is not visible.
There is a lineal infiltrate in the adjacent lung and at the left lung base. In addition, an expansive lytic lesion is visible in the anterior 7th right rib (A, yellow arrow).
The lateral view (B) does not show any significant findings.

AP and oblique views of the thoracic cage show an expansive lesion of the 3rd left rib (C-E, arrows) and confirm the expansive lytic lesion of the right 7th rib (C-E, red arrows). There is also a pure lytic lesion of the 8th left rib (C-E, red circle). There is minimal loss of height of D-11 (C and E, blue circle).

Discovering expanding lesion of the ribs should suggest either multiple myeloma or metastases (renal cell carcinoma, thyroid carcinoma). In this patient a multiple myeloma was found.
 
Final diagnosis: multiple myeloma, IgA type.
 
Congratulations to VL who found the bone lesions in the initial radiographs (many of you ignored satisfaction of search) and to archana reddy.t, who made the final diagnosis.
 
Teaching point: remember to look at the underlying rib in any extrapulmonary lesion. Discovering rib involvement focus your diagnostic approach and limits the differential diagnosis.

12 thoughts on “Cáceres’ Corner Case 204 – SOLVED

  1. There is decrease left lung volume, rounded opacity in the left middle zone with overlying pleural thickening.
    The left hilum slightly elevated and some hilar vessels extending toward the mass.
    Other region of pleural thickening seen in the left lower zone, no pleural calcification is appropriated.
    The overlying ribs appear normal.
    No pleural effusion.
    Not too much seen on lateral film.
    My first impression is round atelectasis.

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  2. Chest PA view:
    1. Broad based lesion noted in the left upper and mid zone. The medial border of the scapula at that level in not clearly made out. Few vessels seen extending unto the lesion.
    2. There is an small radioopacity noted in the left lower zone with adjacent pleural thickening.
    3. Left trace pleural effusion

    Differentials:
    1. Loculated effusion with underlying lung atelectasis.
    2. Less likely extrapleural lesion ( bony origin)

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  3. Greetings Professor
    there is a mass in left upper zone which appears extrapulmonary (peripheral, preganant sign,sharp margin) .anterior end of third rib is not visualised . lesion could be arising from third rib . there is another smaller expansile lesion arising from lateral aspect of right 7th rib. there are interstitial opacities in left lower lobe. left cp angle is blunted and there is opacity along left lateral chest wall.

    is it tuberculosis -parenchymal with pleural with chest wall involvement -empyema neccasitatis. I will be mindful about actinomyces because it can also give similar picture.

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  4. – Decreased left lung volume
    – Broad based extrapulmonary mass do to pleural thickening in the left upper lobe
    – Another apparent pulmonary mass along the pleural thickening without visible pulmonary disease in the lateral view
    – Fibrosis between the left hilus ant the apparent pulmonary disease on the AP view
    – Elevated left hilus
    – Pleural thickening/ calcification in the left lingula
    – Third rib is not visualized ( post op? destruction ?)
    -Bony defect lateralt on the left 7-th rib
    – Slightly elevated left paraspinal line(?)
    – Slightly blunting

    1. Previously operated lung disease (TB?)
    2. Chronic tuberculous empyema is less plausible

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  5. Dear Professor
    because of this blog, I am getting enriched with radiology knowledge. Now because of human tendencies of greed I am feeling only if we have similar dedicated resources for parts other than chest. I know you are chest specialist . Are you aware of any other similar blogs ?
    Thanks
    Greetings .

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    1. Dear friend, in this address there are cases similar to mine. You may also try the web of the ECR (blog.myecr.org).
      And there plans to expand the Diploma Casework to include cases from other specialities.

      Thanks for participating

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  6. multiple lytic expansile rib lesions, in the left third, 8th rib and right 7th.
    mostly are well circumscribed with grouf glass matrix and no periosteal reaction.
    suspect FD(polyostotic)
    in 54ys old patient,
    -Multiple myloma is possible.
    -Lytic metastasis… but the lesion appeas not to aggressive.
    -Brown tumour : no other signs in the films.

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