Dr. Pepe’s Diploma Casebook: CASE 143 – The wisdom of Dr. Pepe – SOLVED

Dear Friends,

This case belong to the section “The wisdom of Dr. Pepe”, in which an (useful?) aphorism ends the presentation.

I am presenting a routine PA radiograph in an asymptomatic 79-year-old woman operated on for a breast DCIS five years ago. PA radiograph taken five years earlier is shown for comparison. More images will be shown on Wednesday.


1. Granulomas
2. Metastases
3. Primary lung tumor(s)
4. Any of the above

Click here to see the images

Dear Friends,

showing CT images with and without contrast enhancement.

What would your diagnosis be?

1. Carcinoma
2. Active TB
3. Fibrous lung tumor
4. Any of the above

Click here to see the CT

Click here to see the answer

Findings: The PA chest radiograph shows two obvious small nodules in the left middle lung field (A, circle), not present five years earlier (B). In my experience, two nodules close together are usually granulomas. But in this case we have another finding: a subtle bulge in the left hilum (A, arrow), not visible in the previous film, highly suspicious of hilar adenopathy. This changes the diagnostic orientation and makes us think of an active process.

Unenhanced axial CT shows an hourglass-shaped pulmonary lesion (C and D, arrows) that simulated two nodules in the chest radiograph. The lesion enhances after contrast injection and contains a large arterial vessel (E, arrow). Non-enhancing lymph nodes are visible in the left hilum (F, arrow).
Although all three diagnoses offered in the blog can cause hilar adenopathy, the vascularity of the lesion points to a tumor.

PET-CT shows faint uptake of the primary lesion and the hilar lymph nodes (G and H, arrows). A needle biopsy (I, arrow) came back as an atypical small-cell tumor.

The patient was treated with chemotherapy and radiotherapy, with a good response of the primary tumor (J, arrow) and lymph nodes (K, circle).

Final diagnosis: SCLC with hilar metastasis and a good response to QT and RT

Discussion: I just finished reading “The subtle art of not giving a f*ck“ and there is an enlightening (and sadly true) chapter entitled “You are not special”. In this particular case I was feeling special, as I diagnosed a malignant pulmonary fibroma based on a single case seen 20 years ago (see below) because of the similarity of the vascular pattern in the two cases. After 50 years of practice, I forgot a basic principle: common conditions are, well, common. I’m showing this case to remind you that when faced with a diagnostic dilemma you should first consider common options rather than uncommon ones.

To redeem myself, I am showing my only case of fibrous tumor of lung in a 37-year-old woman with hemoptysis. The PA radiograph shows a well-defined paramediastinal nodule (A, arrow). Enhanced coronal and sagittal CT confirms the intrapulmonary location of the nodule, which has a large arterial vessel in the center with an aneurysm at the end (B and C, arrows).

Surgery confirmed a fibrous tumor of the lung.

Two bits of information about fibrous tumor of the lung: It is a very unusual spindle-cell tumor with the same histology as fibrous tumors of pleura, and like them, it has malignant potential. It is usually asymptomatic and is seen as a rounded or ovoid nodule of varying size. Immunohistochemistry is important for the diagnosis.

Follow Dr. Pepe’s pearls of wisdom:

Always consider that what you are seeing is a rare manifestation of a common disease rather than a common manifestation of a rare disease.

16 thoughts on “Dr. Pepe’s Diploma Casebook: CASE 143 – The wisdom of Dr. Pepe – SOLVED

  1. 4. Any of the above
    Probably, these opacities may be not in the lung. I think there should be some changes in adjacent lung tissue and bronchi accompnying such masses.

  2. Good night!!!

    It´s very strange that a DCIS produces mtx.

    Both x-rays are very similar except for the presence of 2 nodules on the left hemithorax, with well defined-margins, high density… it seems to be benign lesions. Perhaps we can see the lateral view because another option would be to have external elements projected on the thorax.

  3. Good morning Professor
    current radiograph shows interval development of two well defined nodular opacities. 5 year gap is not very helpful as the lesion were not present in the previous radiograph. so we do not know the rate of growth of lesion .only information available to us is that these are new lesions. The nodules appear well defined ,no obvious calcification seen however high KV can cause burn out of calcium.
    interval stability of right apical pleural thickening is noted. Left hemidiaphragm is raised suggesting volume loss. Mid part of descending aorta is not sharp . left hilar region also appears abnormal- bulky and not sharp.
    In summery I am suspicious of these being primary lung tm considering the age of pt , volume loss . However I can not completely rule out granuloma. Regarding these being Mets from DCIS is out from my list . However 5 year is long time and if pt has another primary then these nodules could represent mets.
    I will proceed with CT chest.

    1. Good description! And you discovered the abnormality of the left hilum.
      CT tomorrow.

  4. Up to now, only one of you has mentioned that the patient has hilar lymph nodes.
    Remember satisfaction of search!
    More images tomorrow

  5. Good morning!! There is a nodular with tubular structure and linear enhencement with hiliar adenopathy.

    I think about parasitic pathology (perhaphs helmintic)

  6. parenchymal abnormality looks tubular and doesnot enhance much ,appear slightly hyperdense on NCCT. Third image shows lines hyperdensity ,could be calcium.All above findings takes me towards mucus filles bronchus .
    now focussing on mediastinal abnormility which shows subtle peripheral enhancement .
    is it tubercular/necrotic ln.
    is it ABPA –unusual to single bronchoceless. not sure about ln
    is it tb –fits .
    is it histoplasmosis–mimics tb in many aspect.

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