Cáceres’ Corner Case 207 – SOLVED!

Dear Friends, 

Today I am presenting a case given to me by my good friend José Luis López Moreno. The PA radiograph belongs to a 77-year-old woman with pain in the right hemithorax.
What do you see?

More images will be shown on Wednesday.

Dear Friends,

showing today axial and coronal CT.
What do you think?

Click here to see more images


Click here to see the answer

Findings: PA radiographs shows an ovoid opacity in the right lung (A, arrow), that parallels the path of the anterior ribs. Careful observation demonstrates that the third and fifth anterior ribs are visible (B, red arrows), whereas the anterior fourth rib is absent (B, asterisks). An additional finding is moderated flattening of D11 and D12 (A, circle). The findings suggest multicentric bone lesions.

Enhanced axial and coronal CT confirm a lytic expanding lesion of the anterior fourth rib (C and D, arrows), better seen in the 3-D reconstructions (E and F, arrows).

In an adult, lytic expanding rib lesions are usually either metastases (thyroid, renal cell carcinoma) or multiple myeloma. Further studies confirmed a myeloma.
 
Final diagnosis: multiple myeloma affecting the right fourth rib and several thoracic and lumbar vertebrae.
 
Congratulations to Wafaa who suggested the diagnosis in the plain film and to VL who discovered the collapsed vertebrae.
 
Teaching point: remember to look at the underlying rib when facing a pleural/chest wall lesion. An affected rib will narrow down your diagnostic options. And don’t forget satisfaction of search (collapsed vertebrae in this case).

10 thoughts on “Cáceres’ Corner Case 207 – SOLVED!

  1. Good morning!!

    There is a loss of volume of the right hemithorax. The right hilum is displaced lower.

    There is a loculated right pleural effusion.

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  2. There is mass abutting chest wall. Mass has got very sharp medial border . Part of lateral border which is not abutting chest wall appears fudgy. Orientation of lesion is along oblique fissure. Doubtful scalloping of inferior aspect of 5 and 6 rib noted . Adjacent pleural thickening noted.
    So is it neurofibroma / pleural collection with extension along oblique fissure but that should be well defined. It looks extra pulmonary next step to do lateral view followed by CT

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  3. Expancile lesion of the rt fourth rib anteriorly.no aggressive features…paget yet although old fibrous dysplasia is also a possibility. Mets and MM in dd.

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  4. All of three of you saw the obvious. It’s there anything else? Remember satisfaction of search. Sometimes additional findings may orient your diagnosis…

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  5. Lower thoracic vertebra is collapsed . Few of lower vertebrae show loss of pedicel . Now I am suspicious about metastasis and pleural mass could be metastasis

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  6. Rib plasmocytoma?
    Vertberal lesions?
    There is also not good enhamcement of pulmonary arteries, not sure as a result of phase, artifact, PE?

    Multiple myeloma?

    Like

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