Dear Friends,
Presenting today radiographs of a 65-year-old man with back pain.
What do you see?
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Findings: PA chest radiograph shows an ill-defined opacity in the right middle lung field (A, asterisk), located in the anterior clear space in the lateral view (B, arrows). The anterior arch of the 4th right rib is missing.
A cone down view demonstrates an expanding lytic lesion in the anterior arch of the 4th right rib (C, asterisk), confirmed with CT (D and E, red arrows).
I thought this was an easy case, but I am disappointed because some of you missed a collapsed vertebra (F, circle), not present three years earlier (G, circle). Sagittal CT confirms it as well as additional affectation of L1 and posterior elements of D10 (H, red arrows).
In a patient with a port-a-cath, the presence of multiple lytic lesion suggests metastatic disease as the first possibility.
Final diagnosis: Carcinoma of esophagus with bone metastases
Congratulations to Andy, who was the first and to Archana Reddy.t who discovered the collapsed vertebra.
Teaching point: this case is similar to the previous one and the teaching point is the same: look at the underlying rib. And, above all, don’t forget to examine the rest of the bones!
soft tissue mass right ventral 4th rib with osseous destruction. probably metastatic dd myeloma. patient has port, so possibly known malignancy.
CHEST X-RAY:
PA view:
The anterior aspect of the right 4th rib is replaced by expansile radioopaque lesion.
Mild blunting of the left costo-phrenic angle – minimal pleural effusion.
Left subclavian port insitu.
Lateral view: There is anterior wedging of the mid-thoracic vertebra.
Differential diagnosis:
1. Multiple myeloma.
2. Malignant bone ( rib) lesion with vertebral mets.
Right mid zone soft tissue density area looks like not related to the pulmonary parenchyma
There is no evidence of bony destruction
Picture may be a chest wall mass
Look at the bones again 🙂
hello professor
lytic lesion of anterior aspect of rt 4th rib with collapse of lower thoracic vertebra with port a cath . suggest myeloma or metastases
Opacity seen close to right 4th rib anterior which looks like vanish anterior rib.
Wedge shaped compression fracture mid dorsal spine
Suggestive of metastatic
Bone lesion right 4th rib