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!