Cáceres’ Corner Case 210 – SOLVED

Dear Friends,

showing another case seen during this summer. Preoperative chest radiography for knee surgery in a 57-year-old man. More images will be shown on Wednesday.

What do you see?

New images are shown:

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Findings: PA radiographs shows a right mediastinal mass at the level of the tracheal bifurcation (A, arrow), which has not changed significantly in comparison with a chest film taken for pneumonia one year earlier (B, arrow).

Several of you have mentioned a triangular shadow at the right cardiophrenic angle
(A-B, red arrows). This appearance should suggest paracardial fat pad as the first choice.

The differential diagnosis of a right mediastinal mass at the level of the tracheal bifurcation is simple: most of the times it is either an enlarged azygos vein or lymphadenopathy.
 CT shows a dilated azygos vein with a prominent azygos arch (C-D, arrows), suggesting a impeded blood flood either in the inferior or superior vena cava. Considering that the patient is asymptomatic, the most likely diagnosis is congenital interruption of the inferior vena cava, with azygos continuation. The diagnosis is confirmed noting the absence of the suprarenal portion of the IVC (C, circle) and the association of other congenital anomalies, such as polisplenia (C, red arrows) and abnormal bifurcation of the bronchial tree (E, arrows).

Coronal CT confirms that the triangular paracardial shadow represents paracardiac fat.

Final diagnosis: Congenital absence of IVC with azygos continuation
Congratulations to MK, who made a late (and accurate) diagnosis of prominent azygos vein
Teaching point: remember that the most common right lower paratracheal masses are either an enlarged azygos vein or mediastinal lymph nodes.

14 thoughts on “Cáceres’ Corner Case 210 – SOLVED

  1. I see an opacity in the right cardiophrenic angle with a very well defined and straight upper border (possible accessory inferior fissure?)
    I would consider a differential of cardiophrenic opacities, most likely a pericardial cyst, pericardial fat pad or Morgagni hernia, but couldn’t rule out opacity in the medial basal segment.

    Also there is a prominent mediastinal contour in the right suprahilar region, possibly from the ascending aorta.

  2. Good morning!!

    I think the patient can have a right cardio-phrenic lipomatosis.
    There is something retrocardiac, paravertebral in the left side. I think about an extrapleural posterior mediastinal lesion.

  3. Pt is deviated to let. Side(not well centralized)
    Prominent aortic knob as?? Nipple
    ?? Lower Lt. paravertebral density
    Dense focus rt hilum Calcified LN
    Rt. Cardiophrenic fat pad.
    Multiple lt parahilar nodules mostly vascular.

  4. Prominent acigos.
    I think that there is a retrocardiac increased density, that one year ago was better seen than now. I would recommended a CT scan to study the posterior mediastinum

  5. there is retrocardiac density ,seen on both xrays -this suggest slow growing process. There is progressive narrowing of left main stem bronchus. Descending thoracic silhouette is maintained- suggestion it is not posterior mediastinal .
    so we have middle mediastinal pathology related to airway ,causing narrowing of airway.
    slow growing process hence possibility of bronchogenic carcinoma is rare.
    my favourite differential would be carcinoid tumour with large exophytic component.
    other benign tumours of airways have to be considered.

    1. I forgot to say that the previous film was taking for an episode of pneumonia. This explain the pulmonary infiltrates. My fault. Sorry.

  6. right retrocardiac opacity, right hilun appear larger and more dense comparing with left, there is prominent right paratracheal stripe. can be ca. lung with hilar and mediastinal LNs.
    Chest CT would be the next step

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