Dr. Pepe’s Diploma Casebook 152 – All you need to know to interpret a chest radiograph – Sixth Session – SOLVED

Dear Friends,

Welcome to the new year and a new webinar. The leading images of the webinar six belong to a 73-year-old woman with dyspnea and chest pain. What do you see?


1. Intrathoracic goiter
2. Dilated esophagus
3. Aortic aneurysm
4. Any of the above

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Findings: PA radiograph shows widening of the right superior mediastinum (A, arrow), which in the lateral view is located behind the trachea (B, arrows). The initial impression is of an upper middle mediastinal mass. The first diagnosis that come to mind is a goiter.

However, looking downward in the PA view, bulging of the azygo-esophageal line is evident (A, red arrow). In the lateral view there is opacification of the retrocardiac space (B, red arrow). Therefore, we are dealing with a lesion that extends along the middle mediastinum from top to bottom. The findings point to a dilated esophagus.

Esophagogram was unremarkable. Coronal and sagittal CT shows a cystic tubular mass extending along the posterior wall of the esophagus (C-D, arrows).

Final diagnosis: cystic lymphangioma of mediastinum
This is a difficult case and I didn’t expect you to make the diagnosis. But I believe that you should have noticed the bulging of the azygo-esophageal line in the PA view and the occupation of the retrocardiac space in the lateral view, suggesting a dilated esophagus as the most likely diagnosis.
Congratulations to MG who was the first to see the findings.
Teaching point: Remember that an opacity that goes from top to bottom in the middle mediastinum should suggest a dilated esophagus or an esophagus-related process

12 thoughts on “Dr. Pepe’s Diploma Casebook 152 – All you need to know to interpret a chest radiograph – Sixth Session – SOLVED

  1. Good evening professor

    Lesion widening left paratracheal stripe extending to anterior and middle mediastinum- intrathoracic goitre

  2. Good evening Professor


    1. Widened upper mediastinum


    1.Displacement of the tracheal air column forward by rounded opacity.


  3. There is also filling of the retrosternal and retrotracheal space, thickening of the retrotracheal stripe and hazy delineation of the right neck soft tissues (compared to the left). A possible goiter imho

  4. To all of you, thanks for participating and a friendly advice: look carefully at the chest images and see if your diagnosis changes 🙂

  5. Good morning!!

    In the PA x-ray there is a lesion with convex borders lateral to the trachea. In the lateral view the trachea is displaced anteriorly, and I can´t see the esophagus. I think about mediastinal lesion.

    Cifotic spine

  6. There is widening of the paratracheal line and displacement of the azygo-esophageal line. On the lateral view the trachea seems to be displaced anteriorly – maybe due to degenerative disease of the spine with several broken vertebrae.
    I would go with the answer 4 and suggest achalasia or other widening of the esophagus.

  7. What is located behind the trachea and pushes it forward? And displaces the azygoesophageal line?

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