Today’s images belong to a 67-year-old woman with pain in the chest.
What do you see?
More images will be presented next Wednesday and the answer will be published on Friday, as usual.
Click here to see more images
Showing additional axial CT images of the patient.
What do you see?
Click here for the solution
Findings: PA chest radiograph shows a lytic lesion of the 3rd right rib, accompanied by an extrapulmonary sign (A, circle). Lateral view (not shown) is unremarkable.
The lesion is more obvious in the cone-down view (B, circle), specially when compared to a previous study (C, circle).
Axial CT confirms a permeative lesion of the rib (D-E, arrows), as well as lytic lesion in the posterior elements of the 4th thoracic vertebra (E, red arrow). A serendipitous finding is a nodule in the medial quadrant of the left breast (F, arrow), demonstrated in a subsequent mammography (G, arrow) and confirmed to be a carcinoma.
Final diagnosis: carcinoma of the breast with osseous metastases
Congratulations to Diogo who saw and described the rib lesion in the plain film.
Teaching point:remember that our most common error is missing obvious lesions.
Checklists help to correct oversights. I believe the rib lesion could have been found if you had applied the checklist recommended in webinar one (H).
15 thoughts on “Cáceres’ Corner Case 219 – SOLVED!”
Fusiform dilatation of the aorta with deviation to the left side suggustive of aortic aneurysm however aortic dissection should be ruled out for clinical correlation
….la patologia e’ sull’arco aortico ove e’ visibile un doppio contorno come da dissezione aortica…..
There’s an expansily lytic lesion in the 3rd right rib and probably a pathologic fracture. At this age, i’d be concerned about a metastasis (RCC, breast) and multiple myeloma/plasmocytoma.
Good evening Professor
CHEST PA VIEW :
1. Left paraspinal line displaced laterally – d/d paravertebral abscess, Aortic aneurysm.
2. Expansile lesion in the right 3rd rib.
There is a double aortic contour in descending aorta, so disection must be rule out. Fracture of the right third costal arc
Unusual location for a fractured rib, specially with no history of previous trauma.
Tortuos aorta. Tracheal narrowing at carina.
?Retrosternal space less translucent.
CT ratio normal.
could be PAU of prox descending aorta. ->angio CT next
Abnormal shadow of thedescending aorta more displaced with unclassic course mildly dilated high possibility of aneurysm, dissection to be excluded
Good evening professor
Radiograph showing deviation of left paraspinal line
An enhancing irregular lesion in the left anterior chest -malignant mass in breast
Multiple lytic lesion in? D4 thoracic vertebrae and posterolateral aspect of third rib
Breast malignancy with multiple lytic Metastasis
The answer is easy in the CT and also in the chest radiograph if you follow the checklist described in the first webinar 🙂
expansile lytic lesion in right third rib with soft tissue lesion with irregular borders in left breast , mets from breast cancer