Today´s images belong to a 76-year-old man with pain in the back. Antecedents of urothelial carcinoma.
PA chest radiograph was normal and radiographs of the dorsal spine were taken.
What do you see?
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Findings: AP view of dorsal spine shows fixation screws in the lower spine and partial vertebroplasty of D12. The most important finding is that the left pedicle of D8 is absent (A, circle). In the lateral view, the posterior wall of the same vertebra is not seen (B, circle).
The findings are more evident in the cone down views (C-D, circles). In this particular case I was lucky because the superimposed air of the left main bronchus allows an unimpeded view of the missing pedicle.
Review of a recent chest CT demonstrated a lytic lesion in the body and pedicle of D8 (E-G, circles) that were no reported.
Final diagnosis: metastasis to D8 discovered in the plain film of the spine and overlooked in a previous CT.
Congratulations to BujarB, who was the only one to discover the missing pedicle (my hero!)
You may think that this case is difficult (only one of seven found the lesion). In the old times our routine included looking at the pedicles in the AP view of dorsal and lumbar spine. To familiarize you with the appearance of the normal spine, an AP view is shown below.
Teaching point: remember to look at the pedicles in the AP view. A missing pedicle in a patient with a known primary tumor is highly suspicious of metastasis.
20 thoughts on “Cáceres’ Corner Case 221 – SOLVED”
….migrazione cemento vertebroplatica nei vasi polmonari venosi a sx,…embolismo.
Good afternoon professor
Osteoporotic spine,with intact fixation device
Bone cement noted in lower dorsal spine
Opacity in lower zone of left hemithorax
I can’t detect any extremely dense vascular markings suggesting embolism of vertebroplasty acrylic cement. No evident consolidation.
I am very curious about the answer.
Sorry, you will have to wait until Friday. Or you can can get an earlier answer solving the equation: carcinoma + dorsal pain = ?
Good morning .
I think that there is evidence of an osteolytic lesion with well define sclerotic margins on D6 vertebral body (d.d.over imposed structures )
Good morning Professor
Thoracic spine (AP, LAT)
Posterior spinal fixation in the form of low density pedicle screws insitu.
Wedge compression of the T11 vertebra with radiaopaque left pedicle – blastic mets.
Radio opaque nodule in the left lower zone.
Pulmonary cement embolism
See answer to Takis above
Multiple dorsal screw. In the left pedicle of D11 there is a blastic well defined lesion that remember cement, but is the formula is carcinoma + dorsal pain I supposed that the first option has to be vertebral mtx (we have to revised the personal hystory of the patient).
The metastasis is elsewhere. Keep looking 🙂
Looks like there’s a lytic lesion of the left 12th rib which I believe is also visible on the lateral view.
See answer to MK above
….metastasi endocanalare , meningea?….
Left T 12 rib metastasis
2 nodules projected over cardiac shadow
I see osteonecrosis as MS of left pediculus arcus vertebrae of the 7th vertebrae, better seen in Ap image, the so – called “ vertebrae with on eye”.
Litic lesion on D6 vertebral body in the lateral x-ray?
Left pediculus arcus osteolitic lesion 7th toracic vertebrae, better seen on Ap image, the so-called “ one eye vertebrae”. Metastasis.
Left pediculus arcus vertebrae osteoltic lesion of 7th toracic vertebrae, better seen on Ap image. Second lesion – metastasis.
Osteolitic lesion of left pediculus arcus vertebrae 7th toracis vert., better seen on Ap image the so – called “ vertebrae with one eye”