Cáceres’ Corner Case 239 – SOLVED


Dear Friends,

Today’s case has been provided by my good friend Alberto Villanueva. PA radiograph of a 55-year-old male, taken during a workup for rectal carcinoma.

Diagnosis:

1. Metastasis
2. Pericardial cyst
3. Carcinoma of the lung
4. None of the above

More images will be shown next Wednesday. What do you see?

Click here to see images shown on Monday


Dear Friends,

in my opinion it is difficult to determine in the plain film the origin of large masses adjacent to the mediastinum. I am showing today coronal and axial enhanced CTs.

What do you think?

Click here to see more images


Click here to see the answer

Findings: PA radiograph shows a rounded well-defined mass at the costophrenic angle in the lower left hemithorax (A, arrow). We can infer that the mass is anterior because is displacing the heart towards the right and it does not obliterate the para-aortic line.
In my opinion, when a large mass if adjacent to the midline it is difficult to determine whether it is mediastinal or pulmonary.

Coronal and axial enhanced CT show a solid mediastinal mass with areas of necrosis (B-C, arrows). The most common solid lesion in the cardiophrenic angle are enlarged lymph nodes, which usually are multiple and not very large. In big soft-tissue tumors of this area a thymic origin should be suspected. Although thymic tumors originate in the anterior superior mediastinum, they may slide down along the mediastinal planes and appear at the cardiophrenic angle in the lower mediastinum. Biopsy confirmed the diagnosis of thymoma.

Final diagnosis: mediastinal thymoma

Congratulations to Mohamed Abdulghaffarand MK who were the first to suggest the correct diagnosis

Teaching point: Remember that CT is very helpful in diagnosing cardiophrenic angle masses according to their radiographic density: fat (pericardial fat pad, Morgagni’s hernia); fluid (pericardial cyst) and soft-tissue ( lymphadenopahy and the occasional thymic tumour).

15 thoughts on “Cáceres’ Corner Case 239 – SOLVED

  1. A huge LV wall aneurysm? I don’t know if they could be asymptomatic with that size. There ir a small left pleural effusion also.

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  2. A large well-defined rounded mostly cystic lesion in the left inferior lung field, pushing the heart contralaterally with no rib erosions or invasion, likely pericardial cyst. DD left ventricular aneurysm ?

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    1. Remember that you cannot differentiate between solid and cystic lesion in the chest radiograph. Both have the same radiographic opacity

      Liked by 1 person

  3. Maybe bronchogenic cyst. Can be asymptomatic and incidentally discovered on a CXR.
    The aortic stripe is visible so no posterior lesion. Does not look contiguos with the heart.

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    1. I agree with the location: it has to be anterior because the aortic stripe is visible and the heart is displaced towards the right.

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  4. It is well defined homogenous lesion surrounded by otherwise normal lung parenchyma on a plain chest x-ray. The lower lobes, posterior lung segments are affected more often and X-ray suggestive of Parasitic Lung disease !! common in immunocompromised patients.

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  5. Good morning!! There is a mass in the left cardiophrenic angle (extrapulmonary). It´s a solid and hypervascular lesion with hypodense center (necrosis vs cystic). I would think about thymic pathology.

    Thanks

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