The leading case of this week’s Diploma has been provided by my good friend Jordi Andreu. Radiographs belong to an asymptomatic 48-year-old woman.
1. Neurogenic tumor
2. Pulmonary hamartoma
3. Pleural fibrous tumor
4. None of the above
What do you think? Come back on Friday to see the answer!
Click here to see the answer
Findings: PA chest radiograph shows a rounded opacity in the left apex (A, arrow). All diagnosis are possible, as the pulmonary apex is a narrow space and it is very difficult to determine the origin of a mass. The clue lies in the nodular opacities in the neck (A, circle) which raise the possibility of superimposed hair braid.
Unenhanced coronal CT (B) does not show any mass, confirming that the finding is artifactual.
Final diagnosis: superimposed hair braid simulating pulmonary disease
The purpose of this presentation is to discuss elements in or about the soft tissues of the chest wall that may simulate lung disease. Those related to the thoracic skeleton were shown in Diploma case # 57.
This Diploma complements the non-significant findings described in webinar eight.
I have classified them into three groups, the first one related to the soft tissues of the chest wall while the other two are external to the body:
1. Nipples and skin lesions
2. Hair and/or hair implements
Nipple shadows are seen in 3% to 10% of PA chest radiographs. In about 10% of these patients, the identification may raise doubts. Comparison with previous films will confirm the stability of the nodules (Fig. 1). In case of doubt, nipple markers should be placed. Routine use of nipple markers has been proposed in oncologic patients.
Unilateral enlarged nipple shadows are suspicious findings. Visual inspection should be done to confirm that the nipple is indeed enlarged (Fig. 2). Occasionally, a true lung nodule may simulate a nipple shadow, even with nipple markers. In such cases, CT will correct our error (Figs. 3-4)
Skin lesions may also cause false lung nodules. Visual inspection of the chest will demonstrate them and confirm the diagnosis (Fig. 5). If there is any doubt, a marker can be used.
Occasionally, a discrepancy in density between both breasts, usually related to previous surgery, may simulate pulmonary pathology (Fig 6).
In my experience, hair is a common cause of opacities in the lung apices (Fig 7).
Strands of loose hair may project over the upper lung, simulating linear fibrotic infiltrates (Fig 8). Rubber bands at the end of braids may be confused with pulmonary nodules (Fig. 9). A long braid may fool us and consider it intrapulmonary disease (Fig 10).
In most cases, the clue to the diagnosis lies in recognizing that the abnormality extends to the neck.
Clothing artifacts occur when the technician does not ask patients to remove garments that have logos or images on them. This usually happens with women, out of respect for modesty (Figs. 11 and 12).
Other types of body artifacts may cause dubious opacities in the chest radiograph (Figs 13 and 14)
To end the presentation, in the last two months we have been acquainted with a new artifact: the wire in the face masks (Fig 14)
Follow Dr. Pepe’s advice:
1. Unilateral nipple shadows may generate diagnostic problems.
2. If a hair artifact is suspected, look at the soft tissues of the neck.
3. Garments may create weird lung shadows.
5 thoughts on “Dr. Pepe’s Diploma Casebook 157 – SOLVED”
Appears to be a mainly posteriorly located lesion. No discernible pedicle erosion. First rib seems to be affected. There are also some scattered opacities in the soft tissues above the 1st rib. My guess would be 4 – maybe a bony tumor.
It seems with posterior mediastinum origin
There is a increased density of the left first rib and of the apical region with extrathoracic cervical extension. The patient is a woman so the first thing I would do is check for external elements…(ponytail…)
Well done! You get first prize 🙂
answer 4. probably its external, as its very hard to identify on the lateral chest X Ray