Cáceres’ Corner Case 245 – SOLVED

Dear friends, Dr Pepe has eloped with Miss Piggy (again) and has let me alone, holding the fort. Hope he will be back in time to give the next webinar.

Today’s radiographs belong to a 60-year-old male with cough and moderate dyspnea.

Diagnosis:

1. Hilar lymphadenopathy
2. Right pulmonary artery aneurysm
3. Mediastinal tumor
4. None of the above

Click here to see the answer

Findings: PA and lateral chest radiographs show a right hilar mass (A-B, arrows). In my opinion, the appearance of the mass and its location in the right hilum in the lateral view rules out a mediastinal mass.
There is a small nodule in the RUL (A, red arrow) that can be overlooked unless we look for it

The nodule is better seen in the cone down view and the axial CT (C-D, red arrows), with high SUV in the PET-CT (E, arrow), accompanied by a metastatic node in the mediastinum (E, circle).

Caudal slices of enhanced CT show multiple lymph nodes in right hilum (F, arrow) and mediastinum (G, circle).

Biopsy of a lymph node returned as metastatic carcinoma.

Final diagnosis: carcinoma of the lung with mediastinal metastases

Congratulations to archanareddyt who was the only one to discover the RUL nodule

Teaching point: this is an interesting case for educational purposes.
1. Knowing the most common causes of unilateral hilar enlargement (lymph nodes vs. enlarged artery) helps the differential diagnosis.
2. We should think of common processes rather than unusual ones (lymph nodes vs. aneurysm).
3.  Suspecting unilateral hilar lymph nodes leads to search for the two more common etiologies (TB or carcinoma) leading to the discovery of the RUL nodule.

Hope the case was useful!

22 thoughts on “Cáceres’ Corner Case 245 – SOLVED

  1. Inferior triangle appears normal on lateral view.
    The right bronchus intermedius has a rather steep course and seems to be posteriorly displaced. The mass appears to be projected on the right PA. Could be an aneurysm.

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    1. If it was an PA aneurysm you should not see the hilar arteries as well in the pa. the mass seems to have contact with the VCS. The left hilum looks kind of strange.
      He seems to have an enlarged aortic root, could be a Sinus Valsalva aneurysm.

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  2. 1. Hilar lymphadenopathy
    The region 4 on lateral x-ray have no “donat-view”.
    Besides, on lateral view the contures of the mass are abnormally bulging out, more ventral.
    The trachea is narrowing while one track it from above downwards in region 3.
    CT chest with CA recommended/PET-CT(?)

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  3. 1. Hilar lymphadenopathy – I do not see typical “black hole” – the lumen of both main bronchi on lateral view, besides, on the same view the mass has abnormally multiple bulging out contours though on PA in the right hilum it seems to be smooth and also while tracking trachea the last one seems to narrow near bifurcation and little above.

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  4. Good morning!

    There is a well defined nodular lesion over the right hilum! The left one is normal, the pulmonary-aortic window is free. There are not paratracheal adenopathies. Not donut sign. Elongated aorta with increased side of ascending Ao. Not atelectasi… with all of this negative findings I would think in vascular pathology, but the CT will has the diagnosis.

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    1. The patient is 60 y.o. and the aorta is elongated. To me it does not look abnormal.
      If you believe that the aorta is dilated, remember that we only see the anterior wall. The posterior wall blends with the mediastinum and it is not visible. Therefore, the width of the aorta cannot be evaluated.

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  5. A well defined soft tissue opacity in the right hilum with hilum overlay sign as hilum cn b seen through it. Likely anterior medistinal mass.

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  6. At this moment, the majority of you are divided between pulmonary artery aneurysm and lymphadenopathy.
    I will offer two questions and one comment:

    Which one is more common, hilar lymphadenopathy or aneurysm?
    What are the two more common causes of unilateral hilar lymphadenopathy?

    Comment: don’t forget about satisfaction of search!

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  7. Good evening professor

    1. Hilar lymphadenopathy is more common the aneurysm.
    2. Two common causes of unilateral hilar lymphadenopathy 1. Infection (TB) 2.Sarcoidosis

    There is a small radioopacity in the right upper zone.

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    1. See? If you ask yourself the right questions, you get the right answers.

      I disagree about sarcoidosis being a common cause of unilateral hilar lymphadenopathy 🙂
      See Diploma case 49

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