Dr. Pepe’s Diploma Casebook 162 – SOLVED

Dear Friends,

taking advantage of Dr Pepe’s absence I am showing today an unproven case (always wanted to do it!). All relevant images are shown, without comment, looking forward to hear your opinions.
I will share my impressions with you next Friday. Hope we will coincide. We have to wait together until we get the final diagnosis (or not).

Chest radiographs belong to a 66-year-old man with abdominal pain and a history of diverticulitis. The round opacity at the left base led to a review of previous examinations, dating back to 2007.

Abdominal CT for diverticulitis in 2007 and 2008 show a cystic lesion in the left costophrenic sinus

The patient had recurrent episodes of diverticulitis and/or abdominal pain. I am offering several axial CTs in different years to document the evolution of the lesion

Occasionally the chest was also examined. Showing three samples of sagittal CTs with pulmonary window over a ten years’ period.

The last abdominal CT was taken on August 30, 2020. I have selected the most relevant axial, coronal and sagittal images.

Have you reached a conclusion after reviewing all the images?

Click here to see the answer

The case starts in 2019 with chest radiographs of a 66-year-old man with abdominal pain and previous history of diverticulitis. A rounded opacity is seen the left lung base (A-B, arrows). This finding led to a review of previous examinations, dating back to 2007.

Abdominal CTs for diverticulitis in 2007 and 2008 show a cystic lesion in the left costophrenic sinus(C-D, circles). The lesion has grown slightly in one year.

Since 2007 the patient had recurrent episodes of diverticulitis and/or abdominal pain. Several abdominal CTs in different years document the evolution of the lesion: the purely cystic lesion in 2008 (E, arrow) has grown in 2013 and fine septa are seen within it (F, circle).
CT in 2015 shows that the septa are thicker and enhance after contrast injection (G, circle). An unenhanced CT in 2018 demonstrates a smaller lesion with a thick peripheral rim of solid tissue (H, arrows).

Sometimes the chest was included in the CT examination. Three samples of sagittal CTs with pulmonary window over a ten years’ period show that the lesion lies within the left major fissure (A-C, arrows). It looks like a pendulum held by the fissure and has an irregular contour in the last image in 2018.

A final unenhanced abdominal CT taken on August 2020 shows that the appearance of the lesion has not changed significantly in the last two years. In the meantime a small punctate calcification has appeared (L and O, arrows).

Conclusion after review of the images:

1- Slow-growing mass over a period of ten years.

2- The initial cystic mass has developed thick septa and thick peripheral rim.

3- Located within the left major fissure.

4- Punctate calcification.

Given all these finding, my best option is a fibrous pleural tumor of the left pleural fissure which is undergoing malignant transformation.

An alternative diagnosis could be a mucinous pleural tumor if such entity exists.
In my opinion, hydatid cyst is very unlikely. It has been practically eradicated from Spain and I have never seen one within a fissure.

The patient is now in the hands of a competent pneumologist. Hope we will get a definitive diagnosis soon. As soon as I get it, I will post it in the blog ( and, if it happens to be a hydatid cyst, I will do penance in a nunnery).

9 thoughts on “Dr. Pepe’s Diploma Casebook 162 – SOLVED

  1. Interesting is the white spot on the last CT 2018 scan in esophagus. A slight enhancement is seen also on two previous CTs 2015,2013.
    It is definitely slowly growing in the great fissure thus being restricted with pleura folds with no signs of infiltrative /malignant/ growth. Though in case that the mass increases in growth in years it could be at the beginning benign but with the tendency to malignant degeneration.
    Also the bone parts of the ribs seem to have no signs of destruction. (Bone window CT).
    (It is interesting what is the HU characteristics of that mass in nativ and CE scans).
    I would classify it to diaphragmal lesions.
    At the very beginning it seems to be more homogeneous and cystic.
    Could be parasitic lesion.

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  2. Good morning!

    In the x-ray there is an increased density proyected over RUL and in the lateral view there is an hiliar lesion. The pleural nodular lesion looks like an hydatidic cyst, with calcificacions over the years.

    Hydatidic disease with hiliar and pleural lesion.

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