Dr. Pepe’s Diploma Casebook 163 – SOLVED

Dear Friends,
I am back with a new Diploma case. Miss Piggy sends her regards😍 and has helped to choose the case.
Chest radiographs belong to a 74-year-old man with a cough and pain in the chest.

What do you see?

Click here to see the answer

Findings: PA radiograph shows a bulge in the left paraspinal line (A, arrow), suggestive of a posterior mediastinal mass. A rounded posterior opacity is seen in the lateral view (B, arrow).

Unenhanced coronal and sagittal CT show large osteophytes displacing the paraspinal line (C, circle) pushing the aorta forward in the sagittal view(D, circle). Incidental gas is visible in the intervertebral disk.

Final diagnosis: large osteophytes simulating a pulmonary/mediastinal mass

The aim of this Diploma is to discuss chest imaging in the elderly. As patients get older the appearance of their chest radiographs changes in comparison with young persons. I intend to discuss changes associated to aging as well as the most common pathologies in the old.

I have divided the presentation into three separate chapters:

1- Bony structures of the chest
2- Heart and mediastinum
3- Lungs and diaphragm

Today I will comment on the main manifestations of aging in the chest skeleton, discussing variations that may simulate disease, followed by the most common bone pathologies in the elderly.

NORMAL VARIANTS IN THE AGED

Degenerative changes are the hallmark of the aging skeleton.Vertebral osteophytes are common and large ones should not be confused with pulmonary nodules (Fig 1) or mediastinal masses (Fig 2), as shown in the initial case. The diagnosis is easily made with chest CT.

Fig 1. 67-year-old male without significant symptoms. PA radiograph (A) is unremarkable. Lateral view shows a posterior nodule that could be intrapulmonary (B, arrow).

Coronal and sagittal unenhanced CT show that the nodule represents a large osteophyte (C-D, arrows). The absence of other osteophytes makes it difficult to suspect this diagnosis in the plain film.
Fig 2. 65-year-old man in whom a posterior mediastinal mass was discovered (A-B. arrows). The mass was unchanged in comparison with a previous examination. CT was recommended because a neurogenic tumor could not be excluded.
Unenhanced coronal and sagittal CT demonstrates that the mass represents a single large osteophyte (C-D, arrows)

Calcification of the first costal cartilage may happen in the young but it is more common in the elderly. When asymmetrical, it may be confused with a pulmonary nodule (Fig 3). Exuberant cartilage calcification may simulate an upper lobe infiltrate (Fig 4).

Fig 3. 70-year-old man with a large pleural effusion, suspected to be malignant because of a possible nodule in the LUL (A, arrow). Cone down view shows that the nodule es calcified and corresponds to the first costal cartilage (B, arrow). Post-pneumonic empyema.
Fig 4. 69-year-old woman with fever. Exuberant calcification of the first right costal cartilage was initially diagnosed as pneumonia (A, circle). Comparison with a radiograph taken four years earlier did not show any change (B-C, arrows).

Aging causes brittle bones and explains the increased incidence of costal fractures in the elderly. The callus of a healed fracture should not be confused with a pulmonary nodule (Fig. 6).

Fig 6. 74-year-old woman in whom a RUL nodule appeared one year after cardiac surgery (A, arrow).
A 3-D reconstruction shows that the nodule represents a healed fracture of the second rib (B, circle). Ribs fractures after cardiac surgery are not uncommon

Resuscitation maneuvers, not uncommon in advanced age, may cause bilateral rib fractures, that should be recognized as such (fig 7).

Fig 7. 63-year-old man with prostate carcinoma, complaining of chest pain. PA radiograph shows
sclerotic areas in the lower ribs (A, arrows), not present in previous films. My initial impression was metastatic disease, until I learned that the patient has had resuscitation maneuvers a few months earlier. Axial and coronal CT confirms symmetrical healed fractures of the anterior lower ribs (B-C, circles).

SKELETAL PATHOLOGY

The most common bone pathology in the elderly are fractures. Acute rib fractures are common, most of them secondary to falls (Fig 8). Detection is important because they cause respiratory impairment that may end in pneumonia with the subsequent increase of morbidity and mortality.

Fig 8. 78-year-old alcoholic man after a fall. PA radiograph shows displaced rib fractures (A, circle) as well as pneumothorax (A, red arrow) and subcutaneous emphysema Note the straight air-fluid level of hemothorax at the left base (A, arrow)

Compression fractures of vertebral bodies are related to osteoporosis and common in the elderly. They cause significant pain, leading to inability to perform daily activities. If they are not recognized they cause a decline of the quality of life in elderly patients (Fig 9).

Fig 9. 84-year-old woman with chronic back pain. PA radiograph (A) is unremarkable. Lateral chest shows a severe compression fracture of D9 (B, circle), better seen in the cone down view (C, arrows).

Lytic bone lesions in the elderly are usually related to metastases or multiple myeloma. Sclerotic metastases are common in old males. Given the prevalence of prostate carcinoma this should be our first diagnostic consideration in widespread sclerotic lesions (Fig 10). The differential diagnosis includes myelofibrosis (fig 11) and chronic renal failure (Fig 12).

Fig 10. 71-year-old male with widespread sclerotic lesions of ribs and spine secondary to metastases from prostatic carcinoma.

Myelofibrosis is a myeloproliferative neoplasm which cause osteosclerosis. The association of an enlarged spleen should alert us to this possible diagnosis.

Fig 11. Preoperatory chest film in a 67-year-old woman. Diffuse increased bone density (A), better seen in the cone down view of left shoulder (B). The medially displaced gastric bubble suggests splenic enlargement (A, arrow). Myelofibrosis suspected and confirmed.
Fig 12. 73-year-old woman with chronic renal failure. PA radiograph (A) shows deformity of the rib cage. Lateral view (B) show the rugged-jersey spine, typical of this entity.

Solitary sclerotic lesions of the skeleton raises the possibility of metastasis vs. Paget disease. In the spine, Paget disease usually increases the size of the vertebra whereas metastases do not (Fig 13). In the peripheral skeleton the increase in width of the cortical bone is characteristic of Paget disease (Figs 14-15) .

Fig 13. 68-year-old man who presented with back pain. PA radiograph (A) is unremarkable. Lateral view shows an ivory vertebra (B, circle) that has the same size than the others.
Diagnosis: metastasis from prostatic carcinoma.
Fig 14. Two patients with Paget disease of a rib. Note the increased cortical thickness of the 6th rib in the first patient compared to the other ribs (A, arrow) a hallmark of Paget disease. The second patient has sclerosis of the whole 6th rib which is increased in size
(B, arrow), another characteristic of Paget.
Fig 15. 70-year-old man with prostate carcinoma and metastasis to the anterior third rib (A-B, arrows). Note the difference with the previous cases.


Follow Dr. Pepe’s advice:

1. Osteophytes and healed rib fractures may simulate pulmonary nodules in the elderly

2. It is important to detect rib or vertebral fractures in the elderly because they may be the source of complications

3. Sclerotic bone lesions in the elderly are usually due to prostate metastases or Paget disease

17 thoughts on “Dr. Pepe’s Diploma Casebook 163 – SOLVED

  1. In right hemithorax both costodiaphragmal and cardiodiaphragmal sinuses are obscured with thickened pleura on anterior thorax wall and small gas-fluid levels projecting on costodiaphragmal sinus on PA and anteriorly at the level of diaphragmal contour.
    Some air is seen in soft tissue – emphysema.
    On lateral view at the level of lower lobe not homogeneous opacity is seen – could be shadow summation due to vessels, interstitial lung changes and osteophytes of thorax vertebrae.

    Right insular hydropneumothorax with soft tissue (muscle) emphysema possibly iatrogenic.

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    1. Elderly persons have multiple changes in the chest, most of them related to old age and without clinical relevance.

      In my opinion, the most important finding is the lower lobe opacity in the lateral view.

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  2. ….carissimo PROF….opacita’ omogenea in sede paramediastinica dx, con lieve sollevamento del diaframma ed iperchiarezza del restante polmone da atelettasia marcata del lobo medio ed inferiore….

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  3. Good morning!!

    There is an obliteration of the right costophric angle and seems to condition retraction of the hilum and neighboring structures. Prominente vascular bilateral hilum. In the lateral view there is an increased density in the inferior lobe.

    Prominente aortic arc that displaces the trachea.

    There is a calcificacion of the anterior longitudinal ligament (any relevant medical history?).

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  4. Right costophrenic angle blunting
    Epicardial fat causing obscuration of right cardiophrenic angle
    Retrocardiac irregular opacity seen on lateral view in prevertebral region in lower zone
    Spine appears kyphotic and osteopenia with marginal syndesmophytes
    Bilateral paravertebral stripe widened inferiorly on PA view but no corresponding correlate on lateral view
    Imp- ankylosing spondylitis with left lower lobe fibrotic changes and right costophrenic pleural thickening

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  5. Pa reveals a focal lateral bulge of left paravertebral stripe. On lateral view , iregular ipacity in the left lower lobe. My opinion: suspect posterior mediastinal leasion – mass.

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