Cáceres’ Corner Case 249

Dear Friends,

today I am presenting the PA chest radiograph of a 77-year-old man who came to the Emergency Room with severe dyspnea.

How many significant findings do you see?

1. One
2. Two
3. Three
4. Four

Click here to see the answer

Findings: AP chest radiograph shows an opaque left hemithorax with displacement of the mediastinum towards the right. The splenic flexure of the colon is pushed downwards (A, arrow) a sign of left diaphragmatic inversion. The appearance of the chest is typical of a massive left pleural effusion. In addition, there are two nodular opacities in the right lung (A, red arrows). There is a lytic lesion of the left third rib (A, white arrow) and the anterior arch is missing (A, asterisk).

These findings are better seen in the cone down views (B-C, arrows). They are highly suggestive of widespread malignant disease.
The patient had a cardiac arrest in the ER and could not be reanimated. Autopsy demonstrated a gastric carcinoma with multiple metastases.

Final diagnosis: Metastases to the chest from carcinoma of the stomach

Congratulations to Rafał, who was the first to see the lytic lesion in the left third rib.
Teaching point: Although the main finding is very obvious (massive pleural effusion), detecting the nodules and the lytic lesion of the rib is the clue to the correct diagnosis of malignancy.
Remember satisfaction of search!

11 thoughts on “Cáceres’ Corner Case 249

  1. I’d go for 4:
    – lucent/lytic lesion in left 3rd rib
    – left lung white-out
    – left lung mass effect: right-sided mediastinum deviation & right lung volume decrease
    – last one I’m not sure about: round opacity in the right tracheobronchial angle (lymph nodes? vascular opacity?)

  2. 1. Opaque Lt hemithorax. Obliteration of Lt heart border and CP angle. No significant crowding of ribs. Obliterated left dome of diaphragm.
    2. Trachea and heart shifted to the Rt
    3. Round opacity Rt hilum – ?LN2.

    Above indicate large pleural effusion on the left.
    These are ‘significant’ findings contributing to immediate symptoms.

    Other findings:

    1. Small nodules superimposed on cardiac shadow, but not otherwise seen in Rt lung field.
    2. Loop of dilated small bowel.

    Do not know significance.

    No significance:
    Cannot see lateral end of left clavicle. Probably due to projection.
    Calcification near left CP angle is most likely costal cartilage.


    1. Radioopaque left hemithorax with mediastinal shift towards right side.
    2. Fracture of the lateral third of the left clavicle.
    3. Fractures of the anterior aspect of left 3rd rib.
    4. Stomach bubble not made out – ? diaphragmatic hernia.

  4. There are opacities in the right lung on the level of anterior parts of 3-4 ribs – lesions vs effusion in the small fissure.

    The mediastinum is shifted completely into right hemithorax and seems to be twisted thus the major vessels appear round. Could be also enlarged lymph nodes.

    The 3d left rib seems to be cut off – the end is too smooth – patient underwent surgery? Than it could be pyothorax.

    Seems he could be oncological patient.

  5. Good morning!!

    White lung with right mediastinal displacement (massive pleural effusion, pulmonary mass or both)

    There is a nodular lesion with well-defined borders proyected over the right hemithorax.

    Both principal bronchi are displaced downwards

  6. Hi there!

    I think of 4 pathologies or even more!

    First, we have a “white lung” in the left hemithorax.
    Second, the left hemidiaphragm and the left border of the heart and mediastinum is obliterated
    Third, there is an obvious mass effect in the left hemithorax that caused shifting of other structures to the opposite direction. as far as I can see, left and right bronchi are patent. Therefore, I would rather suggest something like massive pleural effusion.
    Fourth, round opacities are seen in the middle zone of the right lung.
    and the last one, I can barely see some parts of the 2nd and 3rd anterior left ribs, maybe due to technical factors, but I’m not sure…

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