Cáceres’ Corner Case 250 – SOLVED

Dear Friends,

Welcome to the year 2021! Beginning with an easy case: chest radiographs of a 76-year-old man with pain in the left hemithorax.

What do you see?

More images will be shown on Wednesday.

Click here to see Monday images

Dear friends, showing today CT images of the chest and abdomen.
What do you think?

Click here to see more images

Click here to see the answer

Findings: PA radiograph shows a well-defined opacity in the right apex (A, arrow). The posterior arch of the third rib is missing (A, asterisk). These findings were not present in a previous radiograph taken five years earlier (B).

Lateral view shows a posterior extrapulmonary mass (C, arrow), better seen in the cone down view (D, arrow).

The findings are indicative of a lytic rib lesion accompanied by an extrapulmonary mass. The most likely etiology in the adult is a malignant process, either metastasis or myeloma. A benign process such as fibrous dysplasia usually increases the size and the density of the bone. The location and the well-defined border goes against a Pancoast tumor.

Axial and sagittal CTs confirm the extrapulmonary mass (E-F, arrows) as well as the destroyed third rib (F, circle).

Axial CT of the upper abdomen demonstrates a mass in the tail of the pancreas (G, circle). Needle biopsy confirmed the diagnosis of pancreatic carcinoma.

Final diagnosis: pancreatic carcinoma with metastases to the left third rib

Congratulations to Mestasmarcos who was the first to suggest metastasis in the plain film.
Teaching point: Remember that a lytic rib lesion in the adult should be considered malignant (metastasis vs myeloma) until proven otherwise.

12 thoughts on “Cáceres’ Corner Case 250 – SOLVED

  1. There is the destruction of posterior part of 4th rib on left side with additional tissue component, which on lateral view is well seen as convex lens. The margins of the shadow are smooth, well defined, irregular.

      1. seems to be pancreatic ca with chest wall mts, but I also heard that local abscess could provoke septicemia with metastatic abscess somewhere else.

        but more inclined to think about malignancy

  2. Left 4th rib is not visualised.
    Opacification of left retrosternal clear space with well defined margins.
    Well defined convexity is also seen in the posterior mediastinum with mild compression of dorsal vertebral body.

  3. Left Posterosuperior extrapleural opacification/mass; 4th rib not seen (probably destroyed) it looks like a rib tumor.

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