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.