Dr. Pepe’s Diploma Casebook 168 – Solved!

Findings: there is a rounded opacity behind the heart (A, arrow). CTs show a non-enhancing pulmonary mass with irregular borders attached to the pericardium (B-C, circles).
Post-operative diagnosis: mucoid carcinoma of the lung.

Findings: PA radiograph shows that the left hilum is larger and more opaque than the right one (A, arrow). The pulmonary arch is prominent (A, red arrow). The lateral view shows an enlarged left pulmonary artery (B, arrows) excluding the diagnosis of carcinoma or TB as causes of hilar enlargement. Enhanced axial CT confirms the enlarged left pulmonary artery (insert, arrow).
Diagnosis: Congenital pulmonary valve stenosis with secondary dilatation of the left pulmonary artery due to the jet effect.

Findings: there is a well-defined rounded left apical opacity (A, arrow), better seen in the cone down view (B, arrow)

Coronal and axial enhanced CT confirm the apical mass (C-D, arrows). The patient complained of pain in the left shoulder. Needle biopsy came back as adenocarcinoma.

Final diagnosis: Pancoast tumor

Findings: the initial impression of the PA chest is a left hyperlucent lung with diminished vascularity. A second look shows a descended left hilum (A, arrow) and a concave paraspinal line (A, red arrow) representing the major fissure. These findings are indicative of LLL collapse with compensatory expansion of LUL.

 
Enhanced axial CT confirms the marked LLL collapse (B, arrow). Coronal reconstruction shows irregular bronchial narrowing (C, red arrow) with complete occlusion of the LLL bronchus.

Diagnosis: epidermoid carcinoma with LLL collapse.

Findings: PA radiograph shows a rounded opacity in the lower right chest (A, circle) with incomplete border sign (medial aspect outlined by air, lateral border not visible because in contact with chest wall). The clue to its location is given by the rib erosion (A, red arrow) which places the lesion in the underside of the rib. The border of the erosion is sclerotic, indicating a slow-growing process.
CT confirms a soft-tissue mass (B, circle) and the rib erosion (B-C, red arrows).

Final diagnosis: neurofibroma in a patient with neurofibromatosis.

Findings: PA radiograph shows increased lucency of the lower right lung with decreased vasculature (A, circle). This finding has two main causes: increased lung air or paucity of lung vessels (pulmonary embolism, arterial stenosis). In these cases, the best approach is to take an expiratory film, which will demonstrate whether or not there is air-trapping. If present, it will orient us to a bronchial obstructive process, either central or peripheral

Coronal CT (B) confirms the increased lucency and diminished vasculature of RLL and RML. Scattered bronchiectasis are seen within the lucent lung (B-C, arrows).
Axial expiratory CT (D) demonstrates marked air-trapping of RML and RLL.

The patient had a history of swallowing a peanut at the age of five years, developing RLL pneumonia at that time. Control radiographs demonstrated increased lucency of the lower right lung over the years.
 
Final diagnosis: Lobar Swyer-James/McLeod syndrome secondary to aspiration of a peanut in childhood.

Findings: PA radiograph shows a rounded opacity in the periphery of the left lung (A, arrow) that seems to be calcified. Cone down view shows a whorled pattern (B, arrow). A braid is visible in the left supraclavicular area (A, red arrow).

Scout view of the CT does not show the apparent lung lesion, which is not visible in the axial view of the lung (D). The technician that did the CT noticed that the patient had a long braid with a rubber band at the end.

Final diagnosis: hair braid simulating a lung nodule.