Cáceres’ Corner Case 256 – SOLVED

Dear Friends,

welcome to the second trimester of 2021! Showing today PA chest radiograph of a 66-year-old man with chest pain without any other symptoms.

What do you see?
More images will be shown on Tuesday and Wednesday.

Dear friends, showing today the lateral chest view.
Does it help?

Today I am showing an enhanced axial CT.
What would be your diagnosis?

Click here to see the answer

Findings: PA chest radiograph shows an increase in size and opacity of the left hilum
(A, arrow), due to superimposition of a well-defined posterior mass visible in the lateral view (B, arrow). At first glance, the appearance of the mass is compatible with an extrapulmonary lesion. However, there is retrocardiac nodule in the PA view (A, red arrow), suggesting a metastasis from an intrapulmonary mass.

Enhanced axial CT confirms an irregular pulmonary mass (C, arrow), which is invading the chest wall, as confirmed by the displaced intercostal artery (C, yellow arrow) and erosion of the underlying rib (D, circle).

Caudal slices confirm the retrocardiac nodule (E, white arrow) and additional nodules (E-F, red arrows) representing pleural implants.
Biopsy of the main mass returned as lung carcinoma.

Final diagnosis: Carcinoma of the lung simulating an enlarged hilum in the PA view.
 
Congratulations to Dr LeLam and thaf1212, who detected the retrocardiac nodule, which is the clue to determine that the main mass is intrapulmonary.
 
Teaching point: Remember that one of the three causes of unilateral enlarged hilum is superposition of a pulmonary opacity either in front or behind the hilum (the other two are enlarged hilar lymph nodes and increase in size of the pulmonary artery)

15 thoughts on “Cáceres’ Corner Case 256 – SOLVED

  1. Prominent pulmonary vascular markings especially both upper zone . The left hilar shadow is prominent and the vascular markings are leading to the left hilar shadow. Few fibrotic streaks lower zone left lung

  2. Nodular lesion in the left lower lung lobe and the right hemidiaphragm interrupted, opaque right – side cardiophrenic angle (fat ??)

  3. Good morning Dr.Pepe ..
    There seem to be lamellar intimal calcifications luminally displaced in the aortic arch, which is not dilated .. given the chest pain, could it be an aortic dissection?

  4. I identify a change in appearance in the contour of the aorto-pulmonary band which is shown with sum of densities and convex border, this is ratified as an area of ​​posterior opacity in the lateral view

  5. On lateral view there is homogeneous opacity at the level of hilum in 6th zone. Thoracic vertebrae of upper leve seem to be too hyperlucent (severe osteoporosis)

  6. On the lateral view, there is mass in posterior mediastinal.
    Neurogenic tumors are the most common

  7. There is a mass projected over the left hilum. You can see the hilar vessels ‘hilum overlay sign’ suggesting this mass is either anterior or posterior.
    On lateral view, the mass is located in the posterior mediastinal.
    CT thorax shows well-defined soft tissue density lobulated solid mass lesion within the superior segment of the left upper lobe in the left paravertebral/subpleural location. It shows mild homogeneous post-contrast enhancement.No obvious bony erosions or destruction within adjacent vertebra or widening of neural foramina. No obvious posterior chest wall extension or paraspinal muscle infiltration of the lesion.
    Most masses in the posterior mediastinum (paravertebral location) are neurogenic in nature. These can arise from the sympathetic ganglia (e.g. neuroblastoma) or from the nerve roots (e.g. schwannoma or neurofibroma).
    My opinion : schwannoma or neurofibroma

  8. There is a thin vessel in the center of the mass that corresponds to the intercostal artery. It is displaced by invasion of the extrapleural tissues, which would be very unusual in a neurogenic tumor.

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