Dr. Pepe’s Diploma Casebook 169 – SOLVED

Dear Friends,

Presenting a new case of “Big little findings”. Preoperative chest radiograph for meniscus surgery in a 56-year-old woman.

What do you see?

Click here to see the answer

Findings: PA view shows a small right hemithorax. There is elevation of the right hemidiaphragm and a small hilum (A, red arrow). The findings are very suggestive of RLL lobectomy. The oblique fissure in the RLL represents the displaced minor fissure (A, white arrow). Previous CT shows a normal-size right lung with a ground-glass opacity in the RLL (B, arrow).

Final diagnosis: RLL lobectomy for adenocarcinoma of the lung

I am showing this case to discuss displacement of the lung fissures, an important finding that can indicate partial collapse of the underlying lobe. Usually, lobar collapse is detected because of the increased opacity of the lobe. Occasionally, the collapsed lobe retains much of its air, so a shift of the fissure may be the only sign of collapse.

A potential pitfall of fissure displacement is previous surgery, as seen in the case presented. In my experience, excluding previous surgery, aerated lobar collapse occurs mainly in the following conditions:

1. Inflammatory peripheral lung disease
2. Central lobar bronchial obstruction
3. Rounded atelectasis

The right minor fissure is visible in about 50% of chest radiographs as a straight horizontal line at the level of the right hilum (Fig. 1, A and B) The right and left major fissures are not visible in the PA film because their course is not tangential to the x-ray beam. (A, curved dotted lines). They are both visible as oblique lines in the lateral view (B).

Fig. 1
Fig. 2. PA radiograph showing the minor fissure (A, arrow). The lateral view shows both the right minor and major fissures (B, white arrows) and the upper portion of the left major fissure (B, red arrow)

Inflammatory lesions can cause scarring which diminishes the size of the affected lobe. TB is the most common cause in upper lobes. Bronchiectasis is the predominant cause in lower lobes. Both conditions can show an aerated lobe with loss of volume (Figs. 3-5).

Fig. 3. 68-year-old woman with previous history of TB. There is aerated partial collapse of RUL as evidenced by the elevated minor fissure (A and B, white arrows). Fibrotic changes are seen in the apex (A and B, red arrows). An incidental finding is calcification of breast prostheses.
Fig. 4. RLL collapse secondary to bronchiectasis. There is an oblique line at the right base (A, white arrow) that simulates an inferior accessory fissure. However, the right hilum is markedly low (A, red arrow), indicating loss of volume of RLL. Coronal CT shows marked RLL collapse with bronchiectasis, outlined by the displaced major fissure (B, arrow).
Fig. 5. 56-year-old man with previous TB. Lateral view shows forward displacement of the left major fissure (A, arrows), indicating partial collapse of LUL. PA radiograph depicts marked elevation of left hilum (B, arrow), secondary to fibrotic TB.

Central lobar bronchial obstruction is occasionally associated with aerated lobar collapse. It is thought to be due to collateral air ventilation through incomplete fissures (Figs. 6-7).

Fig. 6. Routine follow-up of an 82 y.o. man who underwent surgery for laryngeal carcinoma 10 years ago. PA view shows abnormal left hilum and blurring of the left cardiac contour (A, arrow). Lateral view shows marked forward displacement of the left major fissure (B, arrows) indicating severe LUL collapse.

Unenhanced axial CT confirms the marked LUL collapse (C, white arrow) secondary to endobronchial obstruction (C, red arrow). CT taken one year earlier shows an endobronchial lesion (D, red arrow) and discrete forward displacement of the major fissure (D,E, white arrows). These changes were overlooked. Surgical diagnosis: bronchogenic carcinoma

Fig. 8. Aerated RLL collapse in central carcinoma. PA radiographs shows a very low right major fissure (A, red arrow), better depicted in the cone down view (B, arrow). The left hilum is descended (A, white arrow). Bronchoscopy discovered a carcinoma of the RLL bronchus. The oblique line in the RUL corresponds to a scar.

Rounded atelectasis is a common cause of fissure displacement. It occurs secondary to spiral folding of the lung parenchyma when fixed by thickened pleura. The consequence is a peripheral rounded opacity in an aerated collapsed lobe. The volume loss, detected by the displaced fissure, avoids possible confusion with a true nodule in the plain film.

Fig. 9. Asymptomatic 49-year-old man with rounded atelectasis. Notice the visibility of the left major fissure, indicating LLL volume loss (A, arrows). Lateral view shows an ill-defined posterior opacity which corresponds to the rounded atelectasis (B, arrow).

Axial and sagittal CT confirm displacement of the left major fissure (C and D, white arrows), the small LLL, and the posterior rounded atelectasis (C, red arrow).

As a final thought, occasionally you may find fissure displacement without an apparent cause (Fig. 10).

Fig. 10. 92-year-old man, asymptomatic. PA radiograph shows downward displacement of the minor fissure (A, white arrow), major fissure (A, yellow arrow) and right hilum (A, red arrow). In a previous film four years earlier, the minor fissure (B, yellow arrow) and the right hilum (B, red arrow) were moderately descended. Since the patient was 92 y.o. and had no symptoms, his physician decided not to do a CT scan. My impression is that he has fibrotic changes in the RLL, which is not unusual in advanced age.

Follow Dr. Pepe’s advice:
1. A displaced fissure may be the only manifestation of aerated lobar collapse (always exclude previous surgery).

2. Most common causes:

a) Peripheral lobar inflammatory disease

b) Central bronchial obstruction

c) Rounded atelectasis

Cáceres’ Corner Case 253 – SOLVED

Dear Friends,

Today’s case is a PA chest radiograph for knee surgery in a 28-year-old man.

What do you see?

Click here to see the answer

Findings: PA chest radiograph shows an osteochondroma in the right humerus (A, yellow arrow). There are two more in the anterior arch of the left fifth rib and in the proximal end of the right clavicle (A, red arrows).
They are better seen in the cone down views (B-D, arrows).

The first and only diagnosis that comes to mind is multiple osteochondromatosis, confirmed with views of the lower extremities (E-G).

Final diagnosis: Multiple osteochondromatosis.
Most of you did very well in this case. Congratulations to Mauro, who was the first and to Kaushalya and Ali who made back-to-back diagnosis in a five-minute interval.
Teaching point: remember to look at the bones of the chest, especially when taking an examination. It may surprise the examiner and win you a few extra points.

Dr. Pepe’s Diploma Casebook 168 – Solved!

This week’s case is a little special! Prof. Cáceres has prepared a Quiz that will to challenge your knowledge and your speed reviewing radiographs! The quiz contains 7 different cases with radiographs and you will have 60 seconds to answer each question! The three participants with highest score will receive a signed picture of Dr. Pepe 😀

Are you up for the challenge? Join the quiz here It will start on Thursday 18th, at 12:00 CET.

On Friday Prof. Cáceres will publish the explanation for each case on the blog.



71-year-old man with hemoptysis:

In which quadrant will you place the lesion?

1. Right upper quadrant
2. Right lower quadrant
3. Left upper quadrant
4. Left lower quadrant

Click here to see the answer

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.



43-year-o.ld male with moderate cough.

Most likely diagnosis:

1. Tuberculosis
2. Enlarged left pulmonary artery
3. Carcinoma
4. Any of the above

Click here to see the answer

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.



60-year-old man with chest pain.

In which quadrant will you place the lesion?

1. Right upper quadrant
2. Right lower quadrant
3. Left upper quadrant
4. Left lower quadrant

Click here to see the answer

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



65-year-old man with cough and dyspnea


1. Unilateral hyperlucent lung
2. Pneumothorax
3. Giant bulla
4. Carcinoma of the lung

Click here to see the answer

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.



33-year-old man with pain in the right hemithorax

Where is the nodule located:

1. Lung
2. Pleura
3. Chest wall
4. Need a CT

Click here to see the answer

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.



32-year-old man with chronic cough

In which quadrant will you place the lesion?

1. Right upper quadrant
2. Right lower quadrant
3. Left upper quadrant
4. Left tower quadrant

Click here to see the answer

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.



17-year-old woman with moderate cough

Most likely diagnosis:

1. Benign pulmonary nodule
2. Arteriovenous malformation
3. Pleural plaque
4. Artifact

Click here to see the answer

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.

Cáceres’ Corner Case 252 – SOLVED

Dear Friends,

Since this week is my birthday, I am showing a simple case. Chest radiographs were taken in a routine study for asbestos exposure in a 42-year-old man.

Will show more images on Wednesday.

Click here to see the images shown on Monday

Dear Friends,

showing today a cone down view of the lateral chest. What does the pattern suggest?

Click here to see the new images

Click here to see the answer

Findings: PA radiograph shows punctate opacities in the upper and middle thirds of the right lung. The right heart border is indistinct (A, circle) suggesting RML disease.

The lateral view confirms RML disease (B, circle). A cone down view demonstrates thick lineal branching lines (C, circle) highly suspicious of dilated mucous-filled bronchi.
(Branching structures in chest radiograph are either vessels or mucous -filled bronchi).

Unenhanced sagittal and axial CTs show bronchiectasis of RML and lingula (D-E, circles).

Final diagnosis: RML bronchiectasis detected in the lateral view of the chest
Congratulations to MK, who made the diagnosis.
Teaching point: I presented this case because it is a nice example of bronchiectasis with mucous impaction suspected in the plain film. I posted it on Monday without having seen the CT because whoever read it told me that bronchiectasis were present.
I reviewed the CT two days ago and was surprised to discover two vital findings
that I had not been told:
1. The CT showed centrilobular and tree-in-bud opacities (F-G, circles), typical signs of bronchiolitis.
2. These findings plus RML and lingular bronchiectasis are a classic presentation of atypical mycobacterial infection.

So, what started as an unsuspected discovery in the plain film ended up with the serendipitous diagnosis of atypical mycobacterial infection (unproven, but likely). The attending physician has been notified and when a germ is found I would let you know

Dr. Pepe’s Diploma Casebook 167 – Big little findings – SOLVED

Dear friends,
Presenting today a new case of “Big little findings”. This case is not recommended for the faint-hearted 😱
Chest images belong to a 65-year-old woman with moderate cough. Since I am your friend, I am including an axial CT.

What do you think?

Click here to see the answer

Findings: PA radiograph shows a curvilinear opacity in the right middle/lower lung (A, arrows). The right lung is slightly smaller than the left and the hilum looks abnormal (A, circle). Aside from slight elevation of the right hemidiaphragm, the lateral view (B) is unremarkable.

Coronal CT shows that the curvilinear line represents a scimitar vein draining below the diaphragm (C, arrow). The right pulmonary artery describes an unusual path (D, circle) and there is abnormal branching of the right main bronchus (D, circle).

An unexpected finding is an oblique band in the lower right lung (E and F, arrows). The bronchi and RLL vessels pass through an opening in the center (E and F, circles).

Final diagnosis: hypogenetic right lung with duplicated diaphragm

The reason I’m presenting this case is to discuss duplication of the diaphragm, an uncommon congenital malformation associated with hypogenetic lung.

As you all know, hypogenetic lung is a congenital malformation characterized by absence of one or two lobes of the right lung, with abnormal lower lung venous drainage (scimitar vein) in 80% of cases. It is asymptomatic and almost always occurs on the right side. Because it is symptomless, it is usually found incidentally in adults .

Typical signs in the PA chest radiograph (Fig. 1) reflect the small size of the lung:

1. Small right hemithorax with secondary dextrocardia
2. Small right hilum
3. Anomalous vein in RLL (scimitar sign), not always present

Fig. 1. PA radiograph (A) shows typical appearance of hypogenetic lung: small right hemithorax, secondary dextrocardia, and a scimitar vein (A, arrows) coursing downwards to join the IVC. Enhanced coronal CT in a different patient shows the scimitar vein to better advantage (B, arrow). Axial CT confirms the small right hemithorax and abnormal branching of the right main bronchus (insert, circle).

Occasionally, hypogenetic lung occurs with minimal hypoplasia, a normal-sized right lung, and absent dextrocardia. In these patients (such as the initial one), the scimitar vein and abnormal right hilum are the clues to the diagnosis.

In my experience, these cases are the ones most commonly associated with duplicated diaphragm, an infrequent malformation resulting from an alteration of caudal migration of the embryonic diaphragm.

Anatomically it appears as a band running obliquely from the chest wall to the right hemidiaphragm (Fig. 3, drawing).

If we’re lucky, we might see it as an oblique line in PA and lateral radiographs (Fig. 4), but it is usually not visible or overlooked (Fig. 5). An additional sign is blurring of the central part of the right hemidiaphragm, where the duplication ends (Figs. 4 and 5).

Fig. 3. Coronal and axial drawings demonstrating the appearance of the duplicated diaphragm (A and B, blue lines) and vessels crossing through the central orifice (A and B, in red).
Fig. 4. Duplicated diaphragm visible in the PA and lateral radiographs as an oblique band (A and B, white arrows). Note that the contour of the right hemidiaphragm becomes blurred where the duplicate joins it (A and B, red arrows). Axial CT confirms the duplicated diaphragm (C, white arrows) and crossing vessels (C, red arrow). A scimitar vein was not present in this patient.
Fig. 5. Blurring of the central right hemidiaphragm (A, red arrow) and an oblique line in the lateral view (B, red arrow) were present in the initial case, but they were overlooked. Signs in the chest radiograph can be too subtle. My advice is to rely on the CT findings.

My hard-learned experience tells me it is very difficult to suspect duplicated diaphragm on plain films. It is usually discovered in a CT performed to confirm a hypogenetic right lung or for other reasons.
The good news is that the CT findings are pathognomonic and consist of:

1. An oblique band with a central opening
2. RLL bronchi and vessels passing through the opening and fanning out thereafter

You may wonder why I present such a rare condition, but the answer is simple:

a) It is easily recognized because of the distinctive findings. Once recognized, advise against surgery or other invasive procedures.

b) I don’t believe it’s that rare. In my career I have seen a dozen cases, the last three in this century and at the same institution. The last, seen in 2015, is the one that headed this Diploma. Two more were seen in 2004 and 2008 (Cases 1 and 2, below).

I am due to see a new case soon. Perhaps in a COVID patient, allowing me to write a useless paper about the relationship between COVID and duplicated diaphragm 🙂

CASE 1. 56-year-old woman investigated for lymphoproliferative syndrome. Axial and coronal CT show an unsuspected duplicated diaphragm (A and B, white arrows) and the crossing vessels (A and B, red arrows).
CASE 2. CT requested for chronic bronchitis in a 44-year-old woman. Axial CTs document the complete duplicated diaphragm (red arrows), the vessels insinuating through it (B, circle) and lower down, the orifice with the vessels passing through (C, green arrow). White arrows point to the downward course of the scimitar vein before draining in the IVC.

Follow Dr. Pepe’s advice:
1. Duplicated diaphragm is an infrequent malformation associated with hypogenetic right lung

2. Difficult to detect in the chest radiograph

3. Easy to diagnose in CT images by the following signs:

a) Oblique band with a central hiatus in the right lower lung

b) Central hiatus that constricts RLL bronchi and vessels

Cáceres’ Corner Case 251 – SOLVED

Dear Friends,

Showing today radiographs of a 27-year-old man with fever and hemoptysis.
More images will be shown on Wednesday

What do you see?

Click here to see Monday images

Dear friends, attaching CT images of the chest and abdomen. Do they help?

Click here to see more images

Click here to see the answer

Findings: chest radiographs show a cavitated pulmonary lesion in the apical-posterior segment of the LUL (A-B, arrows). There is convexity of the left middle mediastinum
(A, red arrow).

Enhanced axial CTs show an irregular pulmonary mass with cavitations (C-D, arrows). The thymus is enlarged, with a central area of decreased density (D, red arrow).

Enhanced axial abdominal CTs demonstrate enlarged retroperitoneal lymph nodes
(E-F, circles) as well as enlarged mesenteric lymph nodes (E, red ellipse).

In summary, the findings are:
Cavitated lung mass. Etiology: TB, fungal infection, lymphoma, Wegener and other granulomatosis.
Enlarged thymus. Etiology: thymoma, germ-cell tumor, thymic lymphoma
Enlarged retroperitoneal and mesenteric lymph nodes. In my opinion, this is a crucial finding, because it is highly suspicious of lymphoproliferative disease.
Putting all the findings together, lymphoma is the most likely diagnosis.
In this patient the initial diagnosis was TB. No TB germs were grown from the bronchial aspirate and PPD was negative. Abdominal CT seven days after admission suggested the diagnosis of lymphoma, confirmed by biopsy, which demonstrated widespread Hodgkin disease, nodular sclerosis type.
Final diagnosis: Cavitated Hodgkin disease of the lung.

Congratulations to all of you who made a gallant effort to diagnose the case. Will single out Olena because she was the first to mention lymphoma.
Teaching point: As this case proves, cavitated lesions of the lung are difficult to diagnose by chest imaging alone. Sometimes you need all the help you can get.

Dr. Pepe’s Diploma Casebook 166 – Big little findings – SOLVED

Dear friends,

I am starting a new section named “Big little findings”. The aim is to emphasize the importance of discovering subtle findings that should not be missed. They are easily seen if you know what to look for.

Today I’m showing preoperative chest radiographs of a 69-year-old man with bladder carcinoma.

What do you see?

Click here to see the answer

Findings: the most important feature is a negative finding: absence of air in the gastric fornix (A, circle). Although this is sometimes seen in healthy persons, it is more frequent in distal esophageal obstruction. A careful look discovers that the left mediastinum has a double contour, actually the left wall of the dilated esophagus (A, blue arrow) and the descending aorta (A, red arrow). There is bulging of the right paraesophageal line (A, yellow arrow). A dilated air-filled upper esophagus is visible in the lateral view (B, arrows).

The findings are typical of lower esophageal obstruction with dilatation of the esophagus. The double contour of the left mediastinum is better seen in the cone down view (C, arrows) and confirmed with CT (D, arrows).

The air-filled dilated esophagus in the lateral view (E, arrows) is confirmed with sagittal CT (F, arrows) (T= trachea).

Final diagnosis: unsuspected esophageal achalasia

To my eternal shame, I confess that when I read the initial radiographs I overlooked the findings (nobody’s perfect!). Achalasia was discovered in a routine follow-up CT taken one year later. I redeemed myself in a subsequent pre-op PA radiograph of the patient, in which I saw a double contour of the descending aorta (A and B, red and blue arrows) and bulging of the paraesophageal line (A and B, yellow arrows). I missed the absent air in the gastric fornix, again!

Esophageal achalasia is not an uncommon condition, and early stages can be suspected in the chest radiograph if we pay attention to the telltale signs. Note that these signs are not specific for achalasia and can be secondary to any obstructive process of the distal esophagus. The most revealing findings are:

Absent gastric bubble
Displaced lower mediastinal lines
Air-fluid level in the mediastinum


Occurs in about 10% of the normal population and 50% of achalasia patients, and is due to failure of swallowed air to cross the distal esophageal sphincter. It is a negative finding and therefore, difficult to recognize. When it is detected, we should examine the lower mediastinum, looking for signs of esophageal dilatation (Fig. 1).

Fig. 1. 54-year-old man with moderate dysphagia. In the PA radiograph, there is no gastric bubble (do not confuse air in the colon – A and B, black arrows – with air in the gastric fornix). The paraesophageal line is convex (A, red arrow). These two signs are suspicious for achalasia, confirmed with barium swallow. Note the distal esophageal stenosis (B, white arrow).


A dilated esophagus displaces the paraesophageal line toward the right, making it convex. The left wall of the esophagus moves outward, and is sometimes seen as a double contour with the descending aorta (Figs. 2 and 3). Convexity of the paraesophageal line is the most reliable sign and the easiest to detect.

Fig. 2. 48-year-old. woman with achalasia. Initial film shows a normal mediastinum with a visible gastric bubble (A, black arrow). Four years later (B) the gastric bubble is absent. There is a second contour (B, red arrow), paralleling the aorta (B, black arrow). Note that the initial concave paraesophageal line has become straight four years later (A and B, yellow arrows). Esophagogram confirms the esophageal dilatation and the narrow esophagogastric junction (C, red arrow).
Fig. 3. 47-year-old man with dysphagia. PA radiograph shows a convex paraesophageal line (A, white arrow). There is also a convex line on the left (A, red arrow). CT confirms the dilated esophagus containing air and fluid (B and C, asterisks). Diagnosis: esophageal achalasia.


Excluding hiatal hernia, an air-fluid level in the mediastinum is usually located in the esophagus. It is seen as a straight horizontal line in the middle/upper mediastinum. It is usually related to esophageal obstruction of any cause, the most common being achalasia. Discovery of an air-fluid level should lead us to investigate other signs of esophageal dilatation (Figs. 4 and 5).

Fig. 4. 47-year-old woman with dysphagia. PA radiograph shows an air-fluid level in the upper mediastinum (A, red arrow) accompanied by bulging of the paraesophageal line (A, white arrow) and absent gastric fornix. Esophagogram: dilated esophagus with distal stenosis (B, arrow) typical of achalasia.
Fig. 5. Showing this case because it’s a beauty. 73-year-old man referred by the pulmonologist to investigate chronic cough. PA and lateral chest radiographs show a dilated esophagus containing mainly air (A and B, white arrows), with a distal air-fluid level (A and B red arrows). Axial CT confirms the dilated esophagus with retained food (Insert, arrow). Achalasia, confirmed. Air is visible in the gastric fornix in this case (A, black arrow).

Aspiration pneumonia is a complication of achalasia. I’m showing two cases in which the signs mentioned helped to suggest the correct diagnosis (Figs. 6 and 7).


55-year-old man with pancreatic carcinoma and known achalasia who presented with marked cough. Chest radiographs show bilateral airspace infiltrates. In the PA view there is also dilatation of the upper esophagus (A, white arrows) with an air-fluid level (A, red arrow). The lateral view shows a retrocardiac mass (B, white arrow), suggestive of a dilated lower esophagus. The trachea is displaced forward (B, red arrow). These signs were overlooked by the radiologist, whose diagnosis was widespread pneumonia.

Coronal CT demonstrates widespread air-space disease. It also shows a dilated esophagus (C, arrow). Axial CT images confirm dilatation of the esophagus, which is full of residue
(D and E, arrows).
Final diagnosis: esophageal achalasia with secondary aspiration pneumonia.


This an old case of a 27-year-old woman with a chronic RUL opacity suspected to be TB (disregard the opacities in both middle lung fields, caused by superimposed breast implants).
PA chest radiograph shows an opacity in the right upper lobe (A, circle). A right paramediastinal line extends from top to bottom (A, arrows). The lateral view shows anterior displacement of the trachea by a tubular structure (B, arrows), which occupies the upper and middle mediastinum. Both findings suggest a dilated esophagus.
Barium swallow confirms the dilated esophagus, secondary to narrowing at the esophagogastric junction (insert, arrow). Considering the age of the patient, achalasia with aspiration pneumonia was the most likely diagnosis, confirmed later.
(Remember that aspiration pneumonia goes to the right upper lobe when the patient is recumbent at night).

Follow Dr. Pepe’s advice:

Subtle findings of distal esophageal obstruction (achalasia) that should not be overlooked:

1. Absent gastric bubble

2. Displaced lower mediastinal lines

3. Air-fluid level in mediastinum

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.

Dr. Pepe’s Diploma Casebook 165 – SOLVED

Dear Friends,

showing today a preoperative AP chest of a 93-year-old man who broke his right femur after a fall.

What do you see?

Click here to see the answer

Findings: AP chest radiograph shows a poorly defined opacity in the RUL (A, circle).

Axial and coronal enhanced CT show that the opacity corresponds to a tortuous brachiocephalic artery (B and C, arrow). There is no pulmonary infiltrate.

Final diagnosis: Tortuous brachiocephalic artery simulating a pulmonary infiltrate.

The aim of this Diploma is to continue discussing chest imaging in the older population.

Today I will comment about the main manifestations of aging in the mediastinum and heart, discussing variants that may simulate disease, followed by the most common conditions affecting these regions in elderly patients.


The standard PA radiograph in aging adults usually shows a somewhat enlarged mediastinum, due to poor inspiratory effort combined with an elongated aorta and mediastinal fat accumulation (Fig. 1) .

Fig. 1. Normal chest in an 85-year-old man. Note the limited inspiration and increased width of mediastinum. The aorta is elongated, and the cardiothoracic ratio is 50%. A pacemaker is visible in the left hemithorax.

A common variant in older patients is a tortuous brachiocephalic artery, which may project into the lung, simulating a pulmonary lesion (Fig. 2), as was shown in the initial case.

Fig. 2. 88-year-old woman with vague chest complaints. PA radiograph shows an RUL opacity (A, circle). Unenhanced axial CT confirms that the opacity corresponds to a tortuous brachiocephalic trunk projecting into the lung (B, arrow).

Sometimes the tortuous artery simulates a mediastinal mass. In these cases, the diagnosis is easy because a mediastinal mass pushes the trachea toward the left (Fig. 3A), whereas an elongated artery does not; instead, the associated elongated aorta displaces the trachea to the right (Fig. 3B).

Fig. 3. 52-year-old man with a right thyroid mass pushing the trachea towards the left (A, arrow).
The second patient is an 83-year-old man with tortuous brachiocephalic vessels simulating a mediastinal mass (B, arrow). Note that the trachea is displaced towards the right by an elongated aorta.

The aorta is elongated in most older adults. A kink in the distal descending aorta often casts a posterior shadow in the lateral view that should not be confused with disease (Fig. 4).

Fig. 4. 73-year-old man with an elongated aorta (A). A kink in the descending aorta creates a posterior opacity superimposed on the lower spine (B, circle). Unenhanced sagittal CT confirms the kink as the cause of the opacity (insert, arrow).

Calcification of the annulus fibrosus of the mitral valve is common in elderly individuals. It does not cause symptoms and should not be confused with other conditions. It has a pathognomonic appearance in the chest radiographs (Fig. 5).

Fig. 5. 79-year-old man/woman with mitral annulus calcification. Note the typical “C” shape and location in the PA and lateral radiographs (A and B, circles).

A variant of calcified annulus fibrosus is a condition termed caseous necrosis of the mitral annulus. It appears as an ovoid intracardiac calcification, visible in chest radiographs (Fig. 6) and confirmed with CT. It is also symptomless.

Fig. 6. 73-year-old man, asymptomatic. PA and lateral radiographs demonstrate an ovoid calcification projected over the cardiac shadow (A and B, arrows). Axial CT confirms the calcification (insert, arrow), corresponding to caseous necrosis of the annulus.


The most common mediastinal pathology in the older population is hiatus hernia, easily identifiable when it contains air. An airless hernia should not be confused with a lower mediastinal mass. The best way to diagnose hiatus hernia is by looking at previous films (Fig. 7). If none are available, a barium swallow is sufficient (Fig. 8).

Fig. 7. 68-year-old woman with an airless hiatus hernia simulating a mediastinal mass (A, arrow). Previous film one year earlier shows a typical hernia with an air-fluid level (B, arrow).
Fig. 8. PA and lateral radiographs in a 65-year-old woman with a large airless hiatus hernia (A and B, arrows) . No previous films. Barium swallow confirms the hernia (insert, arrow).

At times, too much air in a hernia may be misleading, as occurred in the case below, which was initially diagnosed as a possible pneumopericardium (Fig. 9).

Fig. 9. 66-year-old woman with known breast carcinoma admitted to the ER in shock. AP radiograph show right lung metastasis (A, arrow) and two lines outlined by air surrounding the heart (A, red arrows).

Pneumopericardium was suspected. Enhanced CT coronal and sagittal images
show that the apparent pneumopericardium was actually a large hiatus hernia (B and C, arrows). On retrospective review of the patient’s chest radiograph, bowel air can be seen projected over the heart.

Mediastinal mass in patients of advanced age are commonly due to metastasis. Lymphoma is an alternative diagnosis, as around 50% of non-Hodgkin lymphomas occur in patients older than 65 years (Fig. 10).

Fig. 10. 77-year-old woman with asthenia and weight loss. Chest radiographs show bilateral pleural effusion and an anterior mediastinal mass (A, arrows. B, asterisk). Axial CT confirms
the mass (insert, arrow). Diagnosis: B-cell lymphoma

Differentiating aortic aneurysm from a tortuous aorta is difficult in chest radiographs, because the medial aortic wall is obscured by the mediastinum. Sometimes the inner wall is outlined by air, allowing detection of aortic dilation in the plain film (Fig. 11).

Fig. 11. 73-year-old woman with chest pain and a tortuous aorta. The medial wall is outlined by air, allowing us to determine that the aorta is dilated (lines in A and B). Enhanced axial CT shows a type-B aortic dissection (insert, arrow).

The incidence of atrial fibrillation increases after the age of 65, and up to 9% of octogenarians are affected with this condition. Detecting a prominent left atrium in the chest radiograph of an elderly person should suggest this diagnosis (Fig. 12).

Fig. 12. 75-year-old woman with atrial fibrillation. Note the prominent left atrium in the PA and lateral radiographs (A and B, arrows).

Ventricular aneurysm is a complication of myocardial infarction. In an elderly patient, the aneurysm may calcify and appear as curvilinear calcium projected over the left heart (Fig. 13).

Fig. 13. 80-year-old man with a history of myocardial infarction ten years earlier. Chest radiographs show a thin curvilinear line projected over the heart, consistent with a calcified aneurysm (A and B, arrows). Unenhanced CT confirms the diagnosis (insert, white arrows). A calcified thrombus is also visible (insert, red arrow).

Follow Dr. Pepe’s advice:

1. Tortuous brachiocephalic artery and calcification of the mitral annulus are common variants in persons of advanced age.

2. Hiatus hernia occurs frequently in older individuals.

3. Enlarged left atrium in this age group should raise the possibility of atrial fibrillation.

This is the last case on 2020 and we will be back on January 11, 2021!

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!