Author: Dr. Pepe

Dr. Pepe’s Diploma Casebook 162 – SOLVED

~ Dr. Pepe ~ 11 Comments

Dear Friends,

taking advantage of Dr Pepe’s absence I am showing today an unproven case (always wanted to do it!). All relevant images are shown, without comment, looking forward to hear your opinions.
I will share my impressions with you next Friday. Hope we will coincide. We have to wait together until we get the final diagnosis (or not).

Chest radiographs belong to a 66-year-old man with abdominal pain and a history of diverticulitis. The round opacity at the left base led to a review of previous examinations, dating back to 2007.

Abdominal CT for diverticulitis in 2007 and 2008 show a cystic lesion in the left costophrenic sinus

The patient had recurrent episodes of diverticulitis and/or abdominal pain. I am offering several axial CTs in different years to document the evolution of the lesion

Occasionally the chest was also examined. Showing three samples of sagittal CTs with pulmonary window over a ten years’ period.

The last abdominal CT was taken on August 30, 2020. I have selected the most relevant axial, coronal and sagittal images.

Have you reached a conclusion after reviewing all the images?

Click here to see the answer

The case starts in 2019 with chest radiographs of a 66-year-old man with abdominal pain and previous history of diverticulitis. A rounded opacity is seen the left lung base (A-B, arrows). This finding led to a review of previous examinations, dating back to 2007.

Abdominal CTs for diverticulitis in 2007 and 2008 show a cystic lesion in the left costophrenic sinus(C-D, circles). The lesion has grown slightly in one year.

Since 2007 the patient had recurrent episodes of diverticulitis and/or abdominal pain. Several abdominal CTs in different years document the evolution of the lesion: the purely cystic lesion in 2008 (E, arrow) has grown in 2013 and fine septa are seen within it (F, circle).
CT in 2015 shows that the septa are thicker and enhance after contrast injection (G, circle). An unenhanced CT in 2018 demonstrates a smaller lesion with a thick peripheral rim of solid tissue (H, arrows).

Sometimes the chest was included in the CT examination. Three samples of sagittal CTs with pulmonary window over a ten years’ period show that the lesion lies within the left major fissure (A-C, arrows). It looks like a pendulum held by the fissure and has an irregular contour in the last image in 2018.

A final unenhanced abdominal CT taken on August 2020 shows that the appearance of the lesion has not changed significantly in the last two years. In the meantime a small punctate calcification has appeared (L and O, arrows).

Conclusion after review of the images:

1- Slow-growing mass over a period of ten years.

2- The initial cystic mass has developed thick septa and thick peripheral rim.

3- Located within the left major fissure.

4- Punctate calcification.

Given all these finding, my best option is a fibrous pleural tumor of the left pleural fissure which is undergoing malignant transformation.

An alternative diagnosis could be a mucinous pleural tumor if such entity exists.
In my opinion, hydatid cyst is very unlikely. It has been practically eradicated from Spain and I have never seen one within a fissure.

The patient is now in the hands of a competent pneumologist. Hope we will get a definitive diagnosis soon. As soon as I get it, I will post it in the blog ( and, if it happens to be a hydatid cyst, I will do penance in a nunnery).

Cáceres’ Corner Case 246 – SOLVED

~ Dr. Pepe ~ 8 Comments

Dear Friends,

Today I am showing the PA radiograph of an 82-year-old woman. Preoperatory for cataracts.

What do you think about the right hilum?

1. Calcified TB nodes
2. Sarcoidosis
3. Amyloid
4. None of the above

More images will be shown on Wednesday.

Click here to see the images shown on Monday


Dear friends, showing today PA and lateral radiographs taken two years earlier. Hope they help.

Click here to see the new images

Click here to see the answer

Findings: Initial PA radiograph shows opacities in the right hilum (A, circle), unchanged in comparison with a previous film taken two years earlier (B, circle).

The clue to the diagnosis lies in the density and appearance of the opacities. They are denser than the typical lymph node calcifications, suggesting that they are metallic. In addition, some of them look tubular or branching (C, red arrows). A lateral view taken two years earlier confirms dense lineal and branching opacities in right lung (D, arrows).
The combination of linear and branching metallic opacities suggests that they are either in the bronchi (previous bronchography) or within the pulmonary vessels (embolism after vertebroplasty o treatment of AV malformation). See Diploma # 44.

Lateral view of the lumbar spine shows surgical changes with vertebroplasty of L3 to L5 and leakage of the cement into the epidural veins (E, arrows), better seen in the sagittal CT (F, arrows).

Unenhanced CT confirms multiple cement emboli in the pulmonary arteries (G-J, circles)

Final diagnosis: cement embolization of the lung after vertebroplasty
 
I must mention Olena and Ayudi who suggested amyloid and broncholithiasis but failed to notice the metallic opacity of the findings.
 
Teaching point: Consider previous vertebroplasty when you see metallic opacities in the lungs. It is a common complication.

Dr. Pepe’s Diploma Casebook 161 – Meet the examiner

~ Dr. Pepe ~ 2 Comments

Dear Friends,

This week’s case follows the pattern of a “Meet the Examiner” presentation, with questions and answers similar to a real examination. Take your time before scrolling down for the answer.

The images belong to a 60-year-old man with moderate cough and dyspnea

What would you recommend?

1. Compare with previous films
2. Chest CT
3. PET-CT
4. None of the above

Click here to see the answer

Findings: PA radiograph shows large bullae in both upper lobes. There is a nodule in the RUL projected over one bulla (A, arrow). Two small calcified granulomas are visible in the periphery of the LUL (A, circle). PA film taken five years earlier (B) does not show any nodule in the RUL. The granulomas in the LUL are unchanged.

Report of the chest : bullous emphysema with a nodule not visible in 2014. Given the relationship between bullous disease and carcinoma, it is imperative to do a chest CT.

Enhanced CT was done the next day. What would you suggest?

1. Antibiotic treatment and CXR in one month
2. PET-CT
3. Antibiotic treatment and CT in one month
4. None of the above

Click here to see the answer

Findings: aside form large bullae in both upper lobes, an irregular nodule is evident in the RUL (A-B, arrows). In my opinion, given the appearance of the nodule I would suspect malignancy and request a PET-CT. However CT was reported as: Pseudonodular opacity in RUL that could be related to an infectious/inflammatory process. A neoplasm cannot be excluded. Recommend control after treatment

Click here to see more images

A chest radiograph was taken one month later.
What would you do?

1. PET-CT
2. CXR in three months
3. CT in three months
4. Control in one year

Click here to see more images

The chest radiograph one month later was reported as unchanged and no further suggestions were made by the radiologist. The clinician took no further action.

The patient came back ten months later, and a new radiograph showed an obvious increase in size of the nodule (B, arrow) when compared to the initial film (A, arrow)

Click here to see more images

Enhanced CT confirms the increase in size of the nodule (A-B, arrows). Surgery discovered a carcinoma in the wall of a bulla.

Final diagnosis: adenocarcinoma of the lung associated to bullous disease.

Lung carcinoma seems to occur more often in bullous disease, although there is not enough evidence compiled at the present time. Despite the lack of evidence, knowing
this association may prevent misdiagnosis.
A lesser known fact is that the cystic space may disappear after the carcinoma develops, as occurred in a second case (see below). Spontaneous regression of a bulla may be due to non-malignant causes, but carcinoma should be excluded with CT because it may take years for the lesion to be visible in the chest radiograph.

I am showing this case because the opinion given in the chest radiograph was unequivocal, whereas the CT report was vapid, giving the impression that the nodule was infectious, and that malignancy was less likely. The follow-up radiograph was disregarded by the radiologist and clinician and this caused a delay in diagnosis of almost one year.

To complete the information, I am showing a second case of carcinoma developing in the wall of a cystic space

Images of the second case were obtained during routine CT screening in a 72-year-old man, heavy smoker.
Apical axial CT image shows a small nodule in the LUL (A, arrow), with increased uptake on PET-CT (C, arrow). There is a cystic airspace in the LLL (B, arrow) with no PET-CT uptake, interpreted as a non-specific cystic airspace lesion.

At surgery a carcinoma of the LUL was found.

It was decided to continue with yearly follow-up studies. The cystic air space (A, arrow) increased in size in 2008 but still had a thin wall (B, arrow). In 2009 it has decreased slightly in size and the wall is thicker than the previous year (C, arrow). A new PET-CT shows increased uptake in the posterior wall (D, arrow).

Malignancy was suspected. The patient refused further surgery or percutaneous biopsy and it was decided to do a follow up study three months later.
Axial CT shows that the cystic airspace has disappeared and in its place, a solid mass has developed (A and B, arrows) with increased overall uptake on PET-CT (C, arrow). At surgery, an adenocarcinoma was found.

Final diagnosis: adenocarcinoma arising in the wall of a cystic airspace, which disappeared as the tumour progressed.


Follow Dr. Pepe’s advice:

1. Bullous emphysema and isolated cystic spaces may be associated with an increased incidence of carcinomas

2. A poorly worded report may cause an unnecessary delay in diagnosis

Cáceres’ Corner Case 245 – SOLVED

~ Dr. Pepe ~ 22 Comments

Dear friends, Dr Pepe has eloped with Miss Piggy (again) and has let me alone, holding the fort. Hope he will be back in time to give the next webinar.

Today’s radiographs belong to a 60-year-old male with cough and moderate dyspnea.

Diagnosis:

1. Hilar lymphadenopathy
2. Right pulmonary artery aneurysm
3. Mediastinal tumor
4. None of the above

Click here to see the answer

Findings: PA and lateral chest radiographs show a right hilar mass (A-B, arrows). In my opinion, the appearance of the mass and its location in the right hilum in the lateral view rules out a mediastinal mass.
There is a small nodule in the RUL (A, red arrow) that can be overlooked unless we look for it

The nodule is better seen in the cone down view and the axial CT (C-D, red arrows), with high SUV in the PET-CT (E, arrow), accompanied by a metastatic node in the mediastinum (E, circle).

Caudal slices of enhanced CT show multiple lymph nodes in right hilum (F, arrow) and mediastinum (G, circle).

Biopsy of a lymph node returned as metastatic carcinoma.

Final diagnosis: carcinoma of the lung with mediastinal metastases

Congratulations to archanareddyt who was the only one to discover the RUL nodule

Teaching point: this is an interesting case for educational purposes.
1. Knowing the most common causes of unilateral hilar enlargement (lymph nodes vs. enlarged artery) helps the differential diagnosis.
2. We should think of common processes rather than unusual ones (lymph nodes vs. aneurysm).
3.  Suspecting unilateral hilar lymph nodes leads to search for the two more common etiologies (TB or carcinoma) leading to the discovery of the RUL nodule.

Hope the case was useful!

Cáceres’ Corner Case 244 – SOLVED

~ Dr. Pepe ~ 20 Comments

Dear friends I am presenting today the pre-op PA chest radiograph of a 40-year-old man.
What do you see?

More images will be shown on Wednesday.

Click here to see more images

Dear friends, showing today images of the barium swallow. What do you think?

The answer will be published on Friday 🙂


Click here to see the answer

Findings: PA radiograph shows convexity of the middle aspect of the right mediastinal border (A, arrow). There is a double contour in the opposite side (A, red arrow). These two lines conform the limits of a rounded mass which is better seen in the penetrated AP radiograph (B, arrows).

An outside CT (not available) confirmed a middle mediastinal mass. Esophageal diverticulum was included in the differential diagnoses (??) and for this reason a barium swallow was done.

AP view of the esophagogram shows a large mass deforming the esophagus (C, circle). Oblique view demonstrates the typical appearance of a submucosal mass of the esophageal wall (D, circle). Endoscopy confirmed an intact mucosa.
A large intramural esophageal tumor that looks like an alien was resected (E, insert)

Final diagnosis: leiomyoma of esophagus.
 
Congratulations to Traidor who made the diagnosis before the barium study and to Genchi Bari, after.

Teaching point: I am showing this case to review basic concepts of paleo-radiology (before CT), when we used to classify GI tumors according to the appearance of the filling defect in the barium column.

A represents an intraluminal mass (polyps and carcinomas, usually)

B is the typical appearance of a submucosal intramural mass (looks like an extrapulmonary lesion in the chest radiograph). Usually due to benign spindle-cell tumors or duplication cyst. Rarely metastasis.

C represents the deformity secondary to an extrinsic mass

Dr. Pepe’s Diploma Casebook 160 – With a webinar! – SOLVED

~ Dr. Pepe ~ 5 Comments

Dear friends, I am starting a new webinar series entitled “Things that we already know, but are important to remember”. The objective is to refresh basic concepts that often are forgotten.

This week’s webinar title is “Who is afraid of the bad, big lateral chest”. The webinar will take place on Wednesday, September 30 at 12:00 CEST. You can register here.

The initial case is a PA chest radiograph of a 61-year-old man with hemoptysis.

Do you see any abnormality?
1. Yes
2. No
3. I want a lateral chest

Register for the webinar and lear more about this case and others!

Click here to see the answer

Findings: PA radiograph (A) does not show any significant findings. The lateral view shows a posterior pulmonary nodule with irregular contour (B, arrow). A typical donut sign is visible (B, circle), indicative of enlarged subcarinal lymph nodes.

Enhanced axial CT and PET-CT show confirm the pulmonary nodule (C-D, arrows) and the subcarinal lymphadenopathies (C-D, red arrows).

Final diagnosis:

Carcinoma hidden in the PA view behind the right hilum with metastases to subcarinal lymph nodes.
 
Congratulations to drpeca who was the first to want a lateral view.
 
Teaching point: remember that about 26% of the lung is hidden in the PA view. A lateral chest radiograph is indispensable to study the chest.

Cáceres’ Corner Case 243 – SOLVED

~ Dr. Pepe ~ 9 Comments

Dear Friends,

Today’s radiographs belong to a 59-year-old man with two week’s history of chest pain and moderate dyspnea.

What do you see? Come back on Friday to see the answer!

Click here to see the answer

Findings: PA radiograph shows a diffuse opacity of left lung (A, asterisk) which obscures the heart border. A luftsichel sign is visible (A, circle). The left hilum is augmented, and the left main bronchus has a horizontal path (A, red arrow). The left hemidiaphragm is elevated and a juxtaphrenic peak sign is visible (A, yellow arrow).
The lateral view shows a horizontal retro-sternal band (B, arrows) and a typical donut sign (B, circle).

Donut sign is more obvious when comparing with a normal previous chest film
(C-D, circles).

This case is a compendium of typical signs of LUL collapse. As you all know, the most common cause is bronchogenic carcinoma, which in this case is confirmed by detecting enlarged mediastinal lymph nodes (donut sign).
Enhanced CT demonstrates the LUL collapse (E-F, asterisks), a mass occluding the bronchus (E-F, red arrows) and subcarinal adenopathy (E-F, arrows).

Final diagnosis: carcinoma of LUL bronchus with lobar collapse and mediastinal metastases.

Dr. Pepe’s Diploma Casebook 159 – SOLVED

~ Dr. Pepe ~ 15 Comments

Dear Friends,

Today I am presenting another “Art of interpretation” case. As I have mentioned before, interpreting a chest radiograph may be a difficult task and analyzing the diagnostic steps helps to a correct evaluation of the findings.

Radiographs belong to a 57-year-old woman with cough and pain in the chest.

Diagnosis:
1. Pulmonary mass
2. Mediastinal mass
3. Pleural mass
4. Any of the above

What do you see? Come back on Friday to see the answer!

Click here to see the images


Click here to see the answer

PA radiograph shows an ill-defined right perihilar and upper lung opacity( A, asterisk). The right hemidiaphragm is elevated. There is an obvious elevation of the right hilum. (A, red arrow).

Lateral view shows a well-defined retro-sternal triangular opacity (B, white arrows) with a rounded convex appearance at the level of the hilum (B, red arrow).

Analysis of relevant findings:

PA chest

1. Elevation of right hilum
2. Hazy opacity in right upper lung
3. Elevated right hemidiaphragm

Lateral chest

1. Well-defined retro-sternal triangular opacity with a bulge in the middle

The clue to the diagnosis lies in discovering the elevation of the right hilum in the PA view. Neither a mediastinal nor a pleural mass should displace the hilum upwards. Therefore, the correct answer is: 1. Pulmonary mass.

The elevated right hilum suggests loss of volume of RUL, supported by the haziness of upper lung and elevation of the hemidiaphragm.

The lateral view provides significant information: the retro-sternal triangular opacity is highly suspicious of RUL collapse, limited superiorly by the displaced major fissure and inferiorly by the minor fissure. The central bulge suggests a mass as the cause of the collapse.

ELEVATED RIGHT HILUM + SIGNS OF RUL COLLAPSE (LATERAL VIEW) + HILAR MASS IN LATERAL VIEW = CARCINOMA WITH ATYPICAL RUL COLLAPSE

Enhanced coronal CT confirms the central mass (A, arrow) and the collapsed RUL (A, red arrow). Sagittal view shows the displaced major fissure (B, arrow). Axial view demonstrates the obstructed RUL bronchus (C, arrow)

Final diagnosis: Carcinoma of RUL bronchus with atypical collapse of RUL

Recognizing lobar collapses in the chest radiograph is important because most of them are caused by endobronchial carcinoma.
RUL collapse has a distinctive appearance which is easily identified in the PA radiograph (see Diploma 58). Occasionally the presentation is atypical and may be unrecognized, causing an unnecessary delay in the diagnosis. In these cases it is important to know the main signs that will suggest the correct diagnosis (see Diploma 141).
Elevation of the right hilum, as in the present case, is practically a constant sign in RUL collapse. Detecting a high hilum is an important clue to suspect this diagnosis.

To emphasize the importance of an elevated hilum as a sign of atypical RUL collapse, I am showing a second case. Patient is a 77 y.o. man with right shoulder pain.

PA radiograph shows an apparent air-filled cavity in the right upper lung. The clue to the diagnosis lies in recognizing the elevation of the right hilum (A, arrow), pointing to a RUL collapse.
Lateral view confirms the suspicion of RUL collapse confined between the elevated minor fissure (B, arrow) and the anteriorly displaced major fissure (B, red arrow).

Comparison with a previous film confirms the typical findings of aerated RUL collapse, with elevation of the minor fissure (C, arrow) and the right hilum (C, red arrow). The appearance of the current film is due to an apical loculated pneumothorax (D, asterisk) which has displaced medially the outer wall of the RUL lobe.

Previous CT taken three years earlier confirms collapse of RUL lobe with open bronchus (E, arrow), bronchiectasis in the lateral view and marked displacement of the fissures (F, arrows). Note the increased apical fat (E, asterisk) suggestive of a chronic process.

Final diagnosis: Chronic inflammatory collapse of RUL with loculated apical pneumothorax


Follow Dr. Pepe’s advice:

1. Detecting an elevated right hilum is an excellent clue to suspect an atypical presentation of RUL collapse

Cáceres’ Corner Case 242 – SOLVED

~ Dr. Pepe ~ 14 Comments

Dear friends, welcome back!

Today I am showing a straightforward case to ease you into the new season. Promise I will not mention Covid-19 at all.

Today’s case is a pre op PA radiograph for knee surgery in a 47-year-old woman.

What do you see?

Come back on Friday to see the answer!

Click here to see the answer

Lung and mediastinum do not show any relevant findings. An isolated air-fluid level is visible in the left upper quadrant of the abdomen (A, arrow). The inner border of the cavity is smooth. The gastric bubble is visible under the left hemidiaphragm (A, red arrow).

Given that the patient is asymptomatic, an abdominal abscess or bowel obstruction/ volvulus can be safely excluded. A large intestinal diverticulum could be a possibility. I suspected a more mundane diagnosis: a review of the clinical history discovered that an intragastric balloon had been inserted fourteen months earlier.

Final diagnosis: air-fluid level in an intragastric balloon for morbid obesity
 
Congratulations to all of you who detected the air-fluid level. Kudos to Flemming Ghomsen who came close to the diagnosis.

Intragastric balloons for bariatric surgery may be filled with air or with saline. In the second case they may present an air-fluid level due to room air mixing during the injection of fluid.
 

Teaching points:


1. Remember to look under the diaphragm. You may discover interesting findings.
2. In your differential diagnosis always include iatrogenesis as a possible cause.

Dr. Pepe’s Diploma Casebook 158 – SOLVED

~ Dr. Pepe ~ 7 Comments

Dear Friends,

this is the last case of the first semester. Will meet again in September.
Wish all of you a very happy summer vacation!

This is a new “art of interpretation” case. Radiographs belong to a 40-year-old woman with mild cough.

What do you see?

Diagnosis:

1. Chronic TB changes
2. AV malformation
3. Bronchial atresia
4. Any of the above

Click here to see the answer

To refresh your memory, remember that interpreting a chest radiograph involves three basic steps:

1. Gather information. Examine the radiographs carefully and collect all the pertinent information. Remember that overlooking visible findings is the main cause of errors.

2. Analyze the findings. Once collected, the findings should be properly evaluated, and an opinion should be offered.

3. Decide on the next step to reach the diagnosis.

Step 1. Information:

In this patient the lateral view is unremarkable.
All relevant findings are seen in the PA radiograph:

1. Tubular branching opacities in the left upper lung (A, red arrows)
2. Increased lucency of left upper lung (A, circle)
3. Negative finding: the left hilum is in its normal position.

Step 2. Analysis of the findings:

1. Branching tubular opacities have a limited differential diagnosis: either they are pulmonary vessels or mucous-filled dilated bronchi.

2. Hyperlucent lung is a reliable sign of lung disease when complemented with an expiration film to demonstrate air-trapping.

3. The normal position of the left hilum is a negative finding that excludes a fibrotic process in the LUL (I.e. chronic TB), which should cause upper retraction of the hilum.

The combination of a lucent lung lesion with branching tubular opacities points towards an obstructive process of a segmental bronchus with mucous impaction (Obstruction of a lobar bronchus would cause lobar collapse instead of increased lucency).

TUBULAR BRANCHING OPACITIES + INCREASED LUNG LUCENCY = SEGMENTAL BRONCHIAL OBSTRUCTION

Step 3. Decide on the next step

Once segmental bronchial obstruction is suspected in the chest radiograph, the best procedure to confirm it is an enhanced chest CT with expiratory views. In this case it shows attenuated upper lobe vessels (B, arrows) and obvious mucous impactions (B-C, red arrows).
Axial CT with lung window confirms the increased lucency of the apical-posterior segment of the RUL (D, circle)

Inspiration/expiration axial CT views (E-F) confirm segmental air trapping on the left.

Bronchoscopy did not show any inflammatory or tumoral changes in the LUL bronchus. The orifice of the apical-posterior segment was missing.

Final diagnosis: bronchial atresia of apical-posterior segment of LUL

In my experience, bronchial atresia is the most common congenital lung malformation seen in adults. Congenital bronchial atresia results from proximal interruption of a segmental bronchus, which causes overinflation of the affected segment and secondary mucus impaction. Chest radiography shows a focal hyperlucent area with internal mucus impaction. CT depicts these findings to better advantage. Inspiration and expiration views help to confirm air-trapping. In case of doubt, bronchoscopy excludes other causes of bronchial obstruction.

Congenital bronchial atresia may present different appearances, as shown in the following case of one of our X-ray technicians.

30-year-old female, asymptomatic. PA chest radiograph (A) shows hyperlucent left lung with discrete dextroposition of the heart. Expiration film (B) shows air-trapping on the left with deviation of the mediastinum towards the right. Note a thick tubular shadow in the left lower lung (A-B, red arrows), compatible with bronchial impaction. The findings are suggestive of congenital bronchial atresia

Axial and coronal enhanced CT show increased lucency of the posterior segments of LLL with a central mucous impaction (C-D, red arrows)

Decreased vascularity of LLL and central mucous impaction (E-F, red arrows) are better demonstrated in the MIP reconstruction.

Coronal view eleven years later show that air is now present within the dilated bronchus, confirming the diagnosis (G-H, circles) .


Dr. Pepe’s teaching point:

Hyperlucent lung with mucous impaction are the hallmark of congenital bronchial atresia.