Cáceres’ Corner Case 208 – SOLVED!

Dear Friends,

Presenting today radiographs of a 65-year-old man with back pain.

What do you see?

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Findings: PA chest radiograph shows an ill-defined opacity in the right middle lung field (A, asterisk), located in the anterior clear space in the lateral view (B, arrows). The anterior arch of the 4th right rib is missing.

A cone down view demonstrates an expanding lytic lesion in the anterior arch of the 4th right rib (C, asterisk), confirmed with CT (D and E, red arrows).

I thought this was an easy case, but I am disappointed because some of you missed a collapsed vertebra (F, circle), not present three years earlier (G, circle). Sagittal CT confirms it as well as additional affectation of L1 and posterior elements of D10 (H, red arrows).

In a patient with a port-a-cath, the presence of multiple lytic lesion suggests metastatic disease as the first possibility.
 
Final diagnosis: Carcinoma of esophagus with bone metastases

Congratulations to Andy, who was the first and to Archana Reddy.t who discovered the collapsed vertebra.

Teaching point: this case is similar to the previous one and the teaching point is the same: look at the underlying rib. And, above all, don’t forget to examine the rest of the bones!

Cáceres’ Corner Case 207 – SOLVED!

Dear Friends, 

Today I am presenting a case given to me by my good friend José Luis López Moreno. The PA radiograph belongs to a 77-year-old woman with pain in the right hemithorax.
What do you see?

More images will be shown on Wednesday.

Dear Friends,

showing today axial and coronal CT.
What do you think?

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Findings: PA radiographs shows an ovoid opacity in the right lung (A, arrow), that parallels the path of the anterior ribs. Careful observation demonstrates that the third and fifth anterior ribs are visible (B, red arrows), whereas the anterior fourth rib is absent (B, asterisks). An additional finding is moderated flattening of D11 and D12 (A, circle). The findings suggest multicentric bone lesions.

Enhanced axial and coronal CT confirm a lytic expanding lesion of the anterior fourth rib (C and D, arrows), better seen in the 3-D reconstructions (E and F, arrows).

In an adult, lytic expanding rib lesions are usually either metastases (thyroid, renal cell carcinoma) or multiple myeloma. Further studies confirmed a myeloma.
 
Final diagnosis: multiple myeloma affecting the right fourth rib and several thoracic and lumbar vertebrae.
 
Congratulations to Wafaa who suggested the diagnosis in the plain film and to VL who discovered the collapsed vertebrae.
 
Teaching point: remember to look at the underlying rib when facing a pleural/chest wall lesion. An affected rib will narrow down your diagnostic options. And don’t forget satisfaction of search (collapsed vertebrae in this case).

Cáceres’ Corner Case 206 – SOLVED

Dear Friends,

Now that Game of Thrones is ending, a new series is planned: Game of Thorax, in which either you diagnose or you die.

As you can see in today’s radiograph, the Iron Throne has been replaced by the Chest Throne.

What would your diagnosis be?

Come back on Friday to see the answer.

Click here to see the answer

Findings: PA chest radiograph show numerous metallic wires spread fan-like throughout the upper two thirds of both lungs.
This appearance is typical of endobronchial coils for lung volume reduction in patients with emphysema. They are used when other therapeutic alternatives are not feasible or as a bridge to lung transplantation.
 
I am showing this case because I have never seen one and wanted to share it with you. And to complain about the last season of Game of Thrones, of course!
 
Congratulations to all of you who made the diagnosis, led by MK, who was the first.

Cáceres’ Corner Case 205

Dear Friends,

Today I am showing preoperative radiographs for hand surgery in a 53-year-old man.

What do you see?

More images will be shown on Wednesday.

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Dear Friends,

showing today chest radiographs taken one year earlier.

Do they help?

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Click here to see the solution

Findings: PA chest radiograph shows an ill-defined opacity in the left middle lung field (A, arrows). It is located in the anterior clear space in the lateral view and has a stippled appearance (B, arrows). In addition, there is a flat irregularity in the dome of the left hemidiaphragm in the PA view which appears to be calcified (A, red arrow).

Previous radiographs one year earlier show the same findings, unchanged (C-D, arrows).

The clue to the diagnosis lies in the irregularity of the dome of the left hemidiaphragm, that looks like a calcified plaque. This finding suggests that the apparent pulmonary opacity in the PA view may be a pleural plaque see “on face”. It is not seen as a line in the lateral view because the curvature of the anterior thoracic wall does not offer a straight interface to the X-ray beam.

CT confirms calcified anterior pleural plaques in both hemithoraces (E-F, arrows).

Coronal and sagittal CT confirm the calcified plaque in the diaphragmatic dome (G-H, red arrows).

The patient was found to have a history of asbestos exposure.
 
Final diagnosis: Asbestos-related pleural disease simulating pulmonary infiltrate.

Congratulations to S, who was the first to make the diagnosis. Silver medal to VL.
 
Teaching point: remember the deceitful appearance of pleural plaques shown in Diploma case 140. Some of you were fooled by it!

Cáceres’ Corner Case 204 – SOLVED

Dear Friends,

Today’s radiographs belong to a 54-year-old man with chest pain.

More images will be shown on Wednesday.

What do you see?

Click here to see the images

Dear Friends,

Showing new images of the thoracic cage. 

What do you think?

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Findings: PA radiograph shows an extrapulmonary lesion in the left hemithorax (A, arrow). The 3rd left rib is broadened (A, red arrows) and the distal segment is not visible.
There is a lineal infiltrate in the adjacent lung and at the left lung base. In addition, an expansive lytic lesion is visible in the anterior 7th right rib (A, yellow arrow).
The lateral view (B) does not show any significant findings.

AP and oblique views of the thoracic cage show an expansive lesion of the 3rd left rib (C-E, arrows) and confirm the expansive lytic lesion of the right 7th rib (C-E, red arrows). There is also a pure lytic lesion of the 8th left rib (C-E, red circle). There is minimal loss of height of D-11 (C and E, blue circle).

Discovering expanding lesion of the ribs should suggest either multiple myeloma or metastases (renal cell carcinoma, thyroid carcinoma). In this patient a multiple myeloma was found.
 
Final diagnosis: multiple myeloma, IgA type.
 
Congratulations to VL who found the bone lesions in the initial radiographs (many of you ignored satisfaction of search) and to archana reddy.t, who made the final diagnosis.
 
Teaching point: remember to look at the underlying rib in any extrapulmonary lesion. Discovering rib involvement focus your diagnostic approach and limits the differential diagnosis.

Cáceres’ Corner Case 203 – SOLVED!

Dear Friends,

Today I am showing radiographs of a 40-year-old man with chest pain.
What do you see?

More images will be shown on Wednesday.

Click here to see the images

Dear Friends,

showing today enhanced CT images of the case.

Do they help?

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Findings: PA radiograph shows a mediastinal mass (A, arrow) superimposed to the right hilum. In the lateral view the mass is faintly visible behind the distal trachea (B, circle). This location excludes a right hilar mass, because the right hilum is anterior to the trachea.

Enhanced coronal and sagittal CT confirm a posterior mediastinal mass (C-D, arrows) with necrotic areas and marked contrast enhancement. This is an important finding because it limits the differential diagnosis to four conditions: intrathoracic goiter, Castleman’s disease, paraganglioma and hemangioma.
Some of you have mentioned extramedullary hematopoiesis. In my (limited) experience I don’t recall seeing avid contrast enhancement in it. I have asked some friends and searched the web without finding a clear answer. If any of you have better information I am willing to be corrected. At any rate, this patient does not have any bone abnormalities, which makes the diagnosis of extrapulmonary hematopoiesis very unlikely.
 
Final diagnosis: posterior mediastinal paraganglioma surgically proved. A similar case was presented in case 168 of Caceres’ corner.
 
Congratulations to MK, who was the first to suggest the correct diagnosis.
 
Teaching point: remember the four mediastinal processes with avid contrast enhancement: intrathoracic goiter (frequent), Castleman´s disease and paraganglioma (uncommon) and hemangioma (never saw a case).

Cáceres’ Corner Case 202 – SOLVED!

Dear Friends,

Dr. Pepe is busy preparing next week’s webinar (click here to register!) and asked me to present a case this week. The case is provided by my friend Jordi Andreu.

Radiograph belong to  a 83-year-old woman with dementia. A mass was detected in the right lung and a CT was done.

What do you think?

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Findings: AP chest radiograph shows a well-defined opacity in the right upper hemithorax (A, arrow) which appears to be extrapulmonary. There are calcified granulomas in the left apex with retraction of the left hilum.

Unenhanced axial and coronal CT show an extrapulmonary mass with a calcified rim (B-C, arrows). The mass has a striated appearance, alternating lineal areas of different opacities. This CT appearance is practically pathognomonic of oleothorax (see case 19 of Caceres’ corner).

Instillation of oil in the extrapleural space (oleothorax, plombage) was used to collapse the lungs facilitating healing of TB cavities. It was abandoned in the early fifties after the discovery of effective antimicrobial therapy.
The patient had pulmonary TB in her youth and told us that it was treated by instillation of a substance. A clinical photograph in another patient (D) documents the surgical scar.

Final diagnosis: Oleothorax
 
Congratulations to Diogo, who was the first to make the diagnosis and to Jake, who concurred two days later.
 
Teaching point: this is an uncommon pathology, but it should be known because the appearance is pathognomonic and shouldn´t be confused with other conditions. This patient was seen four weeks ago and diagnosed initially of pleural tumour.