Cáceres’ Corner Case 222 – SOLVED

Dear Friends,

Showing today preoperative radiographs of 57-year-old man with a torn knee cartilage. Sorry about the poor quality of the lateral view.
What do you see?

Come back on Friday to see the answer!

Click here to see the answer

Findings: PA radiograph show widening of the right superior mediastinum (A, arrow), imprinting the tracheal wall (A, red arrow).
In the lateral view there is increased opacity of Raider triangle (B, circle) with slight bowing of the posterior tracheal wall (B, red arrow).

The main causes of occupation of Raider triangle are two: either esophageal disease or congenital malformation of the aortic arch. The last one is the most likely, given the findings in the PA view.
 
Enhanced CT confirms a right aortic arch (C-D, arrows), crossing behind the trachea (C-E, red arrows) and causing the opacity in Raider triangle.

Findings are better seen in the 3-D reconstruction (F).

Final diagnosis: right aortic arch
 
Congratulations to Jolanta who made the correct diagnosis (my initial impression in the plain film was double aortic arch, so I will award another prize to Faelivrin for being wrong with me).
 
Teaching point: this case does not look very exciting, but right aortic arch is very common, and it is important to avoid confusing it with a mediastinal mass.
 
If you want to know more about malformations of the aortic arch, look up the article by Hanneman, Newman and Chan: Congenital variants and anomalies of the aortic arch, RadioGraphics 2017; 37:32–51

Cáceres’ Corner Case 221 – SOLVED

Dear Friends,

Today´s images belong to a 76-year-old man with pain in the back. Antecedents of urothelial carcinoma.

PA chest radiograph was normal and radiographs of the dorsal spine were taken.

What do you see?

Come back on Friday to see the solution!

Click here to see the answer

Findings: AP view of dorsal spine shows fixation screws in the lower spine and partial vertebroplasty of D12. The most important finding is that the left pedicle of D8 is absent (A, circle). In the lateral view, the posterior wall of the same vertebra is not seen (B, circle).

The findings are more evident in the cone down views (C-D, circles). In this particular case I was lucky because the superimposed air of the left main bronchus allows an unimpeded view of the missing pedicle.

Review of a recent chest CT demonstrated a lytic lesion in the body and pedicle of D8 (E-G, circles) that were no reported.

Final diagnosis: metastasis to D8 discovered in the plain film of the spine and overlooked in a previous CT.
 
Congratulations to BujarB, who was the only one to discover the missing pedicle (my hero!)
 
You may think that this case is difficult (only one of seven found the lesion). In the old times our routine included looking at the pedicles in the AP view of dorsal and lumbar spine. To familiarize you with the appearance of the normal spine, an AP view is shown below.

Teaching point: remember to look at the pedicles in the AP view. A missing pedicle in a patient with a known primary tumor is highly suspicious of metastasis.

Cáceres’ Corner Case 220 – SOLVED


Dear Friends,

I am showing today a case seen last week. Radiographs belong to a 35-year-old man with fever. 

What do you see?

The answer will be published on Friday.

Click here to see the answer

Findings: PA chest radiograph shows widening of the superior mediastinum (A, arrows). There is moderate prominence of both hila (A, red arrows) and two rounded opacities in the inferior aspect of the right hilum (A, yellow arrows). The lateral view shows convex bumps in the left hilum (B, red arrows).
Findings in both views are practically pathognomonic of mediastinal and hilar lymphadenopathies.

Changes in the PA radiograph are more evident when comparing with a previous film taken two years earlier.

In this case, lymphoma is the best possibility. For the sake of the patient I hoped it was infectious mononucleosis. Analysis discovered immature cells in the bloodstream. Further workup confirmed the diagnosis of acute lymphoblastic leukemia.
 
Final diagnosis: acute lymphoblastic leukemia with enlarged hilar and mediastinal lymph nodes.
 
Many of you discovered the enlarged lymph nodes, which makes me very proud.
Kudos for Amal Mahran, who was the first to give a detailed description.
 
Teaching point: I believe this case emphasizes the importance of comparing with previous studies. If I had shown the previous PA chest, I am sure the percentage of correct answers would had been close to one hundred percent.

Cáceres’ Corner Case 219 – SOLVED!

Dear Friends,
Today’s images belong to a 67-year-old woman with pain in the chest.
What do you see?

More images will be presented next Wednesday and the answer will be published on Friday, as usual.

Click here to see more images

Dear Friends,

Showing additional axial CT images of the patient.
What do you see?

Click here for the solution

Findings: PA chest radiograph shows a lytic lesion of the 3rd right rib, accompanied by an extrapulmonary sign (A, circle). Lateral view (not shown) is unremarkable.

The lesion is more obvious in the cone-down view (B, circle), specially when compared to a previous study (C, circle).

Axial CT confirms a permeative lesion of the rib (D-E, arrows), as well as lytic lesion in the posterior elements of the 4th thoracic vertebra (E, red arrow). A serendipitous finding is a nodule in the medial quadrant of the left breast (F, arrow), demonstrated in a subsequent mammography (G, arrow) and confirmed to be a carcinoma.

Final diagnosis: carcinoma of the breast with osseous metastases
 
Congratulations to Diogo who saw and described the rib lesion in the plain film.
 
Teaching point:remember that our most common error is missing obvious lesions.
Checklists help to correct oversights. I believe the rib lesion could have been found if you had applied the checklist recommended in webinar one (H).

Cáceres’ Corner Case 218 – SOLVED

Dear Friends,

an easy case to celebrate the new year. PA radiograph of a 36-year-old woman with chest pain.

What do you see?

Click here to see the answer

Findings: PA chest radiograph shows a fracture of the right clavicle (A, arrow). A magnified view of the area raises the possibility of a lytic lesion (B, arrow).

Specific low-Kv images of the clavicle were taken, showing a rounded permeative lesion with a pathological fracture (C, arrow. D, circle). No other lesions were demonstrated in a bone scan. Biopsy followed by surgery came back as chondrosarcoma.

Final diagnosis: chondrosarcoma of clavicle with pathological fracture
 
Congratulations to Archanareddyt, who discovered the pathological fracture
 
Teaching point: when evaluating bone lesions of the chest, take specific views. They allow a better interpretation of the pathologic changes

Cáceres’ Corner Case 217 – SOLVED

Dear Friends,

I am showing today PA chest radiographs in two asymptomatic patients They have subtle findings that can be discovered if you paid attention to the previous webinars.

What do you see?

Prof. Cáceres will take some well-deserved holidays and will come back on January 6th with new cases!

Click here to see the answer

Case 1 findings: PA radiograph shows a well-defined opacity behind the cardiac shadow (A, arrow), better seen in the cone-down view (B, arrow). It has an extrapulmonary appearance and the best option is diaphragmatic hernia.

Coronal and sagittal CT demonstrate herniated abdominal fat through a rent in the posterior diaphragm (C-D, arrows).
 
Final diagnosis:Bochdaleck hernia

Case 1 has been diagnosed by most of you. Congratulations to Archanareddyt,
who was the first. Hope my recommendations in Webinar 4 were helpful!


REMEMBER

In the cardiac area look for:

* Opacities behind the left heart
* Double contour on the right

Case 2 findings: This patient has a faint but visible right infraclavicular nodule (A-B, arrows).

The nodule was overlooked and one year later had grown markedly (D, arrow). At surgery, a melanoma was found.
 
Final diagnosis: melanoma of the lung, missed in the initial examination

Teaching point: This is a difficult case, but easily diagnosed if you remember my oft-repeated mantra: “Search for pulmonary nodules in the pulmonary apices” (Webinar 1). Nobody saw the nodule and I feel useless (sniff).

Cáceres’ Corner Case 216 – SOLVED!

Dear Friends,

Today I am showing another case provided by my friend Dr. López Moreno. Radiographs belong to a 25-year-old woman with fainting spells. 

What do you see?

More images will be shown on Wednesday.

Dear Friends,

Showing coronal and sagittal images of enhanced CT.
What do you see?

Click here to see more images

Click here to see the answer

Findings: PA radiograph shows convexity of the aorto-pulmonary window (A, arrow) which is encroaching upon the left hilum. Aside from a discrete pectus excavatum, I don’t see any significant findings in the lateral view (B).

According to Diploma 144, the main causes of a prominent A-P window are either enlarged lymph nodes or an arterial aneurysm and a CT should be obtained. In this particular patient coronal enhanced CT shows an aortic aneurysm projecting over the A-P window (C, arrow) and located anterior to the aortic arch in the sagittal projection (D, arrow).

The appearance is compatible with traumatic pseudoaneurysm, but the patient did not have any antecedent of traumatism. In our opinion (Dr López Moreno and mine) we believe that it represents a ductus aneurysm because of the location and the thin band joining the aneurysm and the pulmonary artery (E, circle). The pinpoint calcification in the middle of the band may be calcium in the ductus ligament or be secondary to partial-volume effect.

An unexpected finding is the compression of the left main bronchus by the aneurysm (E-F, arrows). It would have been interesting to perform expiration films to detect air-trapping of the left lung.

Some of you have mentioned Kommerel diverticulum. This malformation is located posteriorly and occurs in aberrant subclavian artery, which courses behind the trachea and pushes it forward in the lateral chest radiograph. You can see examples in case 213 of Caceres’ corner and Diploma cases 2, 9 and 84.
 
Final diagnosis: Probable aneurysm of the ductus arteriosus
 
Congratulations to S who was the first to think of the ductus in the plain film and made the diagnosis of ductus diverticulum after CT.
 
Teaching point: this is my first ductus aneurysm (if we are right) and I cannot have much to say. Perhaps to stress again the importance of looking at the aorto-pulmonary window in the PA radiograph.