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.

Cáceres’ Corner Case 215 – SOLVED

Dear Friends,

Today’s case has been provided by my good friend and former resident Victor Pineda. Radiographs belong to a 56-year-old man with cough and fever.
What do you see?

More images will be shown on Wednesday!

Click here to see the images shown on Monday

Dear friends hope these new images help you with the diagnosis.

Click here to see more images

Click here to see the answer

Findings: PA chest radiograph shows a large paramediastinal lung opacity (A, arrow) that at first glance suggest malignancy. The clue to the diagnosis lies in identifying multiple bronchiectasis in the right and left central lung fields (A, circles).

The lateral view confirms the opacity in the posterior segment of the RUL (B, arrow) and bronchiectasis in the anterior clear space (B, circle).

Central bronchiectasis accompanied by lung opacities are typical of diseases with thick tenacious mucus and are the hallmark of cystic fibrosis o allergic bronchopulmonary aspergillosis. Coronal and axial CT confirm the presence of numerous central bronchiectasis, one of them with a large mucous impaction (C and D, arrows).

In the mediastinal window the impacted mucus is increased in density (E and F, arrows), which is a pathognomonic sign of ABPA.

Final diagnosis: ABPA with central bronchiectasis and dense pulmonary impaction
 
Congratulations to MG who was the first to answer and made a valiant effort to diagnose a difficult case.
 
Teaching point: this case looks difficult, but the diagnosis is easy if we identify basic findings. Discovering central bronchiectasis narrows the diagnosis to two entities and CT confirms one of them.

Cáceres’ Corner Case 214 – SOLVED

Dear Friends,

Presenting today radiographs of an 89-year-old woman with dyspnea and moderate fever.

Diagnosis:

1. Empyema
2. Mediastinal tumor
3. Pneumonia
4. None of the above

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

Click here to see the answer

Findings: PA chest radiograph shows an opacity occupying the middle and lower right lung It is located anteriorly in the lateral view and has a well-defined posterior border.
The clue to the diagnosis lies with the bubbles of air within the opacity (A, red arrows) which resemble bowel loops in the lateral view (B, circle). The heart is displaced towards the left, but this finding cannot be evaluated because of the moderate scoliosis. In addition, a hiatus hernia is present (A-B, arrows).

Enhanced axial CT (C-D) demonstrates that the opacity consists mainly of fat containing some bowel loops.

Coronal and sagittal reconstructions show a large gap in the anterior right hemidiaphragm (E-F, circles), with herniation of bowel and abdominal fat into the hemithorax.

Final diagnosis: large Morgagni´s hernia simulating pulmonary disease.
 
Congratulations to xristoby, who was the only one who mentioned anterior diaphragmatic hernia.
 
Teaching point: Remember that any lower lung lesion adjacent to the diaphragm may arise from the abdomen, as demonstrated with the present case.

Cáceres’ Corner Case 213 – SOLVED

Dear Friends,

Today’s radiographs belong to a 46-year-old man.
Preoperative for knee surgery.

What do you see?

Leave your thoughts on the comments and come back on Friday to see the answer!

Click here to see the answer!

Findings: PA chest radiograph show increased size of both hila (A, arrows), more evident in the right side. There is also convexity of the aorto-pulmonary window (A, red arrow). The findings are highly suspicious of widespread lymphadenopathy, confirmed in the lateral view (B, arrow). There is also anterior bowing of the posterior tracheal wall by a rounded opacity in Raider´s triangle (B, red arrows).

Enhanced axial CT confirms enlarged hilar lymph nodes (C, arrows) as well as an adenopathy in the A-P window (D-E, red arrows).

The retrotracheal opacity was due to an aberrant subclavian artery arising from a Kommerel diverticulum (F-H, red arrows).

The patient had been diagnosed of sarcoidosis in 2015. Follow-up CTs in 2017 and 2019 did not show any change.
 
Final diagnosis: Sarcoidosis with an incidental aberrant right subclavian artery.
 
Congratulations to Manal Gebril, who was the first to make the diagnosis and to Gaborini, who described the aberrant right subclavian artery.
 
Teaching point: remember satisfaction of search. Some of you missed the occupation of Raider´s triangle and nobody mentioned the convex A-P window.

Cáceres’ Corner Case 212 – SOLVED

Dear Friends,

Today’s radiographs belong to a 53-year-old man with dysphagia. 

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

Click here to see the solution

Findings: PA radiograph (A) is unremarkable. The lateral view shows a slight anterior bowing of the trachea (B, arrow) with an apparently dilated upper esophagus with an air/solid interface (B, red arrow).

These findings are well seen in the cone down view, which better shows a thickened retrotracheal stripe (C, red arrows), a sign that suggests esophageal pathology, among others.
For all of you who diagnosed achalasia there is a negative finding: the lack of occupation of the retrocardiac space (D, circle) which practically rules out dilatation of the lower esophagus.

Sorry to say that I do not have additional images. After receiving the possible diagnosis of esophageal tumor, the patient went to another hospital, where esophagoscopy and biopsy confirmed upper esophageal dilatation by a carcinoma of the middle third.
 
Final diagnosis: Carcinoma of the middle third of the esophagus with proximal dilatation and food retention.
 
Congratulations to Dr Ahmad who was the first to describe the findings.
 
Teaching point: this case emphasizes the value of clinical information in selected cases. I suspect that some of you would not have discovered the dilated esophagus in the lateral view if I had withheld the history of dysphagia :).