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

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

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!

Dr. Pepe’s Diploma Casebook 164 – SOLVED

Dear Friends,

Today I will show a new “Meet the examiner case”, with questions and answers similar to a real presentation. You will get more images on Wednesday and the final answer on Friday.

Images belong to a 49-year-old woman with progressive chest pain and dyspnea. She mentions being hit in the chest with a surfboard three weeks ago.

1. Myocardiopathy
2. Pericarditis
3. Myelolipoma
4. Any of the above

What do you see?

Click here to see more images

Cardiac ultrasound discovered a large pericardial effusion that was drained, evacuating a large amount of hematic fluid (A)

Three days days later the patient developed mild symptoms of cardiac tamponade. Portable chest (B) shows increased size of the cardiac silhouette. Enhanced axial CT (C) is shown.
What do you think?

Click here to see the answer

Findings: PA and lateral radiographs (A-B) show what appears to be an enlarged cardiac silhouette. Of the offered options I would think first of pericardial effusion because the pulmonary vessels are small compared to the size of the heart. In cardiomyopathy I would expect engorged pulmonary vessels. Cannot exclude thymolypoma, but I would consider it very unlikely. Probably the best answer is 4. All of the above. And I would recommend a cardiac US because traumatic pericardial effusion is the most likely diagnosis.

Cardiac ultrasound discovered a large pericardial effusion that was drained, evacuating a large amount of hematic fluid. Note the normal thickness of the pericardium (C-D, arrows)

CT also discovered healing fractures of the anterior 4th, 6th and 7th left ribs (E-G, arrows)

After drainage, the heart shadow returned to normal size (H). Three days later the patient developed fever and mild symptoms of cardiac tamponade. Portable chest showed increased size of the cardiac silhouette, despite the presence of a draining catheter (H-I, red arrows).

Enhanced CT demonstrated a moderate amount of pericardial fluid (J-K, arrows) accompanied by bilateral pleural effusions (J, red arrows). The pericardium was surgically explored and cleaned. Staphylococcus Xilosus was grown.

After appropriate antibiotic treatment the symptoms subsided. One month later the chest at discharge appeared normal (L-M).

Final diagnosis: delayed traumatic pericarditis with subsequent infection

Pericardial effusion has many causes, one of them blunt trauma. It is usually associated with other findings: pneumothorax, fractured ribs and lung contusion. Delayed pericardial effusion is a rare manifestation of previous blunt trauma.

Plain film signs of pericardial fluid are unreliable, except for visualization of posterior displacement of epicardial fat in the lateral view, which has high value (epicardial fat sign, Fig. 1). Cardiac ultrasound is the diagnostic technique of choice.

I am showing this case because of the beauty of the initial images and the iatrogenic infectious complication, which muddled the differential diagnosis.

To complete the presentation I am showing a very rare case of cardiac volvulus. It occurred secondary to surgical trauma, after removal of part of the right pericardium (Fig. 2).

I borrowed this case from an American friend a long time ago and am ashamed to confess that I don’t remember who he was. The credit is yours, friend. Many thanks.

Fig. 1. 46-year-old man with liver cirrhosis and pericardial effusion. PA radiograph(A) shows non-specific enlargement of the cardiac silhouette. The lateral view shows posterior displacement of the epicardial fat (B, arrow). The thickened pericardium is visible between the epicardial and mediastinal fat (B, red arrows).

Coronal and sagittal CT confirm the presence of a moderate amount of pericardial fluid (C-D, arrows). Note the displaced epicardial fat in the lateral view (B, red arrow).

Fig 2. 34-year-old woman with Down syndrome with chronic respiratory infections in RLL (A). Bronchoscopy discovered a hemangioma obstructing the intermediary bronchus. At surgery the tumor was adherent to the right pericardium. Pneumonectomy and partial resection of right pericardium were performed.
Post-op portable chest shows moderate prominence of the right heart border (B, arrow).

Six hours after the intervention the patient started to deteriorate and went into shock. Portable radiograph shows displacement of the cardiac silhouette to the right (C, arrow) and complete herniation of the heart into the right hemithorax twelve hours later. (D, arrow). A second intervention confirmed a cardiac volvulus that was corrected with a pericardial patch.

Follow Dr. Pepe’s advice:

1. Delayed pericarditis after blunt trauma is rare. Should be considered when the cardiac silhouette enlarges following blunt chest trauma

2. Echocardiography is the diagnostic method of choice for diagnosing pericardial fluid

3. Plain film signs of pericardial effusion are unreliable, except for visible displaced epicardial fat in the lateral radiograph

Dr. Pepe’s Diploma Casebook 163 – SOLVED

Dear Friends,
I am back with a new Diploma case. Miss Piggy sends her regards😍 and has helped to choose the case.
Chest radiographs belong to a 74-year-old man with a cough and pain in the chest.

What do you see?

Click here to see the answer

Findings: PA radiograph shows a bulge in the left paraspinal line (A, arrow), suggestive of a posterior mediastinal mass. A rounded posterior opacity is seen in the lateral view (B, arrow).

Unenhanced coronal and sagittal CT show large osteophytes displacing the paraspinal line (C, circle) pushing the aorta forward in the sagittal view(D, circle). Incidental gas is visible in the intervertebral disk.

Final diagnosis: large osteophytes simulating a pulmonary/mediastinal mass

The aim of this Diploma is to discuss chest imaging in the elderly. As patients get older the appearance of their chest radiographs changes in comparison with young persons. I intend to discuss changes associated to aging as well as the most common pathologies in the old.

I have divided the presentation into three separate chapters:

1- Bony structures of the chest
2- Heart and mediastinum
3- Lungs and diaphragm

Today I will comment on the main manifestations of aging in the chest skeleton, discussing variations that may simulate disease, followed by the most common bone pathologies in the elderly.


Degenerative changes are the hallmark of the aging skeleton.Vertebral osteophytes are common and large ones should not be confused with pulmonary nodules (Fig 1) or mediastinal masses (Fig 2), as shown in the initial case. The diagnosis is easily made with chest CT.

Fig 1. 67-year-old male without significant symptoms. PA radiograph (A) is unremarkable. Lateral view shows a posterior nodule that could be intrapulmonary (B, arrow).

Coronal and sagittal unenhanced CT show that the nodule represents a large osteophyte (C-D, arrows). The absence of other osteophytes makes it difficult to suspect this diagnosis in the plain film.
Fig 2. 65-year-old man in whom a posterior mediastinal mass was discovered (A-B. arrows). The mass was unchanged in comparison with a previous examination. CT was recommended because a neurogenic tumor could not be excluded.
Unenhanced coronal and sagittal CT demonstrates that the mass represents a single large osteophyte (C-D, arrows)

Calcification of the first costal cartilage may happen in the young but it is more common in the elderly. When asymmetrical, it may be confused with a pulmonary nodule (Fig 3). Exuberant cartilage calcification may simulate an upper lobe infiltrate (Fig 4).

Fig 3. 70-year-old man with a large pleural effusion, suspected to be malignant because of a possible nodule in the LUL (A, arrow). Cone down view shows that the nodule es calcified and corresponds to the first costal cartilage (B, arrow). Post-pneumonic empyema.
Fig 4. 69-year-old woman with fever. Exuberant calcification of the first right costal cartilage was initially diagnosed as pneumonia (A, circle). Comparison with a radiograph taken four years earlier did not show any change (B-C, arrows).

Aging causes brittle bones and explains the increased incidence of costal fractures in the elderly. The callus of a healed fracture should not be confused with a pulmonary nodule (Fig. 6).

Fig 6. 74-year-old woman in whom a RUL nodule appeared one year after cardiac surgery (A, arrow).
A 3-D reconstruction shows that the nodule represents a healed fracture of the second rib (B, circle). Ribs fractures after cardiac surgery are not uncommon

Resuscitation maneuvers, not uncommon in advanced age, may cause bilateral rib fractures, that should be recognized as such (fig 7).

Fig 7. 63-year-old man with prostate carcinoma, complaining of chest pain. PA radiograph shows
sclerotic areas in the lower ribs (A, arrows), not present in previous films. My initial impression was metastatic disease, until I learned that the patient has had resuscitation maneuvers a few months earlier. Axial and coronal CT confirms symmetrical healed fractures of the anterior lower ribs (B-C, circles).


The most common bone pathology in the elderly are fractures. Acute rib fractures are common, most of them secondary to falls (Fig 8). Detection is important because they cause respiratory impairment that may end in pneumonia with the subsequent increase of morbidity and mortality.

Fig 8. 78-year-old alcoholic man after a fall. PA radiograph shows displaced rib fractures (A, circle) as well as pneumothorax (A, red arrow) and subcutaneous emphysema Note the straight air-fluid level of hemothorax at the left base (A, arrow)

Compression fractures of vertebral bodies are related to osteoporosis and common in the elderly. They cause significant pain, leading to inability to perform daily activities. If they are not recognized they cause a decline of the quality of life in elderly patients (Fig 9).

Fig 9. 84-year-old woman with chronic back pain. PA radiograph (A) is unremarkable. Lateral chest shows a severe compression fracture of D9 (B, circle), better seen in the cone down view (C, arrows).

Lytic bone lesions in the elderly are usually related to metastases or multiple myeloma. Sclerotic metastases are common in old males. Given the prevalence of prostate carcinoma this should be our first diagnostic consideration in widespread sclerotic lesions (Fig 10). The differential diagnosis includes myelofibrosis (fig 11) and chronic renal failure (Fig 12).

Fig 10. 71-year-old male with widespread sclerotic lesions of ribs and spine secondary to metastases from prostatic carcinoma.

Myelofibrosis is a myeloproliferative neoplasm which cause osteosclerosis. The association of an enlarged spleen should alert us to this possible diagnosis.

Fig 11. Preoperatory chest film in a 67-year-old woman. Diffuse increased bone density (A), better seen in the cone down view of left shoulder (B). The medially displaced gastric bubble suggests splenic enlargement (A, arrow). Myelofibrosis suspected and confirmed.
Fig 12. 73-year-old woman with chronic renal failure. PA radiograph (A) shows deformity of the rib cage. Lateral view (B) show the rugged-jersey spine, typical of this entity.

Solitary sclerotic lesions of the skeleton raises the possibility of metastasis vs. Paget disease. In the spine, Paget disease usually increases the size of the vertebra whereas metastases do not (Fig 13). In the peripheral skeleton the increase in width of the cortical bone is characteristic of Paget disease (Figs 14-15) .

Fig 13. 68-year-old man who presented with back pain. PA radiograph (A) is unremarkable. Lateral view shows an ivory vertebra (B, circle) that has the same size than the others.
Diagnosis: metastasis from prostatic carcinoma.
Fig 14. Two patients with Paget disease of a rib. Note the increased cortical thickness of the 6th rib in the first patient compared to the other ribs (A, arrow) a hallmark of Paget disease. The second patient has sclerosis of the whole 6th rib which is increased in size
(B, arrow), another characteristic of Paget.
Fig 15. 70-year-old man with prostate carcinoma and metastasis to the anterior third rib (A-B, arrows). Note the difference with the previous cases.

Follow Dr. Pepe’s advice:

1. Osteophytes and healed rib fractures may simulate pulmonary nodules in the elderly

2. It is important to detect rib or vertebral fractures in the elderly because they may be the source of complications

3. Sclerotic bone lesions in the elderly are usually due to prostate metastases or Paget disease

Dr. Pepe’s Diploma Casebook 162 – SOLVED

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).

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

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
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
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?

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

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

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.

Dr. Pepe’s Diploma Casebook 159 – SOLVED

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.

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.


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

Dr. Pepe’s Diploma Casebook 158 – SOLVED

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?


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).


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.

Dr. Pepe’s Diploma Casebook 157 – SOLVED

Dear Friends,

The leading case of this week’s Diploma has been provided by my good friend Jordi Andreu. Radiographs belong to an asymptomatic 48-year-old woman.


1. Neurogenic tumor
2. Pulmonary hamartoma
3. Pleural fibrous tumor
4. None of the above

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

Click here to see the answer

Findings: PA chest radiograph shows a rounded opacity in the left apex (A, arrow). All diagnosis are possible, as the pulmonary apex is a narrow space and it is very difficult to determine the origin of a mass. The clue lies in the nodular opacities in the neck (A, circle) which raise the possibility of superimposed hair braid.
Unenhanced coronal CT (B) does not show any mass, confirming that the finding is artifactual.

Final diagnosis: superimposed hair braid simulating pulmonary disease

The purpose of this presentation is to discuss elements in or about the soft tissues of the chest wall that may simulate lung disease. Those related to the thoracic skeleton were shown in Diploma case # 57.
This Diploma complements the non-significant findings described in webinar eight.

I have classified them into three groups, the first one related to the soft tissues of the chest wall while the other two are external to the body:

1. Nipples and skin lesions
2. Hair and/or hair implements
3. Garments

Nipple Shadows

Nipple shadows are seen in 3% to 10% of PA chest radiographs. In about 10% of these patients, the identification may raise doubts. Comparison with previous films will confirm the stability of the nodules (Fig. 1). In case of doubt, nipple markers should be placed. Routine use of nipple markers has been proposed in oncologic patients.

Fig. 1. 58-year-old man with typical bilateral nipple shadows (A, arrows), unchanged in comparison with a previous film (B, arrows). Nipples are well seen on axial CT in the same patient (C, arrows). Nowadays, patients may come with their own nipple markers! (D).

Unilateral enlarged nipple shadows are suspicious findings. Visual inspection should be done to confirm that the nipple is indeed enlarged (Fig. 2). Occasionally, a true lung nodule may simulate a nipple shadow, even with nipple markers. In such cases, CT will correct our error (Figs. 3-4)

Fig 2. 61-year-old woman with left pleuritic chest pain. PA chest film shows a small amount of left pleural fluid (A, white arrow) and a nodule at the right costophrenic angle (A, red arrow). Visual inspection showed a large right nipple as the cause of the false nodule. Two weeks later, the pleural effusion has disappeared, and the nipple shadow is no longer seen (B).

Fig. 3. 54-year-old man with a renal tumor. PA film shows a nodule in the LLL (A, arrow) that simulates a nipple, even with a nipple marker (B, arrow). Axial CT shows a metastatic nodule in the LLL and a larger one in the RLL, not seen in the PA chest radiograph (insert, arrows).

Skin lesions

Skin lesions may also cause false lung nodules. Visual inspection of the chest will demonstrate them and confirm the diagnosis (Fig. 5). If there is any doubt, a marker can be used.

Fig. 5. Chest wart simulating a lung nodule in the PA film (A, arrow). Lateral film shows the wart in the skin of the anterior chest wall (B, arrow). The wart is higher in this view because the upheld arms elevate it.

Occasionally, a discrepancy in density between both breasts, usually related to previous surgery, may simulate pulmonary pathology (Fig 6).

Fig 6. 65-year-old woman with syncope. PA radiograph shows a rounded opacity in the right lung (A, arrow), suspected to be a pulmonary infiltrate. Axial CT (B) show normal lungs. The opacity is due to a superimposed right breast prosthesis (B-C, arrows).


In my experience, hair is a common cause of opacities in the lung apices (Fig 7).
Strands of loose hair may project over the upper lung, simulating linear fibrotic infiltrates (Fig 8). Rubber bands at the end of braids may be confused with pulmonary nodules (Fig. 9). A long braid may fool us and consider it intrapulmonary disease (Fig 10).

In most cases, the clue to the diagnosis lies in recognizing that the abnormality extends to the neck.

Fig. 7. Braid simulating an apical pulmonary nodule (A-B, arrows). The rubber band (A-B, red arrows) suggests the correct diagnosis

Fig. 8. Loose hair simulating a linear infiltrate or fibrosis in the right apex (A, white arrow). Note the same appearance in the lower neck (A, red arrow). The apex looks normal after the hair is lifted (B). The opaque rounded opacity that looks like a hair clasp (A-B yellow arrow) is a cervical disk prosthesis.

Fig 9. Two patients with rubber bands at the end of a braid simulating pulmonary nodules (A-B, arrows). In both, the braids are visible in the neck (A-B, red arrows). Despite that, patient B was referred for a CT examination to evaluate a left lung nodule.

Fig. 10. 25-year-old man with braided hair simulating a RUL infiltrate (A, arrow). The opacity extends to the neck, giving away the diagnosis (A, red arrow). After raising the braid, the chest looks normal (B). Remember that men also wear their hair long nowadays.

Clothing artifacts

Clothing artifacts occur when the technician does not ask patients to remove garments that have logos or images on them. This usually happens with women, out of respect for modesty (Figs. 11 and 12).

Fig. 11. 27-year-old woman with multiple miliary nodules in both lungs (A, circles). The opacities result from a jeweled panther on the shirt she was wearing (B).

Fig 12. 45-year-old woman with previous breast carcinoma. PA radiograph shows small nodules in lower lungs (A, circles). Lateral view proves that the nodules are in a blouse (B, arrow)

Other types of body artifacts may cause dubious opacities in the chest radiograph (Figs 13 and 14)

Fig 13. 29-year-old man with a barely visible non-displaced fracture of the left clavicle (A, arrow), well demonstrated in the 3-D CT reconstruction (B). Components of the support brace for the fracture simulate enlarged upper lobe vessels (A, red arrows).

To end the presentation, in the last two months we have been acquainted with a new artifact: the wire in the face masks (Fig 14)

Fig 14. Routine chest radiograph during the Covid-19 scare. Notice the wire in the face mask (A-B, arrows)

Follow Dr. Pepe’s advice:

1. Unilateral nipple shadows may generate diagnostic problems.
2. If a hair artifact is suspected, look at the soft tissues of the neck.
3. Garments may create weird lung shadows.