Dr. Pepe’s Diploma Casebook: CASE 138 – MEET THE EXAMINER

Dear Friends,

in the aftermath of the European Congress of Radiology a have elected to show a new “Meet the Examiner” presentation, with questions and answers similar to a real examination. You will get the final answer at the end of the presentation.

Take your time before seeking the answer.

This case starts with a preoperative PA chest radiograph of a 52-year-old man. No other information was provided in the request. What do you see?

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Findings: PA radiograph shows an obvious convexity of the left paraspinal line (arrow). There is an abnormal opacity in the periphery of the right lung (circle), which may be related to the rib cage.

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After seeing the chest radiograph, we looked into the case further and discovered that the patient was scheduled for biopsy of a collapsed mid-thoracic vertebra, which would explain the bulging of the paraspinal line. Below is the MRI study. What would be your diagnosis?
1. Aggressive hemangioma
2. Metastases
3. Myeloma
4. Any of the above

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Findings: The eighth thoracic vertebra is flattened, impinging on the spinal canal. There is a central lesion in D7 and a smaller one in the anterior aspect of D5. (arrows). The findings were interpreted as an aggressive hemangioma at D8 and smaller hemangiomas at C7 and C5. A CT was requested to obtain more information.

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Axial, coronal and sagittal CT images are shown. What would be your diagnosis?

1. Aggressive hemangioma
2. Metastases
3. Myeloma
4. Any of the above

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Findings: axial CT (A) shows the typical “polka dot” appearance of vertebral hemangioma.
Coronal and sagittal views demonstrate the collapsed vertebra (B and C, white arrows) with a soft-tissue mass (B, red arrow) which explains the finding in the chest radiograph. A punched-out cortical lesion in D5 was overlooked (C, yellow arrow).

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In the meantime, we were concerned about the abnormal right peripheral opacity seen in the chest radiograph. Oblique views of the right hemithorax were taken. What do you see?

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Findings: the right oblique view shows what appears to be an old rib fracture accompanied by pleural thickening (A, white arrow). A serendipitous finding is the discovery of lytic lesions in the scapula (A, red arrows). The left oblique view also shows a lytic lesion in the right humerus (B, arrow).

The findings in the oblique chest radiographs prompted a review of the spinal CT. Numerous punched-out cortical lesions that had been overlooked were noted (arrows). This discovery suggested widespread malignant bone infiltration. Given that the patient was in good general condition, multiple myeloma was the first diagnostic choice. Vertebral biopsy provided the final diagnosis of myeloma.

Final diagnosis: multiple myeloma invading a vertebral hemangioma

Vertebral hemangioma is the most common vascular lesion of the spine and is present in about 10% of the population. The favored location is the mid-thoracic spine. In this particular patient we suspect that an unrelated multiple myeloma had invaded a previous vertebral hemangioma, causing collapse of the vertebral body. This responds to the concept of locus minoris resistentia, in this context referring to organs or regions that for some reason are more vulnerable than others. In this case, the wide vascular spaces and increased blood supply of the hemangioma may have facilitated implantation of malignant cells.

The typical appearance of coarse trabeculae (polka dot) of the original hemangioma, plus satisfaction of search were the reasons for the initial misdiagnosis of invasive hemangioma. The findings in the plain films of the chest were decisive to reconsider the diagnosis, leading to a review of the cross-sectional studies and the correct diagnosis.


Follow Dr. Pepe’s advice:

1. Remember Dr. Pepe’s words of wisdom (Diploma case 132): Don’t let one abnormal finding keep you from looking for another

2. Sometimes, plain films have an important role in the diagnosis.

Dr. Pepe’s Diploma Casebook: CASE 137 – MEET THE EXAMINER

Dear Friends,

since we have the European Congress of Radiology this week, I don’t want to stress you unnecessarily. I have selected a “Meet the Examiner” presentation, with questions and answers similar to a real examination. You will get the final answer at the end of the presentation.

Take your time before seeking the answer. And no peeking!

This case was provided by my friend and co-worker Dr. Lucía Hernandez. The patient is a 39-year-old woman who had a tumorectomy for carcinoma of the right breast in March 2008. In February 2009 she noticed a lump in her right axilla. Breast MRI was performed.

What would be your diagnosis:

1. Necrotic lymph node
2. Metastasis
3. Fibrotic tissue
4. None of the above

Click here to see the images

Click here to see the answer

Findings: The MRI finding was interpreted as an enlarged lymph node in the right axillary area, around 35 mm in diameter and with a necrotic center (A and B, arrows).

Ultrasound exam demonstrated a longitudinal echogenic band of about 40 mm in length, suggestive of postsurgical changes. No adenopathy was found.
Fine-needle biopsy returned nonspecific findings, no signs of malignancy.

In view of these results, no action was taken.

The patient returned yearly for follow-up MRI and US studies, which showed no significant changes from the initial examination.

Ten years later, in January 2019, the patient detected a discrete ulceration in the right axilla and consulted her doctor. A new MRI examination was done.

What do you think?

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MRI showed a slight increase in the size of the lesion from 35 mm maximum diameter in 2009 (A, arrow) to 40 mm in 2019 (B, arrow). US showed no changes in comparison with previous studies. PET-CT study was ordered.

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What do you see?

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The study was interpreted as a rounded axillary image with low peripheral uptake (SUV 4) (A-C, arrows). The high-density linear opacity in the center was overlooked (B, yellow arrow).

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At this stage of the game, all imaging studies were reviewed, including the chest radiographs.

Below are postoperative chest radiographs taken in March 2009. What do you see?

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Chest radiographs show a radio-opaque marker in the right axilla (A and B, arrows). The appearance is typical of a retained surgical gauze.

The findings are better seen in the cone down views (C and D, arrows). A cone down view of the axilla with the arm outstretched taken in 2019 clearly shows the axillary mass (E, black arrows) and the radio-opaque marked gauze within (E, red arrow).

Enhanced axial CT also shows the typical appearance of encapsulated surgical gauze (A and B, white arrows), with the radio-opaque marker inside (A and B, red arrows). Confirmed at surgery.

Final diagnosis: Retained surgical gauze in the right axilla

Retained surgical gauzes are occasionally seen in abdominal surgery, but are less common in the chest. I have encountered only one other case (See Fig. 1, below). Nonetheless, they are easily identified by their radio-opaque markers. Early detection of this material avoids unnecessary examinations and prevents future complications, as occurred in the patient presented.

As a chest radiologist, it makes me proud that proper reading of a chest radiograph achieved a diagnosis that prompted 2 biopsies, 9 MRI, 9 sonographies, and 1 PET-CT over 10 years.
It is interesting to note that a normal gauze count does not exclude the possibility of a retained gauze. In one series, the count was reported as correct in 22 of 29 patients (76%) with retained gauzes in the abdomen (Kaiser CW, Friedman S, Spurling KP, Slowick T, Kaiser HA. The retained surgical sponge. Ann Surg 1996;224:79–84).

Fig. 1. 58-year-old man with fever after cardiac surgery. PA radiograph was unremarkable. Lateral view shows a radio-opaque marker in the posterior heart shadow (A, arrow), better depicted in the cone down view (B, arrow), with the typical appearance of a retained gauze. CT confirms the presence of the gauze in the pericardial cavity (C, arrow). Proved at surgery.


Follow Dr. Pepe’s advice:

1. Retained surgical gauzes are easily identified by their radio-opaque markers.

2. Early discovery prevents complications and unnecessary examinations.