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
3. PET-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
2. PET-CT
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?

1. PET-CT
2. CXR in three months
3. CT in three months
4. Control in one year

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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)

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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 156

Dear Friends,

In the aftermath of the Covid-19 scare, I 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 PA and lateral chest radiographs of a 63-year-old man with acute chest pain. Would you suspect pulmonary embolism?

1.Yes
2.No
3.Need a CT

Click here to see the answer

Findings: the most significant finding is a broad right descending pulmonary artery (A, arrow) with an abrupt cut-off (A, red arrow), a sign of embolus in the artery (Palla sign). Oligemia of the right lung is also visible (Westermark sign). Both signs are suggestive of pulmonary embolism, to be confirmed with enhanced CT.
An enlarged azygos vein is also seen (A, yellow arrow), as well as a bump in the para-aortic line (A, blue arrow)

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Enhanced CT confirms multiple pulmonary emboli (C, arrows) as well as a large embolus in the right descending pulmonary artery responsible for the Palla sign (D, red arrow)

Caudal slices show a non-enhancing opacity in the lower mediastinum. What would be the most likely diagnosis?

1- Lymphangioma
2- Varices
3- Neurofibromatosis
4- Any of the above

Click here to see the answer

Findings: the serpiginous appearance of the opacity (E-F, red arrows) is compatible with all three diagnosis. Mediastinal varices are the most likely diagnosis because they are not unusual, and the top of the spleen appears to be enlarged (F, asterisk).
The varices are not opacified because the images were taken during the arterial phase.

Late images taken during the venous phase show enhancement of the varices (G, arrow). Coronal reconstruction confirms the splenomegaly and a whorl of varices (H, arrow) responsible for the bump of the para-aortic line in the PA radiograph. The varices (V) drain into an enlarged azygos vein (I, arrow). The increased flow explains the prominent azygos in the PA chest film.
Review of the clinical history discovered that the patient had cirrhosis of the liver.

Final diagnosis: mediastinal varices in a patient with liver cirrhosis and pulmonary embolism

Paraesophageal varices are not uncommon and are secondary to portal hypertension in patients with hepatic cirrhosis. When enlarged, they are visible as a lower middle mediastinal mass in about 8% of chest radiographs of cirrhotic patients.
They may be misdiagnosed in CT studies because they don´t enhance in the arterial phase, as happened in the case presented and in a second case shown below.

Click here to see the second case

58-year-old man with liver cirrhosis. PA radiograph shows widening of lower mediastinal lines, which are slightly undulated (A, arrows). There is increased opacity of the left upper quadrant of the abdomen and the lateral wall of the stomach is indented, suggesting splenomegaly. On the lateral view there is increased opacity of the middle lower mediastinum, with a suggestion of tubular structures (B, circle).

Enhanced axial CT (arterial phase) shows a non-enhancing mass in the middle mediastinum that looks like a cyst (C, arrows). Venous phase demonstrates multiple enhanced veins within the mass (D, arrows). The cirrhotic liver and the enlarged spleen are visible in the coronal CT (E) .


Dr. Pepe’s teaching points:

Remember that the mediastinum is composed mainly of vascular structures. When a mediastinal abnormality is present, always rule out a vascular origin (arterial or venous).

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?

Click here to see the answer

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.

Click here to obtain more information

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

Click here to see the answer

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.

Click here to see the CT

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

Click here to see the answer

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).

Click here to see more studies

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?

Click here to see the answer

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?

Click here to see the answer

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.

Click here to see the PET-CT

What do you see?

Click here to see the answer

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?

Click here to see the answer

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.