Dr. Pepe’s Diploma Casebook 152 – All you need to know to interpret a chest radiograph – Sixth Session – SOLVED

Dear Friends,

Welcome to the new year and a new webinar. The leading images of the webinar six belong to a 73-year-old woman with dyspnea and chest pain. What do you see?

Diagnosis:

1. Intrathoracic goiter
2. Dilated esophagus
3. Aortic aneurysm
4. Any of the above

If you would like to see the previous webinars, check it here!

Click here to see the answer

You can see the webinar here.

Findings: PA radiograph shows widening of the right superior mediastinum (A, arrow), which in the lateral view is located behind the trachea (B, arrows). The initial impression is of an upper middle mediastinal mass. The first diagnosis that come to mind is a goiter.

However, looking downward in the PA view, bulging of the azygo-esophageal line is evident (A, red arrow). In the lateral view there is opacification of the retrocardiac space (B, red arrow). Therefore, we are dealing with a lesion that extends along the middle mediastinum from top to bottom. The findings point to a dilated esophagus.

Esophagogram was unremarkable. Coronal and sagittal CT shows a cystic tubular mass extending along the posterior wall of the esophagus (C-D, arrows).

Final diagnosis: cystic lymphangioma of mediastinum
 
This is a difficult case and I didn’t expect you to make the diagnosis. But I believe that you should have noticed the bulging of the azygo-esophageal line in the PA view and the occupation of the retrocardiac space in the lateral view, suggesting a dilated esophagus as the most likely diagnosis.
 
Congratulations to MG who was the first to see the findings.
 
Teaching point: Remember that an opacity that goes from top to bottom in the middle mediastinum should suggest a dilated esophagus or an esophagus-related process

Dr. Pepe’s Diploma Casebook 151 – All you need to know to interpret a chest radiograph – Fifth Session – SOLVED!

Dear Friends,

Showing today the leading case of the next webinar. PA radiograph belongs to an 86-year-old woman with chest pain.
What do you see?

More images will be shown on Wednesday. You can refresh your memory viewing the older webinars on our youtube channel.

Dear Friends, showing today a lateral film of the case. Hope it helps.

Click here to see the lateral film

Click here to see the answer

Findings: PA radiograph shows a faint opacity in the left mid-lung field (A, arrow), better seen in the cone down view (B, arrow). The opacity is ill-defined, and my first impression would be an intrapulmonary lesion.

The lateral view shows that the opacity is located in the posterior chest wall. It has a typical pregnancy sign (C, arrow), indicating an extrapulmonary origin.
Enhanced axial CT confirms a low-density chest wall mass (D, arrow). Note the anterior displacement of the intercostal vessel (D, red arrow).

Final diagnosis: lymphoma of chest wall
 
Congratulations to all of you who diagnosed a chest wall lesion. Special mention to MK, who was the first to give the answer.
 
Teaching point: This case documents the importance of the lateral chest to clarify indeterminate findings in the PA radiograph.

Check the full webinar here

Dr. Pepe’s Diploma Casebook 150 – All you need to know to interpret a chest radiograph – Fourth Session

Dear Friends,

Presenting today the leading case of the next webinar. PA radiograph of a 58-year-old woman with cough and fever.

What do you see?

The answer will be published on Friday. While you wait, you can check the first three webinars, check the EBR youtube channel!

Click here to see the image

Click here to see the answer

Findings: PA chest radiograph shows an ill-defined opacity behind the right hemidiaphragm (A, red arrows), better seen in the cone-down view (B, red arrows). The fact that the opacity is visible indicates that it is surrounded by air, placing it in the right lower lobe.

A lateral view confirms air-space disease in the RLL (C, circle), blurring the posterior aspect of the right hemidiaphragm.

Final diagnosis: RLL pneumonia
 
Congratulations to archanareddyt who was the first to see the opacity and to MK who saw it and suggested the right diagnosis.
 
Teaching point: Remember that in the PA view the lower lobes go deep behind the diaphragm. Pulmonary disease of any kind can be seen in the upper quadrants of the abdomen, as demonstrated by the present case.

Remember to check the webinar published on the EBR youtube channel!

Dr. Pepe’s Diploma Casebook 149 – All you need to know to interpret a chest radiograph – Third Session – SOLVED

Dear Friends,

I am showing today the leading image of the third webinar. If you haven’t seen them, you can see the first one here and the second one here:

Chest radiograph belongs to a 24-year-old man with occasional episodes of fainting, currently asymptomatic.

What do you see?

Come back on Friday and enjoy the recording of the third webinar with the answer to this case and more information!

Click here to see the answer

Findings: PA chest radiograph shows convexity of the right outline of the middle mediastinum (A, arrow), suggesting dilatation of the ascending aorta. Some of you have mentioned aortic coarctation, which is not a good option because rib notching is not visible, and the aortic knob is unremarkable.
Given the patient´s age, a good possibility is congenital aortic stenosis.

Enhanced sagittal CT reconstruction shows dilatation of the ascending aorta (B, asterisk) and heavy calcification of the aortic valve (B, arrow). Axial CT demonstrated a malformed and calcified aortic valve (C, circle).

Final diagnosis: congenital aortic valve stenosis with post-stenotic dilatation

Congratulations to Renga, who was the first to mention the ascending aorta dilatation.
 
Teaching point: the middle third of the mediastinum is occupied by the aorta and pulmonary artery. Any mediastinal abnormality in this area should be suspected to have a vascular origin.

You can see on our youtube channel the webinar Prof. Cáceres has prepared discussing this case and others.

Dr. Pepe’s Diploma Casebook – All you need to know to interpret a chest radiograph – Second Session – SOLVED

Dear Friends,

Today I am presenting the leading case of the second webinar. The PA radiograph belongs to a 62-year-old man with hemoptysis.

Is the radiograph abnormal?
If so, what do you see?

Starting this week, I have decided to stop giving live webinars. They will be recorded and published at the end of the week, together with the answer to the case. You can see the first session here

Click here to see the answer

Findings: PA chest radiograph shows convexity of the aorto-pulmonary window (A, arrow) and an opacity in the upper left hilum (A, red arrow). The findings were not present in a film taken three years earlier (B, circle) and suggest a pulmonary process with mediastinal adenopathy.

Findings were overlooked and the chest was read as normal. Six months later the patient returned with acute right chest pain. PA chest shows two triangular pleural-based opacities (C, arrows) suggestive of Hampton’s humps. The convexity at the APW is larger (C, green arrow) and the hilar opacity has increased in size (C, red arrow).

Coronal CT shows the typical appearance of pulmonary infarcts at the right lung base (D, arrows). There is large adenopathy at the APW (D, green arrow) accompanied by a lung mass (D, red arrow).

Final diagnosis: carcinoma of the lung with mediastinal metastases and associated pulmonary infarcts.
 
Congratulations to S, who made a brilliant diagnosis.
 
Teaching point: Remember the importance of checklists. If a checklist had been used in the initial radiography, a CT would had been taken and the tumor would had been discovered earlier

If you would like to learn more about this subject, check the webinar Prof. Cáceres recorded explaining this cases and others! You can also check the first webinar here.

Dr. Pepe’s Diploma Casebook – The art of interpretation – CASE 146 – SOLVED

Dear Friends,

Today I am presenting another “Art of interpretation case”, from last August.
Radiographs belong to a 22-year-old Spanish national with fever and dry cough for the last seven days. He had visited South Korea during the month of July. Chest radiographs read as normal by the Emergency Room physician.
What do you see?

More images will be shown on Wednesday.

Click here to see the images shown on Monday


Dear Friends,
showing several images of the enhanced CT.

What do you see?

Click here to see the new images

Click here to see the answer

Findings: PA radiograph shows convexity of the aortopulmonary window (A, white arrow) and increased opacity of the left hilum (A, red arrow). The lateral view shows a faint opacity projected over the middle third of the thoracic spine (B, circle) that was overlooked in the initial reading.
The convexity of the APW suggested mediastinal lymphadenopathy, and CT was performed.

Coronal enhanced CT shows an enlarged lymph node in the APW (A, arrow). Axial CT depicts enlarged lymph nodes in the left hilum (B, circle). Lung window demonstrates air-space disease in the apical segment of the LLL (C, arrow), which explains the posterior faint opacity in the lateral view.

Summary of CT findings:

– Unilateral enlarged hilar lymph nodes
– Lymph node in APW
– Air-space disease in the apical segment of LLL

The most significant finding is the presence of unilateral hilar lymph nodes which have a limited differential diagnosis: in the great majority of patients they are due either to lung carcinoma or active tuberculosis. As this particular patient is 27 y.o., carcinoma is unlikely. Therefore, our tentative diagnosis should be active TB, which is also supported by disease in the apical segment of the LLL, a common location for TB.

The patient was placed in isolation, bronchoscopy was performed, and Mycobacterium tuberculosis was found in the aspirate.

Final diagnosis: active tuberculosis

YOUNG PERSON + UNILATERAL ENLARGED HILAR LYMPH NODES + PULMONARY INFILTRATE IN APICAL SEGMENT OF LLL = ACTIVE TUBERCULOSIS

Active pulmonary tuberculosis is not uncommon, and the chest radiograph plays an important role in its detection. Findings that help to suspect TB in the plain film are:

Location of the parenchymal disease. Involvement of the apices or the apical segment of either lower lobe should raise the possibility of a tuberculous infiltrate, although TB can affect any area of the lung.

Cavitation. The presence of cavities within a pulmonary infiltrate suggest tuberculosis or necrotic pneumonia.

Visible lymphadenopathies. Tuberculous lymph nodes are usually unilateral and located in the hilum and homolateral mediastinum. In about one third of patients they are bilateral. In such cases, lymphoma and sarcoidosis, among others, should also be considered.

CT refines these parameters by discovering cavitation or lymphadenopathy that is not evident in the plain film. The presence of low-attenuation lymph nodes due to caseous necrosis is highly suggestive of TB, although it is not pathognomonic. Other conditions can also show these features. However, normal-density lymph nodes do not exclude TB, as was seen in the present case.

Below, I show a few nice images of active TB in which low-attenuation lymph nodes
suggested the correct diagnosis.

CASE 1

23-year-old woman with cough and low-grade fever. Chest radiographs shows air-space disease in the RLL (A and B, white arrows). There is obvious widening of the right paratracheal line (A, red arrow), indicating mediastinal lymphadenopathy.

Enhanced axial CT confirms the RLL disease which is non-specific (C, arrow). No cavitations are visible. The mediastinal window shows numerous enlarged lymph nodes, some with a hypodense center (D and E, arrows) and others with peripheral enhancement (ring sign) (F, arrows).

Abdominal CT also shows enlarged mesenteric lymph nodes with the ring sign (G and H, circles).

It is interesting to note that lower lobe TB occurs in only 5% of patients. In this particular case the diagnosis of TB was suggested by the CT appearance of the affected lymph nodes. Mycobacterium tuberculosis was recovered from sputum.

Final diagnosis: active TB


Dr. Pepe’s teaching points:

1. Think of TB in unilateral hilar adenopathy in a young person.

2. Low-density lymph nodes on CT are highly suggestive of active TB, although normal-density nodes do not exclude it.

Dr. Pepe’s Diploma Casebook: CASE 145 – Art of interpretation – SOLVED!

Dear Friends,

as I told you last week, my plan for September is to show interesting cases seen during this summer.

Today I have prepared an Art of Interpretation case that I saw in July. Radiographs belong to a 90-year-old man with cardiac arrhythmia.

Most likely diagnosis:
1. Aortic aneurysm
2. Duplication cyst
3. Thymic tumor
4. Any of the above

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

Click here to see the answer:

Findings: PA and lateral radiographs show a left superior middle mediastinal mass adjacent to the aortic knob (A and B, white arrows). Healed fractures of the right clavicle and second left rib are visible (A, red arrows). Pacemaker in the left hemithorax.

Analysis of relevant findings:

1. Left middle mediastinal mass adjacent to the aortic knob
2. Old fracture right clavicle
3. Old fracture second left rib

Summing up the findings: Although the appearance of the mediastinal mass is non-specific, the proximity to the aortic arch raises the possibility of an aortic aneurysm.
The bone fractures indicate previous trauma. Especially relevant is the fractured second rib. The first and second ribs are well protected by the thoracic cage and breaking either of them needs a strong impact, significant enough to shear the thoracic aorta and lead to pseudoaneurysm formation.

Therefore, our tentative diagnosis should be traumatic pseudoaneurysm of aorta, followed by a request for enhanced CT to confirm the diagnosis.

MEDIASTINAL MASS ADJACENT TO THE AORTIC KNOB + FRACTURED SECOND RIB = TRAUMATIC AORTIC PSEUDOANEURYSM.

Enhanced CT confirms a partially thrombosed aneurysm with a connection to the inferior aspect of the aortic arch (A-C, red arrows). On questioning, the patient mentioned an automobile accident fifteen years earlier. Because of his age, it was decided to control the aneurysm in six months’ time.

Final diagnosis: traumatic aortic pseudoaneurysm

Rupture of the thoracic aorta is not uncommon in severe blunt trauma, usually after high impact accidents or falls from a height of more than three meters (see case 1, below). About 85% of affected patients die immediately. The remaining 15% may survive if they arrive to the hospital in time to be treated.

A small percentage of cases are overlooked and patients survive without treatment. Over time a pseudoaneurysm develops at the point of rupture, most commonly the aortic arch.
About half these cases are discovered in routine chest examinations because of the typical location of the pseudoaneurysm around the aortic arch. Another diagnostic tip is that the patients are usually younger than patients with atherosclerotic aneurysms (see Case 2).

Discovering signs of previous trauma facilitates the diagnosis, especially when the first or second ribs are affected. After a history of severe trauma is elicited, the diagnosis is confirmed with enhanced CT. The pseudoaneurysm is usually located in the inferior aspect of the aortic arch, distal to the origin of the left subclavian artery.

Traumatic aortic pseudoaneurysms are infrequent, but I have seen several cases during my professional life. I am showing two representative cases to familiarize you with their radiographic appearance.

CASE 1

Chest radiographs of a 75-year-old male tourist with chest pain . A peripherally calcified mediastinal mass is projected over the aortic knob in the PA radiograph (A, arrow). The lateral view shows that the mass arises from the inferior aspect of the aortic arch (B, arrow).

Coronal and sagittal enhanced CT images demonstrate a calcified aneurysm arising from the inferior aspect of the aortic arch (C and D, arrows), distal to the origin of the left subclavian artery (E, circle). On questioning, the patient mentioned surviving a helicopter crash six years earlier. A diagnosis of traumatic pseudoaneurysm was made. The patient returned to his country of origin and was lost to follow-up.

CASE 2

42-year-old man with vague chest symptoms. A chest radiograph from another center (unavailable) showed a mediastinal mass with peripheral calcification. CT scout view yields the same finding (A, arrow).

Enhanced CT shows a large calcified aneurysm distal to the origin of the left subclavian artery (B and C, arrows). The rest of the aorta is normal. The patient had experienced an automobile accident ten years earlier. Traumatic pseudoaneurysm was proven at surgery.


Dr. Pepe’s teaching points:

Tips to suspect a traumatic aortic pseudoaneurysm in the chest radiograph:

1. Mediastinal mass around the aortic arch

2. Signs of previous trauma, especially fractures of the first or second ribs.

Dr. Pepe’s Diploma Casebook: CASE 144 – SOLVED

Dear Friends,
presenting chest radiograph of a 77-year-old man with malaise and weight loss.
What do you see?

This is the last case before the summer. Will see you again in September. Enjoy your vacation!

Click here to see the images


Click here to see the solution

Findings: PA radiograph shows increased opacity of the left hilum (A, arrow), which is due to a mass projected over it, as seen in the lateral view (B, arrows). In addition, there is convexity of the aortopulmonary window (A, red arrow)

The increased hilar opacity (C, arrow) was not visible in a PA radiograph taken six months earlier (D, circle). Convexity of the aortopulmonary window (C, red arrow) was not present at that time.

In the lateral view, the mass (E, arrows) was visible six month earlier, albeit smaller (F, arrow). This progression indicates rapid growth.

Enhanced axial and coronal CT confirms a pulmonary mass invading the aortopulmonary window (G and H, arrows). Lung metastases were present (insert, red arrows)

Diagnosis: lung carcinoma invading the aortopulmonary window

I am presenting this case to discuss the aortopulmonary window (APW), which is a small mediastinal space located between the aortic knob and the pulmonary artery in the PA view (Fig 1A). The APW is normally concave; convexity (Fig 1B) suggests an abnormality that should be studied with enhanced CT.

Fig. 1.

Visibility of the APW is difficult in the elderly, because the superimposed uncoiled descending aorta makes the interpretation more difficult (Fig 2).

Fig 2. 67-year-old man with moderate dyspnea. A calcified lymph node (A-D, red arrows) marks the APW, which is hidden in the PA view by the elongated descending aorta.

Convexity of the APW may be overlooked unless we look specifically at the area (fig 3). The larger the abnormality, the more readily it is detected in the chest radiograph. Subtle changes are more difficult to identify and comparing with previous films is very helpful.

Fig. 3. 55-year-old man consulting for acute chest pain. PA film shows two Hampton humps in the right lower lung (A, white arrows). The left hilum is abnormal (A, red arrow). Enhanced coronal CT confirms the infarcts (B, white arrows), as well as a pulmonary mass (B, red arrow) and lymphadenopathy in the APW (B, yellow arrow). Findings were overlooked in a radiograph taken seven months earlier (C, yellow and red arrows). Proven bronchogenic carcinoma.

Causes that may alter the APW are: tumors, enlarged lymph nodes, aortic aneurysms and increased mediastinal fat. The phrenic nerve crosses this space and a phrenic neurinoma may also grow in the APW, although I have never seen a case.

Enlarged lymph nodes are by far the most common cause of occupation of the APW. They may occur in malignant and non-malignant diseases. They usually coexist with radiographic manifestations of the primary process (Figs 4 and 5).

Fig 4. 59-year-old man with apical LUL carcinoma (A and B, arrows). There is a marked bulge of the APW (A and B, red arrows). Moderate pneumothorax after needle biopsy.

Coronal and axial CT confirm metastatic lymph nodes in the APW (C and D, red arrows)

Fig 5. 33-year-old woman with low-grade fever and malaise. Chest radiographs shows a non-descript infiltrate in the anterior segment of the RUL (A and B, arrows). In addition, there is a prominent bulge in the APW, highly suspicious of lymphadenopathy (A, red arrow). Diagnosis: Hodgkin lymphoma.

In isolated occupation of the APW the etiology cannot be determined in the chest radiograph and enhanced CT should be obtained (fig 6).

Fig 6. Routine check-up in a 60-year-old woman. PA radiograph shows moderate convexity of the APW (A, arrow). Enhanced CT confirms enlarged lymph nodes in the APW (B and C, arrows), mediastinum and hila. Diagnosis: sarcoidosis

Aortic aneurysm is an uncommon cause of convexity of the APW (Fig 7). The abnormality is initially subtle and it becomes more evident as the aneurysm grows (Fig 8).

Fig 7. 78-year-old man without significant symptoms. PA radiograph shows a mediastinal mass protruding at the level of the APW (A and C arrows). The mass is also evident in the lateral view (B and D, arrows).

Radiographs taken five years earlier did not show the abnormality (E and F, circles).

Enhanced axial and coronal CT demonstrate that the mass represents a saccular aneurysm arising from the aortic arch (G and H, arrows).

Fig 8. 78-year-old man after a fall. PA radiograph shows numerous rib fractures (A, white arrows). An additional finding is a mediastinal opacity at the APW (A, red arrow), also visible in the lateral view (B, red arrow).

Comparison with previous films shows a normal APW in 2007 and progression of the opacity over a three-year period (arrows).

Enhanced CT shows that the opacity represents a partially thrombosed aneurysm arising from the inferior aspect of the aortic arch (C-D and E, arrows).

Last but not least, we should remember that mediastinal fat is an innocuous cause of convexity of the APW (Fig 9).

Fig 9. Asymptomatic 57-year-old man with superior mediastinal widening (A, arrow) and discrete convexity of the APW (A, red arrow). Coronal CT shows that the changes are due to mediastinal fat (B and C, arrows).


Follow Dr. Pepe’s advice:

1. Convexity of the APW suggests underlying pathology.

2. Enlarged lymph nodes are the most common cause of a convex APW.

3. Aneurysm and mediastinal fat may also enlarge the APW

Dr. Pepe’s Diploma Casebook: CASE 143 – The wisdom of Dr. Pepe – SOLVED

Dear Friends,

This case belong to the section “The wisdom of Dr. Pepe”, in which an (useful?) aphorism ends the presentation.

I am presenting a routine PA radiograph in an asymptomatic 79-year-old woman operated on for a breast DCIS five years ago. PA radiograph taken five years earlier is shown for comparison. More images will be shown on Wednesday.

Diagnosis:

1. Granulomas
2. Metastases
3. Primary lung tumor(s)
4. Any of the above

Click here to see the images

Dear Friends,

showing CT images with and without contrast enhancement.

What would your diagnosis be?

1. Carcinoma
2. Active TB
3. Fibrous lung tumor
4. Any of the above

Click here to see the CT


Click here to see the answer

Findings: The PA chest radiograph shows two obvious small nodules in the left middle lung field (A, circle), not present five years earlier (B). In my experience, two nodules close together are usually granulomas. But in this case we have another finding: a subtle bulge in the left hilum (A, arrow), not visible in the previous film, highly suspicious of hilar adenopathy. This changes the diagnostic orientation and makes us think of an active process.

Unenhanced axial CT shows an hourglass-shaped pulmonary lesion (C and D, arrows) that simulated two nodules in the chest radiograph. The lesion enhances after contrast injection and contains a large arterial vessel (E, arrow). Non-enhancing lymph nodes are visible in the left hilum (F, arrow).
Although all three diagnoses offered in the blog can cause hilar adenopathy, the vascularity of the lesion points to a tumor.

PET-CT shows faint uptake of the primary lesion and the hilar lymph nodes (G and H, arrows). A needle biopsy (I, arrow) came back as an atypical small-cell tumor.

The patient was treated with chemotherapy and radiotherapy, with a good response of the primary tumor (J, arrow) and lymph nodes (K, circle).

Final diagnosis: SCLC with hilar metastasis and a good response to QT and RT

Discussion: I just finished reading “The subtle art of not giving a f*ck“ and there is an enlightening (and sadly true) chapter entitled “You are not special”. In this particular case I was feeling special, as I diagnosed a malignant pulmonary fibroma based on a single case seen 20 years ago (see below) because of the similarity of the vascular pattern in the two cases. After 50 years of practice, I forgot a basic principle: common conditions are, well, common. I’m showing this case to remind you that when faced with a diagnostic dilemma you should first consider common options rather than uncommon ones.

To redeem myself, I am showing my only case of fibrous tumor of lung in a 37-year-old woman with hemoptysis. The PA radiograph shows a well-defined paramediastinal nodule (A, arrow). Enhanced coronal and sagittal CT confirms the intrapulmonary location of the nodule, which has a large arterial vessel in the center with an aneurysm at the end (B and C, arrows).

Surgery confirmed a fibrous tumor of the lung.

Two bits of information about fibrous tumor of the lung: It is a very unusual spindle-cell tumor with the same histology as fibrous tumors of pleura, and like them, it has malignant potential. It is usually asymptomatic and is seen as a rounded or ovoid nodule of varying size. Immunohistochemistry is important for the diagnosis.


Follow Dr. Pepe’s pearls of wisdom:

Always consider that what you are seeing is a rare manifestation of a common disease rather than a common manifestation of a rare disease.