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
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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:
1. Elevation of right hilum
2. Hazy opacity in right upper lung
3. Elevated right hemidiaphragm
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