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.


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.

Dr. Pepe’s Diploma Casebook: The wisdom of Dr. Pepe: CASE 132 – SOLVED

Dear Friends,

I would like to start a new section entitled “The wisdom of Dr. Pepe”. I like aphorisms and in this section I would present an aphorism that will summarise the teaching point of the cases presented.

Today I want to show two different cases. Radiographs of Case 1 belong to 86-year-old woman with chest pain. Pulmonary abnormalities are unchanged in comparison with a  radiograph taken one year earlier.

Check the images below, leave your thoughts in the comments section. We will publish new images on Wednesday and the answer on Friday!

Click here for the see the images for CASE 1

1. TB granulomas
2. Bronchioalveolar carcinoma
3. Amyloid nodules
4. None of the above

Click here for the answer for CASE 1


PA radiograph show widening of the left mediastinum caused by an elongated aorta (A, arrow). The right mediastinum is also widened, going all the way up to the neck (A, red arrows) with a visible air-fluid level at the top (A, yellow arrow). The appearance is typical of a dilated esophagus. The lateral view shows similar findings, with the trachea pushed forward by the dilated esophagus (B, red arrows) and a posterior double contour which represents the descending aorta (B, arrow).
Small pulmonary nodules are visible in both lungs.

Axial CT confirms the marked dilatation of esophagus (C, arrow) and the pulmonary nodules. There are also enlarged lymph nodes in the mediastinum (D, arrows).
The combination of dilated esophagus and pulmonary nodules suggests two possible etiologies: carcinoma of distal esophagus with metastases or achalasia with aspiration. In this particular case, the pulmonary lesions did not change for two years, which exclude metastases and points to post-aspiration granulomas. It is well known the relationship of achalasia with pulmonary infection by atypical Mycobacteria.

Final diagnosis: achalasia (surgically proved) with pulmonary aspiration, possibly atypical TB granulomas (unproven).

Radiographs of Case 2 belong to a 23-year-old woman with cough and low-grade fever.

Click here for the see the images for CASE 2

Dear friends,

Showing CT images of the chest. Do they help you?

Click here for the see the more images for CASE2

1. Tuberculosis
2. Chronic aspiration
3. Lymphoma
4. None of the above

Click here for the answer for CASE 2


PA and lateral chest show non-specific air-space disease in the right lower lobe (A-B, arrows). In addition, there is marked widening of the right paratracheal line (A, red arrow) suggestive of mediastinal lymphadenopathy.

Axial CT with lung window shows air-space disease in the RLL. The appearance is non-specific and there is no stretching of the bronchi (leafless tree) which, when seen, is typical of lymphoma.
Enhanced axial CT confirms enlarged lymph nodes in several locations. All of them have hypodense centers (D-F, arrows). Lymph nodes with hypodense center may occur in several processes (treated tumors, Whipple’s, etc.), but in the appropriate clinical situation, the first diagnostic consideration should always be tuberculosis. Although TB usually affects upper lobes, involvement of lower lobes can occur.

Final diagnosis: tuberculosis of RLL with widespread mediastinal adenopathy.

Congratulations to Olena and MK for their participation and correct diagnosis.

I am showing these cases to emphasize the importance of examining carefully the radiographic images. Aside from having the same etiology (TB), both cases have multiple findings and the sum of all of them are the clue to the right diagnosis.
In satisfaction of search, findings are missed because we don’t search for additional abnormalities after the first one is found. When there are multiple findings, additional ones are discovered less than 50% of the time.
So, once again, try to avoid satisfaction of search. Remember that it accounts for approximately 22% of our errors.

Follow Dr. Pepe’s advice:

Don’t let one abnormal finding keep you from looking for another.