Cáceres Corner Case – Vignette 238

Dear Friends,

Today I am showing a preoperative PA radiograph in a 72-year-old woman.

Diagnosis:

1. Aortic elongation
2. Aortic dissection
3. Aortic aneurysm
4. Any of the above

What do you see?

Click here to see the answer

Findings: the obvious finding is elongation of the descending aorta. Usually, the diameter of the aorta cannot be determined in the plain film because only the outer wall is outlined by lung air, whereas the medial wall is obscured by the mediastinal structures.

In this case, the tortuous lower aorta projects the medial wall against the lung, allowing to measure the aortic diameter, which is increased (A, red line).
In the other hand, the ascending aorta is not prominent. This a negative finding against aortic elongation, which should involve the whole thoracic aorta.
Therefore, answers 1 and 4 can be excluded. To differentiate between answer 2 and 3 an enhanced CT is needed.

Click here to see more images

Enhanced CT was done. Axial and sagittal images are shown.
What would be your diagnosis?

1. Type B aortic dissection
2. Aneurysm with thrombus
3. Any of the above

Click here to see the answer

Findings: enhanced axial and coronal CT show a normal ascending aorta and a partially thrombosed dilated descending aorta. The fact that the outer wall is calcified (B-C, arrows) indicates that the intima is not displaced and rules out an aortic dissection. The correct diagnosis is aneurysm with partial thrombosis.

Final diagnosis: unsuspected aneurysm of descending aorta

I saw this case three days ago and thought it was a nice demonstration of a negative finding (lack of dilatation of ascending aorta) as mentioned in my last webinar.
As a result of the findings in the plain film, an enhanced CT demonstrated a partially thrombosed aneurysm and the patient was referred for vascular surgery.

This is the last vignette of the season. Since the pandemic is abating, I will resume next week the usual Caceres’ corner cases and Diploma presentations.

Cáceres Corner Case – Vignette 237

Dear Friends,

If you are Sci-Fi fans I recommend this week the novel “The windup girl” and the short stories collection “Pump six” by Paolo Bacigalupi.

Today’s radiographs belong to a 57-year-old woman with cough and fever. She had an osteosarcoma of the lower limb removed eight years earlier.

Diagnosis:

1. Carcinoma
2. Pneumonia
3. Tuberculosis
4. Any of the above

Click here to see the answer

Findings: PA chest shows haziness of left hemithorax, elevation of the left hilum (A, arrow) and luftsichel (A, red arrow), typical signs of LUL collapse. The collapse is confirmed by the marked displacement of the major fissure on the lateral view (B, arrows). At this point, the best diagnosis is an endobronchial lesion, most likely carcinoma

Click here to see more images

CT with and without contrast enhancement was done. What would be your diagnosis?

1. Carcinoid
2. Carcinoma
3. Endobronchial TB
4. Endobronchial metastasis

Click here to see the answer

Findings: unenhanced CT demonstrates LUL collapse with coarse calcification that seems to follow the path of the bronchus (C, arrows). Enhanced CT shows a non-enhancing endobronchial lesion at the origin of the LUL (D, arrow).

Of the diagnosis offered, the coarse calcification makes carcinoma very unlikely and suggests a carcinoid tumor, although I would expect some enhancement after contrast injection. Given the previous history of osteogenic sarcoma, endobronchial metastases should be considered. I would vote against TB.

Bronchoscopy found a mass occluding the LUL bronchus. Biopsy returned the diagnosis of osteosarcoma.

Final diagnosis: endobronchial metastases from osteogenic sarcoma.

I am showing this unusual case because it is my first and probably my last case of endobronchial metastasis from osteogenic sarcoma. It is also unusual the prolonged span of time (eight years) between the removal of the primary and the appearance of the metastasis.
 
Remember that the most common cause of LUL collapse is first and foremost a carcinoma of the lung. Endobronchial metastases can give a similar appearance and are more common in tumors of breast, kidney and melanoma although they may occur in any type of tumor, as in the present case.

Dr. Pepe’s Diploma Casebook 155 – SOLVED!

Dear Friends,

Today I am presenting the leading case of a new webinar entitled: “Sherlock Holmes and the curious finding in the chest radiograph”.

AP radiograph belongs to a newborn with respiratory distress.

Diagnosis:

1. Diaphragmatic hernia
2. Lung tumor
3. Pneumonia
4. None of the above

What do you see? Come back on Wednesday to see the answer and the webinar!

Click here to see the answer

Findings: at a first glance, the predominant abnormality is a large bump in the left hemidiaphragm (A, arrow), suggestive of localized eventration or hernia. However, there is and additional important finding: both humeri are not visible (A, circles).
This baby was born with a congenital absence of the arms (amelia).

I am showing this case to stress the importance of discovering so-called negative findings. Our training emphasizes the discovery of positive findings and forgets teaching us to detect structures that are absent, as this case proves.
 
My apologies for tricking you, but I was trying to prove my point. You can get more information about negative findings in today´s webinar.

Cáceres Corner Case 234 – Vignette

Dear Friends,

Today´s radiographs belong to a 48-year-old woman with aortic stenosis.

Most likely diagnosis:

1. Intrathoracic goiter
2. Aortic arch malformation
3. Neurogenic tumor
4. Any of the above

Click here to see the answer

Findings: PA radiograph shows a left mediastinal mass superimposed on the artic knob (A, arrow). The trachea is not displaced. In the lateral view the mass is in the anterior/middle mediastinum (B, arrows).
Regarding the diagnosis offered, the location excludes neurogenic tumor which usually arises in the posterior mediastinum. Intrathoracic goiter is a possibility, but the fact that part of it is the anterior mediastinum and that there is no tracheal displacement goes against this diagnosis. The location of the mass around the aortic knob plus knowing that the patient has aortic valve stenosis point to an aortic arch malformation.

Click here to see more images

Enhanced CT shows that the mass corresponds to a high aortic knob (C, arrow). An oblique view demonstrates the high knob (D, arrow) with a kink and angulation of the aorta representing the lower knob in the PA radiograph (D, red arrow).
My apologies for showing only 3-D images, but the CT was done during the lockdown and they are all I could get.
The patient has no collateral circulation. He had no systemic hypertension and no gradient across the zone of kinking.

Final diagnosis: aortic pseudocoarctation

Pseudocoarctation of the aorta occurs when the aortic arch originates from the 3rd arch, instead of the 4th. In this condition, the aortic arch is higher than usual, with a kinking at the union of the aortic arch and descending aorta, simulating aortic coarctation. Rib notching is absent and systemic hypertension is not present.
This is a rare condition is, but it is not unusual to see it in clinical practice.

To compensate for the lack of CT images in this case, I am showing another pseudocoarctation with similar findings (Fig 1).

Fig 1. PA chest radiograph shows a superior middle mediastinal mass (A, arrow), displacing the trachea. Mass is vaguely seen on the lateral view (B, circle). The most common diagnosis should be an endothoracic goiter but remember that a vascular structure should be always ruled out with enhanced CT.

Coronal CT demonstrates that the mass corresponds to a dilated aortic arch located higher than usual (C, arrow). On the oblique reconstruction, the high aneurysmatic aortic arch is well seen as well as the kinking at the junction with the descending aorta (D, red arrow).
Final diagnosis: aortic pseudocoarctation with aneurysm of the aortic arch.


Cáceres Corner Case 229 – Vignette

Hello friends,

After three weeks of confinement I believe I have seen all TV series available. If you like Sci-Fi I recommend The Expanse (Amazon Video) and for older citizens The Kominsky method(Netflix).

Today’s case was sent to me from my hospital in the early days of lockdown. The scout film belongs to a 78-year-old man with doubtful COVID-19 infection.
Do you see any abnormality?
If so, where is it?

1. Chest
2. Abdomen
3. Chest and abdomen
4. Don’t see it

Click here to see the answer

Findings: There is a rounded right mediastinal opacity at the junction of the trachea and right main bronchus (A, arrow). There is an apparent abdominal RUQ mass (A, red arrows) with an area of lesser opacity in the center (A, yellow arrow).
The correct answer would be number 3. Visible abnormalities in chest and abdomen

With these findings what would be your diagnosis?

1. Enlarged azygos arch
2. Azygos continuation of IVC
3. Right-sided stomach
4. All of the above

Click here to see the answer

The clue to the diagnosis resides in the apparent RUQ abdominal mass. The shape suggests a right-side stomach, with air in the antrum and duodenal bulb and lesser amount of air in the fornix (Fig A). Findings are better seen in the drawing (B).

A right-sided stomach with a normal-positioned heart is highly suggestive of a congenital abnormality, levocardia with abdominal situs inversus. In this malformation the chest structures are in their normal location, whereas the abdominal viscera are rotated 180 degrees.
This malformation is accompanied by partial interruption of the IVC and azygos continuation, which results in an enlarged azygos arch.
Therefore the correct answer is 4. All of the above

Click here to see the more images

Enhanced axial CT confirms the enlarged azygos arch (A, arrow). Coronal reconstruction demonstrates the dilated ascending azygos vein (B, arrows)

Axial images of the upper abdomen show the gastric fornix in the RUQ (C-D, arrows) as well as a normal left-sided heart (C) and a mid-line liver (D). There is a small splenic remnant in the RUQ (D, red arrow).

Final diagnosis: Levocardia with abdominal situs inversus

I am showing this case because this is our fourth patient with levocardia and abdominal situs inversus seen in the last four years (see Caceres´ corner cases 178 & 194 and Dr. Pepe´s Summer case 1). It may not be as rare as the textbooks state. In addition, the diagnosis can be suggested in the plain film if we discover the right-sided stomach.