Cáceres Corner Case 227 – Vignette

Dear friends, starting today I plan to show simple teaching cases (vignettes) hoping to ease the boredom of the confinement.
I will show two cases every week (Monday and Thursday). To make the presentation more agile the diagnosis will be included. If you get impatient all you have to do is press the answer button.

The first case is a routine control PA radiograph in a 67-year-old woman operated on for breast carcinoma three years ago.

Question: Do you suspect any bone metastasis?

Click here to see the answer

Findings: There is an apparent lytic lesion in the distal end of the right clavicle (A, arrow), better seen in the cone down view (B, arrow).

When I saw this case two months ago, I could not determine whether the lesion was real or not. What would you do?
 
1. Compare with previous films
2. Call the oncologist
3. PET-CT
4. Bone scintigraphy

Click here to see the answer

In my opinion, the first thing to do was comparing with previous films although
this brilliant idea was hampered by the technician placing the marker in top of the distal clavicle in two earlier radiographs (C-D).

What would you do now?
1. Bone scintigraphy
2. Call the oncologist
3. PET-CT
4. CT

Click here to see the answer

Since I was not sure about the lesion, I decided to call the oncologist to find out if she suspected any metastasis and if the patient had any pain in the right acromioclavicular area. The answer was negative. What would you recommend?

1. Bone scintigraphy
2. CT
3. PET-CT
4. Radiograph of the right clavicle

click here to see the answer

In my opinion the fastest way to clarify the diagnosis was to take a radiograph of both clavicles (with the left for comparison). The distal end of the right clavicle has a normal appearance and , since the patient had no local symptoms, no further studies were needed.

Final diagnosis: normal variant simulating pathology in an oncologic patient

I have seen several chest radiographs with apparent lytic lesion of the distal clavicle that turned out to be normal. It is described in the Atlas of normal variants by Keats. In this case I was doubtful because the patient had a carcinoma and the appearance of the lesion was ominous.
 
There are two teaching points in this case:
1. Talking to the referring physician is important to determine the management of findings.
2. A simple and inexpensive procedure clarified the diagnosis and avoided unnecessary additional studies.

Cáceres’ Corner Case 226 – SOLVED

Dear Friends,

Today’s radiographs belong to a 27-year-old woman who came for a routine check-up.

Most likely diagnosis:

1. Thymic tumor
2. Enlarged lymph nodes
3. Aortic arch malformation
4. None of the above

CT images will be shown next Wednesday.

Click here to see the first images

Dear Friends,

Today I am showing enhanced CT images of the mediastinum in the early (A-B) and late phases (C-E).
What do you think?

Click here to see more images

Click here to see the answer

Findings: PA chest radiograph shows a right upper mediastinal mass with undulated border (A, arrow). There is increased opacity of the anterior clear space in the lateral view (B, circle). In my opinion, the most likely diagnosis would be thymic tumor, although the undulated border favors enlarged lymph nodes.

Enhanced axial CTs in the arterial phase show an anterior mediastinal mass with minimal enhancement (C-D, arrows) and a vascular space in the center (C, yellow arrow).

Coronal and axial CTs in the late phase show partial washout of the vascular space (E, yellow arrow). The clue to the diagnosis lies in the presence of several punctate calcifications within the mass (F-G, red arrows) consistent with phleboliths, which are practically diagnostic of hemangioma. The central vascular space also supports the diagnosis.

The patient had been diagnosed of mediastinal hemangioma two years earlier and comparison with previous chest films and CTs did not show any change.
 
Final diagnosis: Mediastinal hemangioma
 
Congratulations to Naegleria and MK who gave similar diagnosis both at exactly 12:55 P.M.
 
Teaching point: This case is unusual (I have seen only two of them in the mediastinum) but can be easily diagnosed if phleboliths are present (and recognized). Early in my residency I learned that, when finding phleboliths within a mass, the diagnosis should be hemangioma until proven otherwise.
 
Ref. HP McAdams, ML Rosado de Christenson, CA Moran. Mediastinal hemangioma: radiographic and CT features in 14 patients. Radiology 1994; 193:399-402

Cáceres’ Corner Case 225 – SOLVED

Dear Friends,

Today’s radiographs belong to a 37-year-old man with moderate fever.
What do you think?

Come back on Friday to see the answer!

Click here to see the answer

Findings: Chest radiographs show an intrapulmonary rounded opacity with ill-defined borders in the left lung (A-B, arrows). In a patient with fever and no other significant symptoms, the most likely diagnosis should be rounded pneumonia, although I was somewhat concerned about the good definition of the lower contour in the lateral view (B, red arrows), which is unusual in pneumonia.

The patient improved with treatment and follow-up radiographs four weeks later show only minimal residual findings in the PA view (C, arrow).

Final diagnosis: rounded pneumonia simulating a pulmonary mass.

Congratulations to Ahmad, who was the first to give the correct diagnosis. Silver medal to Sara Mercado/span>, who arrived second three hours later.

Teaching point: remember that not all pulmonary nodules/masses are malignant. If you want to know more about them, look up Diploma #51 “Innocuous pulmonary nodules”

Cáceres’ Corner Case 224 – SOLVED

Dear Friends,

Due to the coronavirus scare, Dr Pepe and Miss Piggy have eloped to the Bahamas, leaving me alone in charge of the blog. Until his return in late March, I will present interesting cases in the Caceres’ Corner. I may even dare to present a Diploma case, although I am not as knowledgeable as Dr Pepe.

This week’s case is a preoperative PA radiograph of a 47-year-old woman.

Diagnosis:

1. Double aortic arch
2. Enlarged azygos vein
3. Mediastinal mass
4. None of the above

What do you see? Come back on Friday to see the answer!

Click here to see the answer

Findings: PA shows a right mediastinal bump at the confluence between the trachea and the RUL bronchus (A, arrow). There is a curved mediastinal line below (A, red arrow) and an extra mediastinal line in the left lower mediastinal border (A, yellow arrow).

The combination of these findings strongly suggests increased circulation in the azygos system, with prominent azygos and hemiazygos veins. In an asymptomatic patient the most likely diagnosis is a congenital interruption of the IVC with azygos continuation.
A double aortic arch can be ruled out because the right component raises higher than the left, and in this case the opposite occurs.

Unenhanced coronal CT confirms the dilated azygos arch (B, arrow) and the dilated ascending azygos (B-C, red arrows) and hemiazygos (C, yellow arrow)

Final diagnosis: Congenital interruption of the IVC with azygos continuation.
 
Congratulations to Hazem who was the first to give the correct answer and to Krister who gave a nice and accurate description of the findings.
 
Teaching point: this case is a good example of non-significant findings secondary to a congenital malformation, as mentioned in webinar eight.

Cáceres’ Corner Case 223 – SOLVED

Today’s radiographs belong to a 77-year-old man with dyspnea.

Diagnosis:

1.  Allergic aspergillosis
2.  A-V malformations
3.  Chronic changes post-TB
4.  None of the above

What do you see? Come back on Friday to see the answer 🙂

Click here to see the answer

Findings: PA chest radiographs shows elongated opacities apparently arising from the hila (A, arrows). The lack of branching goes against mucous impactions. The clue to the diagnosis lies in the calcified pleural plaque in the right hemidiaphragm (A, red arrow), which is a sign that strongly suggests asbestos exposure.
This diagnosis is corroborated by the lateral view, which shows calcified pleural plaques in the anterior clear space (B, red arrow).

Previous AP and oblique rib radiographs after chest trauma show the undulated calcified plaque in the right hemithorax (C-D, arrows).

Unenhanced coronal CT confirms the plaque in the right hemidiaphragm (E, arrow). Axial CTs demonstrate the anterior plaques (F-G, red arrows), as well as the unaffected lung (F).

Final diagnosis: calcified pleural plaques simulating pulmonary disease.
 
Congratulations to Phi Pham, who was the first to make the correct diagnosis.
 
Teaching point: Remember that superimposed opacities may simulate intrapulmonary pathology.

Dr. Pepe’s Diploma Casebook 154 – All you need to know to interpret a chest radiograph – Eighth Session – SOLVED

Dear Friends,

Showing today the leading case of webinar eight. Radiographs belong to 27-year-old with seminoma and pain in the anterior chest wall. What is your opinion about the  clavicular lesion?

1. Metastasis
2. Osteomyelitis
3. Benign bone lesion
4. Any of the above

Check out the last webinar form the series explaining in detail this case on our youtube channel and and catch up on previous ones on the EBR YouTube channel!

Click here to see the answer

Findings: the chest radiograph shows a lytic lesion in the proximal right clavicle (A-B, circles). It has a sclerotic border (A-B, red arrows), indicating a slow-growing process. This finding excludes options 1 and 2 and leaves option 3. Benign bone lesion as the correct diagnosis.

This lytic lesion correspond to a normal variant, called the rhomboid fossa. It represents the insertion site of the costoclavicular ligament( yellow), which extends from first rib (red) to the proximal clavicle (blue).
Is a normal variant and should not to be mistaken for an osteolytic lesion.

It occurs in 30% of males and 5% of females. It is more common in the young and becomes less visible with age.

Final diagnosis: rhomboid fossa of right clavicle

Congratulations to Faelivrin, who made the correct diagnosis

Teaching point: it is important to know the most common normal variants of the chest, to avoid confusing them with pathology.

Cáceres’ Corner Case 222 – SOLVED

Dear Friends,

Showing today preoperative radiographs of 57-year-old man with a torn knee cartilage. Sorry about the poor quality of the lateral view.
What do you see?

Come back on Friday to see the answer!

Click here to see the answer

Findings: PA radiograph show widening of the right superior mediastinum (A, arrow), imprinting the tracheal wall (A, red arrow).
In the lateral view there is increased opacity of Raider triangle (B, circle) with slight bowing of the posterior tracheal wall (B, red arrow).

The main causes of occupation of Raider triangle are two: either esophageal disease or congenital malformation of the aortic arch. The last one is the most likely, given the findings in the PA view.
 
Enhanced CT confirms a right aortic arch (C-D, arrows), crossing behind the trachea (C-E, red arrows) and causing the opacity in Raider triangle.

Findings are better seen in the 3-D reconstruction (F).

Final diagnosis: right aortic arch
 
Congratulations to Jolanta who made the correct diagnosis (my initial impression in the plain film was double aortic arch, so I will award another prize to Faelivrin for being wrong with me).
 
Teaching point: this case does not look very exciting, but right aortic arch is very common, and it is important to avoid confusing it with a mediastinal mass.
 
If you want to know more about malformations of the aortic arch, look up the article by Hanneman, Newman and Chan: Congenital variants and anomalies of the aortic arch, RadioGraphics 2017; 37:32–51