Tag: chest

Dr. Pepe’s Diploma Casebook 157 – SOLVED

~ Dr. Pepe ~ 5 Comments

Dear Friends,

The leading case of this week’s Diploma has been provided by my good friend Jordi Andreu. Radiographs belong to an asymptomatic 48-year-old woman.

Diagnosis:

1. Neurogenic tumor
2. Pulmonary hamartoma
3. Pleural fibrous tumor
4. None of the above

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

Click here to see the answer

Findings: PA chest radiograph shows a rounded opacity in the left apex (A, arrow). All diagnosis are possible, as the pulmonary apex is a narrow space and it is very difficult to determine the origin of a mass. The clue lies in the nodular opacities in the neck (A, circle) which raise the possibility of superimposed hair braid.
Unenhanced coronal CT (B) does not show any mass, confirming that the finding is artifactual.

Final diagnosis: superimposed hair braid simulating pulmonary disease

The purpose of this presentation is to discuss elements in or about the soft tissues of the chest wall that may simulate lung disease. Those related to the thoracic skeleton were shown in Diploma case # 57.
This Diploma complements the non-significant findings described in webinar eight.

I have classified them into three groups, the first one related to the soft tissues of the chest wall while the other two are external to the body:

1. Nipples and skin lesions
2. Hair and/or hair implements
3. Garments

Nipple Shadows

Nipple shadows are seen in 3% to 10% of PA chest radiographs. In about 10% of these patients, the identification may raise doubts. Comparison with previous films will confirm the stability of the nodules (Fig. 1). In case of doubt, nipple markers should be placed. Routine use of nipple markers has been proposed in oncologic patients.

Fig. 1. 58-year-old man with typical bilateral nipple shadows (A, arrows), unchanged in comparison with a previous film (B, arrows). Nipples are well seen on axial CT in the same patient (C, arrows). Nowadays, patients may come with their own nipple markers! (D).

Unilateral enlarged nipple shadows are suspicious findings. Visual inspection should be done to confirm that the nipple is indeed enlarged (Fig. 2). Occasionally, a true lung nodule may simulate a nipple shadow, even with nipple markers. In such cases, CT will correct our error (Figs. 3-4)

Fig 2. 61-year-old woman with left pleuritic chest pain. PA chest film shows a small amount of left pleural fluid (A, white arrow) and a nodule at the right costophrenic angle (A, red arrow). Visual inspection showed a large right nipple as the cause of the false nodule. Two weeks later, the pleural effusion has disappeared, and the nipple shadow is no longer seen (B).

Fig. 3. 54-year-old man with a renal tumor. PA film shows a nodule in the LLL (A, arrow) that simulates a nipple, even with a nipple marker (B, arrow). Axial CT shows a metastatic nodule in the LLL and a larger one in the RLL, not seen in the PA chest radiograph (insert, arrows).

Skin lesions

Skin lesions may also cause false lung nodules. Visual inspection of the chest will demonstrate them and confirm the diagnosis (Fig. 5). If there is any doubt, a marker can be used.

Fig. 5. Chest wart simulating a lung nodule in the PA film (A, arrow). Lateral film shows the wart in the skin of the anterior chest wall (B, arrow). The wart is higher in this view because the upheld arms elevate it.

Occasionally, a discrepancy in density between both breasts, usually related to previous surgery, may simulate pulmonary pathology (Fig 6).


Fig 6. 65-year-old woman with syncope. PA radiograph shows a rounded opacity in the right lung (A, arrow), suspected to be a pulmonary infiltrate. Axial CT (B) show normal lungs. The opacity is due to a superimposed right breast prosthesis (B-C, arrows).

Hair

In my experience, hair is a common cause of opacities in the lung apices (Fig 7).
Strands of loose hair may project over the upper lung, simulating linear fibrotic infiltrates (Fig 8). Rubber bands at the end of braids may be confused with pulmonary nodules (Fig. 9). A long braid may fool us and consider it intrapulmonary disease (Fig 10).

In most cases, the clue to the diagnosis lies in recognizing that the abnormality extends to the neck.

Fig. 7. Braid simulating an apical pulmonary nodule (A-B, arrows). The rubber band (A-B, red arrows) suggests the correct diagnosis

Fig. 8. Loose hair simulating a linear infiltrate or fibrosis in the right apex (A, white arrow). Note the same appearance in the lower neck (A, red arrow). The apex looks normal after the hair is lifted (B). The opaque rounded opacity that looks like a hair clasp (A-B yellow arrow) is a cervical disk prosthesis.

Fig 9. Two patients with rubber bands at the end of a braid simulating pulmonary nodules (A-B, arrows). In both, the braids are visible in the neck (A-B, red arrows). Despite that, patient B was referred for a CT examination to evaluate a left lung nodule.

Fig. 10. 25-year-old man with braided hair simulating a RUL infiltrate (A, arrow). The opacity extends to the neck, giving away the diagnosis (A, red arrow). After raising the braid, the chest looks normal (B). Remember that men also wear their hair long nowadays.

Clothing artifacts

Clothing artifacts occur when the technician does not ask patients to remove garments that have logos or images on them. This usually happens with women, out of respect for modesty (Figs. 11 and 12).

Fig. 11. 27-year-old woman with multiple miliary nodules in both lungs (A, circles). The opacities result from a jeweled panther on the shirt she was wearing (B).

Fig 12. 45-year-old woman with previous breast carcinoma. PA radiograph shows small nodules in lower lungs (A, circles). Lateral view proves that the nodules are in a blouse (B, arrow)

Other types of body artifacts may cause dubious opacities in the chest radiograph (Figs 13 and 14)

Fig 13. 29-year-old man with a barely visible non-displaced fracture of the left clavicle (A, arrow), well demonstrated in the 3-D CT reconstruction (B). Components of the support brace for the fracture simulate enlarged upper lobe vessels (A, red arrows).

To end the presentation, in the last two months we have been acquainted with a new artifact: the wire in the face masks (Fig 14)

Fig 14. Routine chest radiograph during the Covid-19 scare. Notice the wire in the face mask (A-B, arrows)


Follow Dr. Pepe’s advice:

1. Unilateral nipple shadows may generate diagnostic problems.
2. If a hair artifact is suspected, look at the soft tissues of the neck.
3. Garments may create weird lung shadows.

Cáceres’ Corner Case 240 – SOLVED

~ Dr. Pepe ~ 13 Comments

Dear Friends,

Today’s case has been provided by my good friend Victor Pineda. Radiographs belong to a 36-year-old man with cough and fever. For comparison, I am including radiographs taken nine years earlier.

Diagnosis:

1. Chronic TB changes
2. Endobronchial lesion
3. Congenital lesion
4. None of the above

What do you see? More images will be shown on Wednesday. Come back on Friday to see the answer.

Click here to see the images posted on Monday


Showing coronal and axial CT images. What do you think?

Click here to see the CT images

Click here to see the answer

Findings: Pa radiograph shows a left ill-defined opacity that blurs the upper mediastinal contour (A, arrow) and the lower cardiac border (A, red arrow). In the lateral view there is a retro-sternal line that goes from top to bottom (B, arrows). The appearance is typical of marked LUL collapse, which has not changed in the last nine years. Therefore, the most likely diagnosis is a benign condition that occludes the origin of the LUL bronchus.

Enhanced axial and coronal CTs show marked irregularity of the origin of the LUL bronchus (C, arrow) due to a large mass with coarse calcification (C-D, circles) causing distal lobar collapse. The most likely diagnosis is a benign tumor, either carcinoid or hamartoma. Given the size of the mass and the higher frequency of carcinoid, I would favor this diagnosis. It was proved by biopsy and surgery.

Final diagnosis: endobronchial carcinoid with LUL collapse

Congratulations to Ahmed Al Ani who was the first to suggest the correct diagnosis in the plain film.
 
Teaching point: Detecting LUL collapse in chest radiographs is important because the great majority are secondary to bronchogenic carcinoma. This patient was lucky.

Cáceres’ Corner Case 239 – SOLVED

~ Dr. Pepe ~ 15 Comments


Dear Friends,

Today’s case has been provided by my good friend Alberto Villanueva. PA radiograph of a 55-year-old male, taken during a workup for rectal carcinoma.

Diagnosis:

1. Metastasis
2. Pericardial cyst
3. Carcinoma of the lung
4. None of the above

More images will be shown next Wednesday. What do you see?

Click here to see images shown on Monday


Dear Friends,

in my opinion it is difficult to determine in the plain film the origin of large masses adjacent to the mediastinum. I am showing today coronal and axial enhanced CTs.

What do you think?

Click here to see more images


Click here to see the answer

Findings: PA radiograph shows a rounded well-defined mass at the costophrenic angle in the lower left hemithorax (A, arrow). We can infer that the mass is anterior because is displacing the heart towards the right and it does not obliterate the para-aortic line.
In my opinion, when a large mass if adjacent to the midline it is difficult to determine whether it is mediastinal or pulmonary.

Coronal and axial enhanced CT show a solid mediastinal mass with areas of necrosis (B-C, arrows). The most common solid lesion in the cardiophrenic angle are enlarged lymph nodes, which usually are multiple and not very large. In big soft-tissue tumors of this area a thymic origin should be suspected. Although thymic tumors originate in the anterior superior mediastinum, they may slide down along the mediastinal planes and appear at the cardiophrenic angle in the lower mediastinum. Biopsy confirmed the diagnosis of thymoma.

Final diagnosis: mediastinal thymoma

Congratulations to Mohamed Abdulghaffarand MK who were the first to suggest the correct diagnosis

Teaching point: Remember that CT is very helpful in diagnosing cardiophrenic angle masses according to their radiographic density: fat (pericardial fat pad, Morgagni’s hernia); fluid (pericardial cyst) and soft-tissue ( lymphadenopahy and the occasional thymic tumour).

Cáceres Corner Case – Vignette 238

~ Dr. Pepe ~ 3 Comments

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

~ Dr. Pepe ~ 2 Comments

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!

~ Dr. Pepe ~ 8 Comments

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 236 – Vignette

~ Dr. Pepe ~ Leave a comment

Dear Friends,

Today’s radiographs belong to a 65-year-old woman with back pain. She was operated for myxoid liposarcoma of the lower limb seven years ago.

Do you see any abnormality?
If so, where is it?

1. Upper area
2. Middle area
3. Lower area
4. I don’t see it

Click here to see the answer

Findings: PA radiograph shows a double contour of the aortic knob (A, arrow) which indicates a superimposed mediastinal mass either in front or behind the knob. Lateral view shows increased opacity of the upper thoracic spine (B, circle), suggesting a posterior mass.

Click here to see more images

Unenhanced CT was done. What would be your diagnosis?

1. Neurogenic tumor
2. Metastasis
3. Neurenteric cyst
4. Any of the above

Click here to see the answer

Findings: coronal and axial unenhanced CT show a posterior mediastinal mass (C-D, arrows). Of the three possible diagnosis, I would choose neurogenic tumor/cyst, because they are frequent in the posterior mediastinum.

Click here to see more images

MRI was done. Would you change your diagnosis?

1. Neurogenic tumor
2. Metastasis
3. Neurenteric cyst
4. Any of the above

Click here to see the answer

Findings: MRI discovers that the vertebral body is affected (E-F, arrows). This makes neurogenic tumor unlikely. There are visible vessels within the mass, which excludes a cyst. Since myxoid liposarcomas metastasize to the spine, the best possibility is metastasis.
At surgery, a metastatic focus from liposarcoma was found.

Final diagnosis: Metastasis from liposarcoma

This is an interesting case because in the PA radiograph the abnormality is partially hidden by the aortic knob and can be difficult to see (remember to use checklists!).

As a chest radiologist occupying the lower strata of the totem pole, I confess my profound ignorance of liposarcomas. Surfing the Internet I have discovered several papers that state that myxoid liposarcoma metastasizes frequently to the spine and that MRI is the method of choice to demonstrate vertebral metastases in these cases.
Now I can transmit my new-found knowledge to you.

Cáceres Corner Case 234 – Vignette

~ Dr. Pepe ~ 4 Comments

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 233 – Vignette

~ Dr. Pepe ~ 1 Comment

Dear Friends,

Recommendations for this week: A history of the world in 100 objects written by Neil McGregor, Director of the British Museum. Series: Good omens (Amazon). 

Today’s radiographs belong to a 51-year-old man with moderate cough.
 
Do you see any abnormality?
If so, where?

1.  Upper third
2. Middle third
3. Lower third
4. Don’t see it

Click here to see the answer

Findings: PA radiograph shows a left parahilar opacity (A, arrow), seen as an anterior elongated opacity in the lateral view (B, arrow). Its shape in the lateral view suggests mucous impaction.

Click here to see more images

Enhanced CT was done. What would be your diagnosis?

1. Benign endobronchial tumor
2. Allergic aspergillosis
3. Foreign body
4. None of the above

Click here to see the answer

Findings: enhanced axial CT shows an endobronchial obstruction with a distal mucous impaction (C, arrow), also visible in the coronal reconstruction (D, arrow). The clue to the diagnosis lies in recognizing two small lung nodules in the axial view ( C, red arrows) and another one in the right lung in the coronal view (D, red arrow). In addition, there is an enhancing nodule in the gallbladder (D, yellow arrow). These findings suggest widespread malignancy and the correct answer should be 4. None of the above.

Click here to see more images

Bronchoscopy discovered a dark tumor in the lingular bronchus (E), as well as numerous small implants in the trachea, also visible in the CT (F, arrow).
Review of the clinical history discovered that the patient had been operated on for melanoma of the back four years earlier.

Final diagnosis: widespread metastases from melanoma, one of them causing bronchial mucous impaction

Mucous impactions may be multiple or localized. Multiple impactions are related to respiratory diseases that cause bronchiectasis and thick mucus (allergic aspergillosis, cystic fibrosis) whereas localized ones are secondary to segmental endobronchial lesions.

The prevalence of bronchogenic carcinoma makes it the most common cause of localized mucus impaction in clinical practice. Other malignant tumoral lesions are metastases and carcinoids.

Endobronchial metastases represent about 2% of lung metastases. They are usually accompanied by metastatic nodules. They may occur in association with any tumor, but the most common sources are colon, breast, kidney and melanoma.

Cáceres Corner Case 230 – Vignette

~ Dr. Pepe ~ Leave a comment

Dear friends,

Today’s radiographs belong to a 27-year-old with dyspnea.

Diagnosis:

1. Giant bulla
2. Emphysema
3. Loculated pneumothorax
4. Any of the above

Click here to see the answer

Findings: PA radiograph shows overinflation of the lower right lung pushing the minor fissure upward (A, arrow), simulating partial RUL collapse. In the lateral view there is a circular line (B, red arrows) suggesting the wall of a giant bulla. The correct diagnosis is made by detecting overinflation of the left lower lung and scarce vascularity, an indication that we are not dealing with localized disease of RLL (giant bulla or pneumothorax) but with disease of both lower lobes. Therefore the correct diagnosis should be 3. Emphysema.

Another finding in favor of emphysema of lower lobes is redistribution of the pulmonary circulation in which the diameter of the vessels of upper lobes (B) is larger than those of the lower lobes (C).
Pulmonary vascular redistribution is usually due to cardiac failure but it may also occur in emphysema of lower lobes in which vascular flow is redirected to the functioning upper lobes.

Click here to see more images

Unenhanced axial CT confirm the relative sparing of upper lobes (D) and the severe emphysematous changes of lower lobes (E).

Coronal CT (F) shows severe emphysema of lower lobes and increased vascularity of upper lobes as well as discrete bronchial dilatations. Sagittal reconstruction demonstrates that the apparent wall of a bulla seen in the lateral chest radiograph represents the minor and major fissures (G, arrows) limiting a markedly emphysematous right middle lobe.

Diagnosis: Pulmonary emphysema secondary to alpha 1 antitrypsin deficiency.

This condition affects young persons and causes severe emphysema of lower lobes and bronchial dilatations.

I am showing this case because is a good example of satisfaction of search (missing changes of the left lower lobe will lead you to the wrong diagnosis).
It is also a nice example of vascular redistribution secondary to pulmonary disease.