Dr. Pepe’s Diploma Casebook: CASE 138 – MEET THE EXAMINER

Dear Friends,

in the aftermath of the European Congress of Radiology a have elected to show a new “Meet the Examiner” presentation, with questions and answers similar to a real examination. You will get the final answer at the end of the presentation.

Take your time before seeking the answer.

This case starts with a preoperative PA chest radiograph of a 52-year-old man. No other information was provided in the request. What do you see?

Click here to see the answer

Findings: PA radiograph shows an obvious convexity of the left paraspinal line (arrow). There is an abnormal opacity in the periphery of the right lung (circle), which may be related to the rib cage.

Click here to obtain more information

After seeing the chest radiograph, we looked into the case further and discovered that the patient was scheduled for biopsy of a collapsed mid-thoracic vertebra, which would explain the bulging of the paraspinal line. Below is the MRI study. What would be your diagnosis?
1. Aggressive hemangioma
2. Metastases
3. Myeloma
4. Any of the above

Click here to see the answer

Findings: The eighth thoracic vertebra is flattened, impinging on the spinal canal. There is a central lesion in D7 and a smaller one in the anterior aspect of D5. (arrows). The findings were interpreted as an aggressive hemangioma at D8 and smaller hemangiomas at C7 and C5. A CT was requested to obtain more information.

Click here to see the CT

Axial, coronal and sagittal CT images are shown. What would be your diagnosis?

1. Aggressive hemangioma
2. Metastases
3. Myeloma
4. Any of the above

Click here to see the answer

Findings: axial CT (A) shows the typical “polka dot” appearance of vertebral hemangioma.
Coronal and sagittal views demonstrate the collapsed vertebra (B and C, white arrows) with a soft-tissue mass (B, red arrow) which explains the finding in the chest radiograph. A punched-out cortical lesion in D5 was overlooked (C, yellow arrow).

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In the meantime, we were concerned about the abnormal right peripheral opacity seen in the chest radiograph. Oblique views of the right hemithorax were taken. What do you see?

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Findings: the right oblique view shows what appears to be an old rib fracture accompanied by pleural thickening (A, white arrow). A serendipitous finding is the discovery of lytic lesions in the scapula (A, red arrows). The left oblique view also shows a lytic lesion in the right humerus (B, arrow).

The findings in the oblique chest radiographs prompted a review of the spinal CT. Numerous punched-out cortical lesions that had been overlooked were noted (arrows). This discovery suggested widespread malignant bone infiltration. Given that the patient was in good general condition, multiple myeloma was the first diagnostic choice. Vertebral biopsy provided the final diagnosis of myeloma.

Final diagnosis: multiple myeloma invading a vertebral hemangioma

Vertebral hemangioma is the most common vascular lesion of the spine and is present in about 10% of the population. The favored location is the mid-thoracic spine. In this particular patient we suspect that an unrelated multiple myeloma had invaded a previous vertebral hemangioma, causing collapse of the vertebral body. This responds to the concept of locus minoris resistentia, in this context referring to organs or regions that for some reason are more vulnerable than others. In this case, the wide vascular spaces and increased blood supply of the hemangioma may have facilitated implantation of malignant cells.

The typical appearance of coarse trabeculae (polka dot) of the original hemangioma, plus satisfaction of search were the reasons for the initial misdiagnosis of invasive hemangioma. The findings in the plain films of the chest were decisive to reconsider the diagnosis, leading to a review of the cross-sectional studies and the correct diagnosis.


Follow Dr. Pepe’s advice:

1. Remember Dr. Pepe’s words of wisdom (Diploma case 132): Don’t let one abnormal finding keep you from looking for another

2. Sometimes, plain films have an important role in the diagnosis.

Cáceres’ Corner Case 200 – SOLVED!

Dear Friends,

the first case of Caceres’ corner was published in September 23, 2011. Today, seven years later, we are proud to present case 200. It was not always easy, but it was always fun and worth it. Thank you for your continuous support.

Today’s case was diagnosed by my friend and co-worker Carles Vilá. The PA radiograph was taken as a pre-op exam for renal stones.
Do you see any abnormality?

More images will be shown on Wednesday

Click here to see the images

Dear Friends,

we saw a peripheral opacity in the lower left hemithorax and performed a CT, which showed unexpected findings.
What do you see?

Click here to see the new images

Click here to see the answer

Findings: PA radiograph shows a faint opacity in the periphery of the left lower hemithorax (A, circle). A CT was recommended.

Axial CT shows an unexpected irregular basal opacity (B, arrow). Caudal slices show several parietal nodules (C-D, arrows).

Coronal CT shows the large basal opacity (D, arrow), as well as the small parietal nodules (D-E, red arrows).

The clue to the diagnosis lies in a negative finding: absent spleen in the left upper quadrant of the abdomen (D-E, asterisks), suggesting that the chest opacities may represent accessory spleens.
The patient was interrogated and stated a previous car accident with ruptured spleen and subsequent splenectomy. A test with labelled erythrocytes in another institution confirmed the accessory spleens.
 
Final diagnosis: thoracic splenosis
 
As I am writing this (12:00 PM Thursday), nobody has suggested the right diagnosis. I was expecting many correct answers, since I showed a similar case eight weeks ago (Diploma case 135).
 
Teaching point: remember the importance of negative findings (Diploma cases 135 and 136). In this particular patient, they were crucial to suggest the correct diagnosis.

Congratulations to MK, who made a last-minute diagnosis at 2:08 P.M. on Thursday!

Dr. Pepe’s Diploma Casebook: CASE 137 – MEET THE EXAMINER

Dear Friends,

since we have the European Congress of Radiology this week, I don’t want to stress you unnecessarily. I have selected a “Meet the Examiner” presentation, with questions and answers similar to a real examination. You will get the final answer at the end of the presentation.

Take your time before seeking the answer. And no peeking!

This case was provided by my friend and co-worker Dr. Lucía Hernandez. The patient is a 39-year-old woman who had a tumorectomy for carcinoma of the right breast in March 2008. In February 2009 she noticed a lump in her right axilla. Breast MRI was performed.

What would be your diagnosis:

1. Necrotic lymph node
2. Metastasis
3. Fibrotic tissue
4. None of the above

Click here to see the images

Click here to see the answer

Findings: The MRI finding was interpreted as an enlarged lymph node in the right axillary area, around 35 mm in diameter and with a necrotic center (A and B, arrows).

Ultrasound exam demonstrated a longitudinal echogenic band of about 40 mm in length, suggestive of postsurgical changes. No adenopathy was found.
Fine-needle biopsy returned nonspecific findings, no signs of malignancy.

In view of these results, no action was taken.

The patient returned yearly for follow-up MRI and US studies, which showed no significant changes from the initial examination.

Ten years later, in January 2019, the patient detected a discrete ulceration in the right axilla and consulted her doctor. A new MRI examination was done.

What do you think?

Click here to see the answer

MRI showed a slight increase in the size of the lesion from 35 mm maximum diameter in 2009 (A, arrow) to 40 mm in 2019 (B, arrow). US showed no changes in comparison with previous studies. PET-CT study was ordered.

Click here to see the PET-CT

What do you see?

Click here to see the answer

The study was interpreted as a rounded axillary image with low peripheral uptake (SUV 4) (A-C, arrows). The high-density linear opacity in the center was overlooked (B, yellow arrow).

Click here to see more studies

At this stage of the game, all imaging studies were reviewed, including the chest radiographs.

Below are postoperative chest radiographs taken in March 2009. What do you see?

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Chest radiographs show a radio-opaque marker in the right axilla (A and B, arrows). The appearance is typical of a retained surgical gauze.

The findings are better seen in the cone down views (C and D, arrows). A cone down view of the axilla with the arm outstretched taken in 2019 clearly shows the axillary mass (E, black arrows) and the radio-opaque marked gauze within (E, red arrow).

Enhanced axial CT also shows the typical appearance of encapsulated surgical gauze (A and B, white arrows), with the radio-opaque marker inside (A and B, red arrows). Confirmed at surgery.

Final diagnosis: Retained surgical gauze in the right axilla

Retained surgical gauzes are occasionally seen in abdominal surgery, but are less common in the chest. I have encountered only one other case (See Fig. 1, below). Nonetheless, they are easily identified by their radio-opaque markers. Early detection of this material avoids unnecessary examinations and prevents future complications, as occurred in the patient presented.

As a chest radiologist, it makes me proud that proper reading of a chest radiograph achieved a diagnosis that prompted 2 biopsies, 9 MRI, 9 sonographies, and 1 PET-CT over 10 years.
It is interesting to note that a normal gauze count does not exclude the possibility of a retained gauze. In one series, the count was reported as correct in 22 of 29 patients (76%) with retained gauzes in the abdomen (Kaiser CW, Friedman S, Spurling KP, Slowick T, Kaiser HA. The retained surgical sponge. Ann Surg 1996;224:79–84).

Fig. 1. 58-year-old man with fever after cardiac surgery. PA radiograph was unremarkable. Lateral view shows a radio-opaque marker in the posterior heart shadow (A, arrow), better depicted in the cone down view (B, arrow), with the typical appearance of a retained gauze. CT confirms the presence of the gauze in the pericardial cavity (C, arrow). Proved at surgery.


Follow Dr. Pepe’s advice:

1. Retained surgical gauzes are easily identified by their radio-opaque markers.

2. Early discovery prevents complications and unnecessary examinations.

Cáceres Corner Case 199 – SOLVED!

Dear Friends,
Today´s case is provided by my good friend Alberto Villanueva.

PA radiograph belong to a 58-year-old man with cough and weight loss. Gastrectomy for stomach cancer in 2006. A previous film is shown for comparison.

Do you see any abnormality?

More images will be shown on Wednesday

Click here to see the images shown on Monday

Dear Friends,

showing a PA chest radiograph taken three months later.

What do you see?

Click here to see the new image

Click here to see the answer

Findings: PA radiograph taken in February 2018 shows an area of increased opacity in the subcarinal region (A, red arrows), more evident when compared with a previous film of 2014 (B). This finding was not detected.

Three months later the patient returned with increasing dyspnea. PA chest radiograph shows the typical appearance of RLL collapse, evidenced by a basal triangular shadow (C, arrow), downward hilar displacement (C, yellow arrow) and tracheal displacement. The subcarinal mass is now more evident (C, red arrow). Enhanced coronal CT shows the central mass (D, red arrows) as well as the RLL collapse (D, arrow).

Final diagnosis: oat-cell tumor of the lung

Congratulations to Elisa and Krister A, who were the first to detect the subcarinal mass in the initial examination
 
Teaching point: most of you detected the subcarinal mass that was missed in the original reading. This case emphasizes the importance of comparing with previous films to detect subtle findings.

Dr. Pepe is preparing a new webinar!

Dear Friends,

I’m preparing a cycle of six webinars about basic interpretation of chest radiographs. The first one will be about the PA view, and today I’m presenting six cases that will be shown during this webinar.

You can respond in the blog, as usual. Answers will be given on Monday, November fifth, when the webinar will be posted on the Diploma web.

To encourage your participation, any of you who get three or more right answers will receive a dedicated picture of Dr. Pepe in their mail. Leave your answers in the comments if you want to receive the picture!

Good luck!

Continue reading “Dr. Pepe is preparing a new webinar!”