Cáceres’ Corner Case 248 – SOLVED

Dear Friends,

today I am showing preop radiographs for knee surgery of a 71-year-old man.
What do you see?

More images will be shown on Wednesday.

Click here to see new images

Dear friends, showing additional images of the sternum taken six years earlier, in 2014.
What do you think?

Click here to see the answer

Findings: PA chest is unremarkable (A). The lateral radiograph shows an expanding lytic lesion in the sternal manubrium (B, circle).

Cone down view shows the lesion better (C, arrows). Sagittal, coronal and axial unenhanced CT taken six years earlier (2014) demonstrate that the cortical bone is broken in several places, suggesting an aggressive process (D-F, arrows). A soft-tissue mass is not visible.

No other skeletal lesions were found. Biopsy of the sternum confirmed the diagnosis of solitary myeloma (plasmocytoma), that was subsequently treated. The patient remained asymptomatic.
 
Final diagnosis: Plasmocytoma of the sternum
 
Congratulations to Priyanka Chhabra and Olena, who made the correct diagnosis. And kudos to all of you who saw the lesion in the lateral chest radiograph.
 
Teaching point: Remember that a lytic lesion of the sternum in an adult is malignant until proven otherwise. Main etiologies are primary tumors (chondrosarcoma) and metastases.

Reviewing the literature, I found a case report with similar findings: Solitary plasmacytoma of the sternum with a spiculated periosteal reaction: A case report. ONCOLOGY LETTERS 9: 191-194, 2015

Cáceres’ Corner Case 246 – SOLVED

Dear Friends,

Today I am showing the PA radiograph of an 82-year-old woman. Preoperatory for cataracts.

What do you think about the right hilum?

1. Calcified TB nodes
2. Sarcoidosis
3. Amyloid
4. None of the above

More images will be shown on Wednesday.

Click here to see the images shown on Monday


Dear friends, showing today PA and lateral radiographs taken two years earlier. Hope they help.

Click here to see the new images

Click here to see the answer

Findings: Initial PA radiograph shows opacities in the right hilum (A, circle), unchanged in comparison with a previous film taken two years earlier (B, circle).

The clue to the diagnosis lies in the density and appearance of the opacities. They are denser than the typical lymph node calcifications, suggesting that they are metallic. In addition, some of them look tubular or branching (C, red arrows). A lateral view taken two years earlier confirms dense lineal and branching opacities in right lung (D, arrows).
The combination of linear and branching metallic opacities suggests that they are either in the bronchi (previous bronchography) or within the pulmonary vessels (embolism after vertebroplasty o treatment of AV malformation). See Diploma # 44.

Lateral view of the lumbar spine shows surgical changes with vertebroplasty of L3 to L5 and leakage of the cement into the epidural veins (E, arrows), better seen in the sagittal CT (F, arrows).

Unenhanced CT confirms multiple cement emboli in the pulmonary arteries (G-J, circles)

Final diagnosis: cement embolization of the lung after vertebroplasty
 
I must mention Olena and Ayudi who suggested amyloid and broncholithiasis but failed to notice the metallic opacity of the findings.
 
Teaching point: Consider previous vertebroplasty when you see metallic opacities in the lungs. It is a common complication.

Dr. Pepe’s Diploma Casebook 161 – Meet the examiner

Dear Friends,

This week’s case follows the pattern of a “Meet the Examiner” presentation, with questions and answers similar to a real examination. Take your time before scrolling down for the answer.

The images belong to a 60-year-old man with moderate cough and dyspnea

What would you recommend?

1. Compare with previous films
2. Chest CT
3. PET-CT
4. None of the above

Click here to see the answer

Findings: PA radiograph shows large bullae in both upper lobes. There is a nodule in the RUL projected over one bulla (A, arrow). Two small calcified granulomas are visible in the periphery of the LUL (A, circle). PA film taken five years earlier (B) does not show any nodule in the RUL. The granulomas in the LUL are unchanged.

Report of the chest : bullous emphysema with a nodule not visible in 2014. Given the relationship between bullous disease and carcinoma, it is imperative to do a chest CT.

Enhanced CT was done the next day. What would you suggest?

1. Antibiotic treatment and CXR in one month
2. PET-CT
3. Antibiotic treatment and CT in one month
4. None of the above

Click here to see the answer

Findings: aside form large bullae in both upper lobes, an irregular nodule is evident in the RUL (A-B, arrows). In my opinion, given the appearance of the nodule I would suspect malignancy and request a PET-CT. However CT was reported as: Pseudonodular opacity in RUL that could be related to an infectious/inflammatory process. A neoplasm cannot be excluded. Recommend control after treatment

Click here to see more images

A chest radiograph was taken one month later.
What would you do?

1. PET-CT
2. CXR in three months
3. CT in three months
4. Control in one year

Click here to see more images

The chest radiograph one month later was reported as unchanged and no further suggestions were made by the radiologist. The clinician took no further action.

The patient came back ten months later, and a new radiograph showed an obvious increase in size of the nodule (B, arrow) when compared to the initial film (A, arrow)

Click here to see more images

Enhanced CT confirms the increase in size of the nodule (A-B, arrows). Surgery discovered a carcinoma in the wall of a bulla.

Final diagnosis: adenocarcinoma of the lung associated to bullous disease.

Lung carcinoma seems to occur more often in bullous disease, although there is not enough evidence compiled at the present time. Despite the lack of evidence, knowing
this association may prevent misdiagnosis.
A lesser known fact is that the cystic space may disappear after the carcinoma develops, as occurred in a second case (see below). Spontaneous regression of a bulla may be due to non-malignant causes, but carcinoma should be excluded with CT because it may take years for the lesion to be visible in the chest radiograph.

I am showing this case because the opinion given in the chest radiograph was unequivocal, whereas the CT report was vapid, giving the impression that the nodule was infectious, and that malignancy was less likely. The follow-up radiograph was disregarded by the radiologist and clinician and this caused a delay in diagnosis of almost one year.

To complete the information, I am showing a second case of carcinoma developing in the wall of a cystic space

Images of the second case were obtained during routine CT screening in a 72-year-old man, heavy smoker.
Apical axial CT image shows a small nodule in the LUL (A, arrow), with increased uptake on PET-CT (C, arrow). There is a cystic airspace in the LLL (B, arrow) with no PET-CT uptake, interpreted as a non-specific cystic airspace lesion.

At surgery a carcinoma of the LUL was found.

It was decided to continue with yearly follow-up studies. The cystic air space (A, arrow) increased in size in 2008 but still had a thin wall (B, arrow). In 2009 it has decreased slightly in size and the wall is thicker than the previous year (C, arrow). A new PET-CT shows increased uptake in the posterior wall (D, arrow).

Malignancy was suspected. The patient refused further surgery or percutaneous biopsy and it was decided to do a follow up study three months later.
Axial CT shows that the cystic airspace has disappeared and in its place, a solid mass has developed (A and B, arrows) with increased overall uptake on PET-CT (C, arrow). At surgery, an adenocarcinoma was found.

Final diagnosis: adenocarcinoma arising in the wall of a cystic airspace, which disappeared as the tumour progressed.


Follow Dr. Pepe’s advice:

1. Bullous emphysema and isolated cystic spaces may be associated with an increased incidence of carcinomas

2. A poorly worded report may cause an unnecessary delay in diagnosis

Cáceres’ Corner Case 245 – SOLVED

Dear friends, Dr Pepe has eloped with Miss Piggy (again) and has let me alone, holding the fort. Hope he will be back in time to give the next webinar.

Today’s radiographs belong to a 60-year-old male with cough and moderate dyspnea.

Diagnosis:

1. Hilar lymphadenopathy
2. Right pulmonary artery aneurysm
3. Mediastinal tumor
4. None of the above

Click here to see the answer

Findings: PA and lateral chest radiographs show a right hilar mass (A-B, arrows). In my opinion, the appearance of the mass and its location in the right hilum in the lateral view rules out a mediastinal mass.
There is a small nodule in the RUL (A, red arrow) that can be overlooked unless we look for it

The nodule is better seen in the cone down view and the axial CT (C-D, red arrows), with high SUV in the PET-CT (E, arrow), accompanied by a metastatic node in the mediastinum (E, circle).

Caudal slices of enhanced CT show multiple lymph nodes in right hilum (F, arrow) and mediastinum (G, circle).

Biopsy of a lymph node returned as metastatic carcinoma.

Final diagnosis: carcinoma of the lung with mediastinal metastases

Congratulations to archanareddyt who was the only one to discover the RUL nodule

Teaching point: this is an interesting case for educational purposes.
1. Knowing the most common causes of unilateral hilar enlargement (lymph nodes vs. enlarged artery) helps the differential diagnosis.
2. We should think of common processes rather than unusual ones (lymph nodes vs. aneurysm).
3.  Suspecting unilateral hilar lymph nodes leads to search for the two more common etiologies (TB or carcinoma) leading to the discovery of the RUL nodule.

Hope the case was useful!

Neuroradiology #24 – Flashcard

89-year-old female patient with aplastic anemia. Showing CT images without contrast media. What do you see?

Click here to see the answer

CT images without contrast media: Subacute isodense right subdural hematoma, revealed with narrowing of right cerebral hemispheric sulci and right lateral ventricle and minimal midline shift (red arrows), acute left subdural hematoma (blue arrow)

Dr. Pepe’s Diploma Casebook 160 – With a webinar! – SOLVED

Dear friends, I am starting a new webinar series entitled “Things that we already know, but are important to remember”. The objective is to refresh basic concepts that often are forgotten.

This week’s webinar title is “Who is afraid of the bad, big lateral chest”. The webinar will take place on Wednesday, September 30 at 12:00 CEST. You can register here.

The initial case is a PA chest radiograph of a 61-year-old man with hemoptysis.

Do you see any abnormality?
1. Yes
2. No
3. I want a lateral chest

Register for the webinar and lear more about this case and others!

Click here to see the answer

Findings: PA radiograph (A) does not show any significant findings. The lateral view shows a posterior pulmonary nodule with irregular contour (B, arrow). A typical donut sign is visible (B, circle), indicative of enlarged subcarinal lymph nodes.

Enhanced axial CT and PET-CT show confirm the pulmonary nodule (C-D, arrows) and the subcarinal lymphadenopathies (C-D, red arrows).

Final diagnosis:

Carcinoma hidden in the PA view behind the right hilum with metastases to subcarinal lymph nodes.
 
Congratulations to drpeca who was the first to want a lateral view.
 
Teaching point: remember that about 26% of the lung is hidden in the PA view. A lateral chest radiograph is indispensable to study the chest.

Emergency #24 – Flashcard

A 43-year-old man with inflammation and lower abdominal pain:

What do you see?

Click here to see the answer

* Inflammatory wall thickening of the sigmoid colon.
* Multiple diverticula, but one enlarged with thickened enhancing wall (arrow).
* Surrounding haziness of the mesosigmoid fat.
* Peritoneal accentuation

Typical image of diverticulitis, in a typical location with typical presentation

Teaching point

Look for signs of perforation or abscess formation

Cáceres’ Corner Case 242 – SOLVED

Dear friends, welcome back!

Today I am showing a straightforward case to ease you into the new season. Promise I will not mention Covid-19 at all.

Today’s case is a pre op PA radiograph for knee surgery in a 47-year-old woman.

What do you see?

Come back on Friday to see the answer!

Click here to see the answer

Lung and mediastinum do not show any relevant findings. An isolated air-fluid level is visible in the left upper quadrant of the abdomen (A, arrow). The inner border of the cavity is smooth. The gastric bubble is visible under the left hemidiaphragm (A, red arrow).

Given that the patient is asymptomatic, an abdominal abscess or bowel obstruction/ volvulus can be safely excluded. A large intestinal diverticulum could be a possibility. I suspected a more mundane diagnosis: a review of the clinical history discovered that an intragastric balloon had been inserted fourteen months earlier.

Final diagnosis: air-fluid level in an intragastric balloon for morbid obesity
 
Congratulations to all of you who detected the air-fluid level. Kudos to Flemming Ghomsen who came close to the diagnosis.

Intragastric balloons for bariatric surgery may be filled with air or with saline. In the second case they may present an air-fluid level due to room air mixing during the injection of fluid.
 

Teaching points:


1. Remember to look under the diaphragm. You may discover interesting findings.
2. In your differential diagnosis always include iatrogenesis as a possible cause.