Tag: Dr. Pepe

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

~ Dr. Pepe ~ 2 Comments

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 242 – SOLVED

~ Dr. Pepe ~ 14 Comments

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.

Cáceres’ Corner Case 241 – SOLVED

~ Dr. Pepe ~ 8 Comments

Dear Friends,

Today’s radiographs belong to a 24-year-old woman with cough and fever. What do you see?

More images will be shown next Wednesday and the answer will be published on Friday.

Click here to see Monday images


Dear Friends,

Showing today CT images of the chest. What do you think?

Click here to see the new images

Click here to see the answer

Findings: Chest radiographs show air-space disease in the right lower lobe (A-B, arrows). There is marked widening of the right paratracheal line (A, red arrow) suggestive of mediastinal lymphadenopathy.

Axial CT with lung window shows RLL air-space disease without cavitation (C, arrow). Mediastinal window at different levels confirms enlarged paratracheal, subcarinal and neck lymph nodes with hypodense center (D-F, red arrows). These findings should suggest active tuberculosis as the first possibility.
Although TB usually affects upper lobes, isolated involvement of lower lobes occurs in about 7% of cases.
 
Mycobacterium tuberculosis was found in the sputum.

Final diagnosis: active TB.
 
Congratulations to Archanareddyt who was the first to make the diagnosis.
 
 Teaching point: lymph nodes with hypodense center may occur in several processes (treated tumors, Whipple’s, etc.), but in the appropriate clinical situation, the first diagnostic consideration should be tuberculosis.

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 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.

Cáceres’ Corner Case 225 – SOLVED

~ Dr. Pepe ~ 4 Comments

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”

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

~ Dr. Pepe ~ 6 Comments

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.

Dr. Pepe’s Diploma Casebook 153 – All you need to know to interpret a chest radiograph – Seventh Session

~ Dr. Pepe ~ 7 Comments

Dear Friends,

Today I am presenting the leading images of the seventh webinar. They belong to a 66-year-old man with vague chest complaints. Chest was read as normal, but there is a visible abnormality, difficult to see.
Can you see it?

Remember, you can see the previous sessions of the webinar in our youtube channel. We will published the answer to this question (and the webinar) on Friday.

Click here to see the answer

Findings: PA radiograph (A) is unremarkable. In the lateral view there is a nodule projected over the mid-thoracic spine (B, arrow). The nodule was overlooked, and the examination was read as normal.

One year later the nodule has increased in size (C, arrow) and has become visible behind the heart in the PA view (D, arrow). It was diagnosed as adenocarcinoma and liver metastases were found.

Two years later, CT and PET-CT show marked progression of the liver metastases.

Final diagnosis: lung adenocarcinoma missed in the first chest radiographs, with widespread metastases two years later
 
Congratulations to Spat, who discovered the initial nodule.
 
Teaching point: remember to look at the dorsal spine in the lateral view. By doing so, you may discover early disease, with great benefit for the patient.

Cáceres’ Corner Case 220 – SOLVED

~ Dr. Pepe ~ 14 Comments


Dear Friends,

I am showing today a case seen last week. Radiographs belong to a 35-year-old man with fever. 

What do you see?

The answer will be published on Friday.

Click here to see the answer

Findings: PA chest radiograph shows widening of the superior mediastinum (A, arrows). There is moderate prominence of both hila (A, red arrows) and two rounded opacities in the inferior aspect of the right hilum (A, yellow arrows). The lateral view shows convex bumps in the left hilum (B, red arrows).
Findings in both views are practically pathognomonic of mediastinal and hilar lymphadenopathies.

Changes in the PA radiograph are more evident when comparing with a previous film taken two years earlier.

In this case, lymphoma is the best possibility. For the sake of the patient I hoped it was infectious mononucleosis. Analysis discovered immature cells in the bloodstream. Further workup confirmed the diagnosis of acute lymphoblastic leukemia.
 
Final diagnosis: acute lymphoblastic leukemia with enlarged hilar and mediastinal lymph nodes.
 
Many of you discovered the enlarged lymph nodes, which makes me very proud.
Kudos for Amal Mahran, who was the first to give a detailed description.
 
Teaching point: I believe this case emphasizes the importance of comparing with previous studies. If I had shown the previous PA chest, I am sure the percentage of correct answers would had been close to one hundred percent.