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

Musculoskeletal #15 – Flashcard

This is the third and last case of the musculoskeletal series. Check the first one and second one on this blog.

What do you see on the following images?

Click here to see the answer

Osteoblastoma: Osteoblastoma is histologically similar to osteoid osteoma but they are larger (usually accepted more than 1 cm), often involving the posterior column

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)

ECR2020 – Question of the day #2 – Winner announced

We dare you to solve one of the hardest questions of the EDiR examination!
The European Board of Radiology raffles amongst the winners an examination place for the EDiR during 2021.

70-year-old woman with cough and dyspnea.
What is the most likely diagnosis?

Please, click here to enter your answer. Solve the question before 13:30 CEST

Winner will be announced here, on the EBR blog, at 14:00 CEST

Good luck!

The winner of the Question of the day is

MM

ECR2020 – Question of the day #1 – Winner announced!

We dare you to solve one of the hardest questions of the EDiR examination!
The European Board of Radiology raffles amongst the winners an examination place for the EDiR during 2021.

Regarding coronary anomalies: Which of the following statements are correct?

Please, click here to enter your answer. Solve the question before 13:30 CEST

Winner will be announced here, on the EBR blog, at 14:00 CEST

Good luck!

The winner of the Question of the day is

SWATI PACHARNE

Musculoskeletal #12 – Flashcard

43-year-old healthy patient:
– with fibromyalgia
– No other relevant medical history

What do you see on the following images?

Click here to see the answer

IMAGING FINDINGS:

Multiple focal sclerotic bone lesions clustered around joints in both knees and sacroiliac joints

DIAGNOSIS:

Osteopoikilosis

TEACHING POINTS:

Sclerosing bony dysplasia characterized by multiple enostoses
Typically clustered around joints, aligned parallel to trabeculae. Usually 1-3 mm, they can reach up to 20 mm
Rare condition; inherited; asymptomatic; incidental
Important to avoid misdiagnosis with other relevant pathologies such as metastasis

Neuroradiology #22 – Flashcard

What do you see on these images?

Click here to see the answer

Oligodendroglioma

CT scan shows a large calcified lesion. MRI shows a large cortical-based high T2 lesion with cystic component and dark T2 foci corresponding to the calcifications. Post-contrast images show patchy enhancing areas.  

Differential Diagnosis

DNET (usually may calcify) ganglioglioma (cystic areas, enhancing solid component, may calcify).

Emergency #22 – Long case

81-year-old male:

* Severe pain abdomen
* Tender abdomen
* Clinical ileus

What do you see?

Diagnosis

Mechanical ileus with caliber change in ileum. Distended stomach with air in the major curvature of the wall, with air bubble outside lumen, suspect for pneumatosis intestinalis. Extended air in left portal vein branches and in central portal vein (portal venous gas peripheral, gas in bile ducts central).

Click here to see more images

What additional findings do you see?

1. Contained rupture AAA with slowly progressive lytic destruction and remodeling of lumbar spine
2. Gall stones

Cáceres’ Corner Case 240 – SOLVED

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.