Cáceres’ Corner Case 224 – SOLVED

Dear Friends,

Due to the coronavirus scare, Dr Pepe and Miss Piggy have eloped to the Bahamas, leaving me alone in charge of the blog. Until his return in late March, I will present interesting cases in the Caceres’ Corner. I may even dare to present a Diploma case, although I am not as knowledgeable as Dr Pepe.

This week’s case is a preoperative PA radiograph of a 47-year-old woman.

Diagnosis:

1. Double aortic arch
2. Enlarged azygos vein
3. Mediastinal mass
4. None of the above

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

Click here to see the answer

Findings: PA shows a right mediastinal bump at the confluence between the trachea and the RUL bronchus (A, arrow). There is a curved mediastinal line below (A, red arrow) and an extra mediastinal line in the left lower mediastinal border (A, yellow arrow).

The combination of these findings strongly suggests increased circulation in the azygos system, with prominent azygos and hemiazygos veins. In an asymptomatic patient the most likely diagnosis is a congenital interruption of the IVC with azygos continuation.
A double aortic arch can be ruled out because the right component raises higher than the left, and in this case the opposite occurs.

Unenhanced coronal CT confirms the dilated azygos arch (B, arrow) and the dilated ascending azygos (B-C, red arrows) and hemiazygos (C, yellow arrow)

Final diagnosis: Congenital interruption of the IVC with azygos continuation.
 
Congratulations to Hazem who was the first to give the correct answer and to Krister who gave a nice and accurate description of the findings.
 
Teaching point: this case is a good example of non-significant findings secondary to a congenital malformation, as mentioned in webinar eight.

Cáceres’ Corner Case 219 – SOLVED!

Dear Friends,
Today’s images belong to a 67-year-old woman with pain in the chest.
What do you see?

More images will be presented next Wednesday and the answer will be published on Friday, as usual.

Click here to see more images

Dear Friends,

Showing additional axial CT images of the patient.
What do you see?

Click here for the solution

Findings: PA chest radiograph shows a lytic lesion of the 3rd right rib, accompanied by an extrapulmonary sign (A, circle). Lateral view (not shown) is unremarkable.

The lesion is more obvious in the cone-down view (B, circle), specially when compared to a previous study (C, circle).

Axial CT confirms a permeative lesion of the rib (D-E, arrows), as well as lytic lesion in the posterior elements of the 4th thoracic vertebra (E, red arrow). A serendipitous finding is a nodule in the medial quadrant of the left breast (F, arrow), demonstrated in a subsequent mammography (G, arrow) and confirmed to be a carcinoma.

Final diagnosis: carcinoma of the breast with osseous metastases
 
Congratulations to Diogo who saw and described the rib lesion in the plain film.
 
Teaching point:remember that our most common error is missing obvious lesions.
Checklists help to correct oversights. I believe the rib lesion could have been found if you had applied the checklist recommended in webinar one (H).

Cáceres’ Corner Case 218 – SOLVED

Dear Friends,

an easy case to celebrate the new year. PA radiograph of a 36-year-old woman with chest pain.

What do you see?

Click here to see the answer

Findings: PA chest radiograph shows a fracture of the right clavicle (A, arrow). A magnified view of the area raises the possibility of a lytic lesion (B, arrow).

Specific low-Kv images of the clavicle were taken, showing a rounded permeative lesion with a pathological fracture (C, arrow. D, circle). No other lesions were demonstrated in a bone scan. Biopsy followed by surgery came back as chondrosarcoma.

Final diagnosis: chondrosarcoma of clavicle with pathological fracture
 
Congratulations to Archanareddyt, who discovered the pathological fracture
 
Teaching point: when evaluating bone lesions of the chest, take specific views. They allow a better interpretation of the pathologic changes

Cáceres’ Corner Case 197 – SOLVED!

Dear Friends;

Today I am showing a preoperative PA chest radiograph for knee surgery in a 50-year-old woman. More images will be shown on Wednesday.

What do you see?

Click here to see the images published on Monday


Dear Friends,

showing today axial CTs and a cone down view of lesion. Hope they clarify your thoughts.

Click here to see the new images

Click here to see the see the answer

Findings: PA chest radiograph shows a well-defined opacity in the apex of the right lung. There is pleural thickening in the periphery of the opacity (A, arrow) that suggests an extrapulmonary location. There is a chain-like line in the periphery, better seen in the cone down view (A-B, red arrows), which looks like metallic surgical sutures. In addition, an irregular mass is visible in the right upper mediastinum (A-B, yellow arrows).


Discovering metallic sutures raises the possibility of post-surgical changes. It was found that the patient had been treated five years earlier with bullectomy and talc pleurodesis for persistent pneumothorax (C-D, arrows).

Enhanced axial CT at the present time shows a cystic pleural collection surrounded by talc (E, arrow). A caudal paramediastinal clump of talc (F, arrow) explains the right mediastinal mass seen in the plain film.

Final diagnosis: post-operative changes after bullectomy and talc pleurodesis for persistent pneumothorax.
 
Congratulations to Ner, who gave an excellent discussion and discovered the metallic sutures in the plain film.
 
Teaching point: Remember to look carefully at the radiographs. A simple finding, such as discovering metallic sutures, may lead to the correct diagnosis before CT.