Cáceres Corner Case – Vignette 237

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 228 – Vignette

Dear Friends,

Today I am showing a preoperative chest radiograph for varices of a 60-year-old woman.
Do you see any abnormality?
If so, where is it?

1. Lung
2. Mediastinum
3. Pleura/chest wall
4. Don’t see it

Click here to see the answer

Findings: There are bilateral convex opacities in the lower mediastinum (A, arrows), better seen in the cone down view (B, arrows). The appearance suggests a lower central mediastinal mass and the most likely diagnosis should be hiatus hernia. A fact against this diagnosis is the gastric fornix in its normal location (A, red arrow).

What would you recommend:

1. Lateral view of the chest
2. Esophagogram
3. Chest CT
4. None of the above

Click here to see the answer

In my opinion, the best choice is a lateral view, which shows poor definition of the body of the eleventh dorsal vertebra with a sharp angulation of the spine (C, circle). There is no evidence of hiatus hernia.

Click here to see the more images

AP cone down view of the lower thoracic spine shows a butterfly deformity of D11 (D, circle) with the outer borders accounting for the convexities visible in the chest radiograph. Lateral cone down view confirms marked flattening and collapse of the vertebral body (E, circle)

The patient had been involved in a car accident five years ago resulting in a burst compression fracture of D11. Comparison with previous radiographs did nor show any change.

Final diagnosis: Traumatic compression fracture of D11, stable

Teaching point: Remember that not all opacities in the lower mediastinum in the PA view are hiatus hernias. A lateral view places them in the correct compartment and helps to clarify the etiology.

Cáceres Corner Case 227 – Vignette

Dear friends, starting today I plan to show simple teaching cases (vignettes) hoping to ease the boredom of the confinement.
I will show two cases every week (Monday and Thursday). To make the presentation more agile the diagnosis will be included. If you get impatient all you have to do is press the answer button.

The first case is a routine control PA radiograph in a 67-year-old woman operated on for breast carcinoma three years ago.

Question: Do you suspect any bone metastasis?

Click here to see the answer

Findings: There is an apparent lytic lesion in the distal end of the right clavicle (A, arrow), better seen in the cone down view (B, arrow).

When I saw this case two months ago, I could not determine whether the lesion was real or not. What would you do?
 
1. Compare with previous films
2. Call the oncologist
3. PET-CT
4. Bone scintigraphy

Click here to see the answer

In my opinion, the first thing to do was comparing with previous films although
this brilliant idea was hampered by the technician placing the marker in top of the distal clavicle in two earlier radiographs (C-D).

What would you do now?
1. Bone scintigraphy
2. Call the oncologist
3. PET-CT
4. CT

Click here to see the answer

Since I was not sure about the lesion, I decided to call the oncologist to find out if she suspected any metastasis and if the patient had any pain in the right acromioclavicular area. The answer was negative. What would you recommend?

1. Bone scintigraphy
2. CT
3. PET-CT
4. Radiograph of the right clavicle

click here to see the answer

In my opinion the fastest way to clarify the diagnosis was to take a radiograph of both clavicles (with the left for comparison). The distal end of the right clavicle has a normal appearance and , since the patient had no local symptoms, no further studies were needed.

Final diagnosis: normal variant simulating pathology in an oncologic patient

I have seen several chest radiographs with apparent lytic lesion of the distal clavicle that turned out to be normal. It is described in the Atlas of normal variants by Keats. In this case I was doubtful because the patient had a carcinoma and the appearance of the lesion was ominous.
 
There are two teaching points in this case:
1. Talking to the referring physician is important to determine the management of findings.
2. A simple and inexpensive procedure clarified the diagnosis and avoided unnecessary additional studies.

Cáceres’ Corner Case 226 – SOLVED

Dear Friends,

Today’s radiographs belong to a 27-year-old woman who came for a routine check-up.

Most likely diagnosis:

1. Thymic tumor
2. Enlarged lymph nodes
3. Aortic arch malformation
4. None of the above

CT images will be shown next Wednesday.

Click here to see the first images

Dear Friends,

Today I am showing enhanced CT images of the mediastinum in the early (A-B) and late phases (C-E).
What do you think?

Click here to see more images

Click here to see the answer

Findings: PA chest radiograph shows a right upper mediastinal mass with undulated border (A, arrow). There is increased opacity of the anterior clear space in the lateral view (B, circle). In my opinion, the most likely diagnosis would be thymic tumor, although the undulated border favors enlarged lymph nodes.

Enhanced axial CTs in the arterial phase show an anterior mediastinal mass with minimal enhancement (C-D, arrows) and a vascular space in the center (C, yellow arrow).

Coronal and axial CTs in the late phase show partial washout of the vascular space (E, yellow arrow). The clue to the diagnosis lies in the presence of several punctate calcifications within the mass (F-G, red arrows) consistent with phleboliths, which are practically diagnostic of hemangioma. The central vascular space also supports the diagnosis.

The patient had been diagnosed of mediastinal hemangioma two years earlier and comparison with previous chest films and CTs did not show any change.
 
Final diagnosis: Mediastinal hemangioma
 
Congratulations to Naegleria and MK who gave similar diagnosis both at exactly 12:55 P.M.
 
Teaching point: This case is unusual (I have seen only two of them in the mediastinum) but can be easily diagnosed if phleboliths are present (and recognized). Early in my residency I learned that, when finding phleboliths within a mass, the diagnosis should be hemangioma until proven otherwise.
 
Ref. HP McAdams, ML Rosado de Christenson, CA Moran. Mediastinal hemangioma: radiographic and CT features in 14 patients. Radiology 1994; 193:399-402

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.

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

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 152 – All you need to know to interpret a chest radiograph – Sixth Session – SOLVED

Dear Friends,

Welcome to the new year and a new webinar. The leading images of the webinar six belong to a 73-year-old woman with dyspnea and chest pain. What do you see?

Diagnosis:

1. Intrathoracic goiter
2. Dilated esophagus
3. Aortic aneurysm
4. Any of the above

If you would like to see the previous webinars, check it here!

Click here to see the answer

You can see the webinar here.

Findings: PA radiograph shows widening of the right superior mediastinum (A, arrow), which in the lateral view is located behind the trachea (B, arrows). The initial impression is of an upper middle mediastinal mass. The first diagnosis that come to mind is a goiter.

However, looking downward in the PA view, bulging of the azygo-esophageal line is evident (A, red arrow). In the lateral view there is opacification of the retrocardiac space (B, red arrow). Therefore, we are dealing with a lesion that extends along the middle mediastinum from top to bottom. The findings point to a dilated esophagus.

Esophagogram was unremarkable. Coronal and sagittal CT shows a cystic tubular mass extending along the posterior wall of the esophagus (C-D, arrows).

Final diagnosis: cystic lymphangioma of mediastinum
 
This is a difficult case and I didn’t expect you to make the diagnosis. But I believe that you should have noticed the bulging of the azygo-esophageal line in the PA view and the occupation of the retrocardiac space in the lateral view, suggesting a dilated esophagus as the most likely diagnosis.
 
Congratulations to MG who was the first to see the findings.
 
Teaching point: Remember that an opacity that goes from top to bottom in the middle mediastinum should suggest a dilated esophagus or an esophagus-related process