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

Cáceres’ Corner Case 216 – SOLVED!

Dear Friends,

Today I am showing another case provided by my friend Dr. López Moreno. Radiographs belong to a 25-year-old woman with fainting spells. 

What do you see?

More images will be shown on Wednesday.

Dear Friends,

Showing coronal and sagittal images of enhanced CT.
What do you see?

Click here to see more images

Click here to see the answer

Findings: PA radiograph shows convexity of the aorto-pulmonary window (A, arrow) which is encroaching upon the left hilum. Aside from a discrete pectus excavatum, I don’t see any significant findings in the lateral view (B).

According to Diploma 144, the main causes of a prominent A-P window are either enlarged lymph nodes or an arterial aneurysm and a CT should be obtained. In this particular patient coronal enhanced CT shows an aortic aneurysm projecting over the A-P window (C, arrow) and located anterior to the aortic arch in the sagittal projection (D, arrow).

The appearance is compatible with traumatic pseudoaneurysm, but the patient did not have any antecedent of traumatism. In our opinion (Dr López Moreno and mine) we believe that it represents a ductus aneurysm because of the location and the thin band joining the aneurysm and the pulmonary artery (E, circle). The pinpoint calcification in the middle of the band may be calcium in the ductus ligament or be secondary to partial-volume effect.

An unexpected finding is the compression of the left main bronchus by the aneurysm (E-F, arrows). It would have been interesting to perform expiration films to detect air-trapping of the left lung.

Some of you have mentioned Kommerel diverticulum. This malformation is located posteriorly and occurs in aberrant subclavian artery, which courses behind the trachea and pushes it forward in the lateral chest radiograph. You can see examples in case 213 of Caceres’ corner and Diploma cases 2, 9 and 84.
 
Final diagnosis: Probable aneurysm of the ductus arteriosus
 
Congratulations to S who was the first to think of the ductus in the plain film and made the diagnosis of ductus diverticulum after CT.
 
Teaching point: this is my first ductus aneurysm (if we are right) and I cannot have much to say. Perhaps to stress again the importance of looking at the aorto-pulmonary window in the PA radiograph.

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

Dear Friends,

Today I am presenting the leading case of the second webinar. The PA radiograph belongs to a 62-year-old man with hemoptysis.

Is the radiograph abnormal?
If so, what do you see?

Starting this week, I have decided to stop giving live webinars. They will be recorded and published at the end of the week, together with the answer to the case. You can see the first session here

Click here to see the answer

Findings: PA chest radiograph shows convexity of the aorto-pulmonary window (A, arrow) and an opacity in the upper left hilum (A, red arrow). The findings were not present in a film taken three years earlier (B, circle) and suggest a pulmonary process with mediastinal adenopathy.

Findings were overlooked and the chest was read as normal. Six months later the patient returned with acute right chest pain. PA chest shows two triangular pleural-based opacities (C, arrows) suggestive of Hampton’s humps. The convexity at the APW is larger (C, green arrow) and the hilar opacity has increased in size (C, red arrow).

Coronal CT shows the typical appearance of pulmonary infarcts at the right lung base (D, arrows). There is large adenopathy at the APW (D, green arrow) accompanied by a lung mass (D, red arrow).

Final diagnosis: carcinoma of the lung with mediastinal metastases and associated pulmonary infarcts.
 
Congratulations to S, who made a brilliant diagnosis.
 
Teaching point: Remember the importance of checklists. If a checklist had been used in the initial radiography, a CT would had been taken and the tumor would had been discovered earlier

If you would like to learn more about this subject, check the webinar Prof. Cáceres recorded explaining this cases and others! You can also check the first webinar here.

Cáceres’ Corner Case 212 – SOLVED

Dear Friends,

Today’s radiographs belong to a 53-year-old man with dysphagia. 

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

Click here to see the solution

Findings: PA radiograph (A) is unremarkable. The lateral view shows a slight anterior bowing of the trachea (B, arrow) with an apparently dilated upper esophagus with an air/solid interface (B, red arrow).

These findings are well seen in the cone down view, which better shows a thickened retrotracheal stripe (C, red arrows), a sign that suggests esophageal pathology, among others.
For all of you who diagnosed achalasia there is a negative finding: the lack of occupation of the retrocardiac space (D, circle) which practically rules out dilatation of the lower esophagus.

Sorry to say that I do not have additional images. After receiving the possible diagnosis of esophageal tumor, the patient went to another hospital, where esophagoscopy and biopsy confirmed upper esophageal dilatation by a carcinoma of the middle third.
 
Final diagnosis: Carcinoma of the middle third of the esophagus with proximal dilatation and food retention.
 
Congratulations to Dr Ahmad who was the first to describe the findings.
 
Teaching point: this case emphasizes the value of clinical information in selected cases. I suspect that some of you would not have discovered the dilated esophagus in the lateral view if I had withheld the history of dysphagia :).

Cáceres’ Corner Case 204 – SOLVED

Dear Friends,

Today’s radiographs belong to a 54-year-old man with chest pain.

More images will be shown on Wednesday.

What do you see?

Click here to see the images

Dear Friends,

Showing new images of the thoracic cage. 

What do you think?

Click here to see the new images


Click here to see the answer

Findings: PA radiograph shows an extrapulmonary lesion in the left hemithorax (A, arrow). The 3rd left rib is broadened (A, red arrows) and the distal segment is not visible.
There is a lineal infiltrate in the adjacent lung and at the left lung base. In addition, an expansive lytic lesion is visible in the anterior 7th right rib (A, yellow arrow).
The lateral view (B) does not show any significant findings.

AP and oblique views of the thoracic cage show an expansive lesion of the 3rd left rib (C-E, arrows) and confirm the expansive lytic lesion of the right 7th rib (C-E, red arrows). There is also a pure lytic lesion of the 8th left rib (C-E, red circle). There is minimal loss of height of D-11 (C and E, blue circle).

Discovering expanding lesion of the ribs should suggest either multiple myeloma or metastases (renal cell carcinoma, thyroid carcinoma). In this patient a multiple myeloma was found.
 
Final diagnosis: multiple myeloma, IgA type.
 
Congratulations to VL who found the bone lesions in the initial radiographs (many of you ignored satisfaction of search) and to archana reddy.t, who made the final diagnosis.
 
Teaching point: remember to look at the underlying rib in any extrapulmonary lesion. Discovering rib involvement focus your diagnostic approach and limits the differential diagnosis.