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.