Dr. Pepe’s Diploma Casebook: CASE 142 – Art of interpretation – SOLVED

Dear Friends,

today I am presenting another “Art of interpretation” case. I like them and think they have good teaching value.
Radiographs were taken for preoperative knee surgery in a 21-year-old man.

What is the most likely diagnosis?

Diagnosis:
1. Swyer-James-McLeod syndrome
2. Congenital hypoplasia of left lung
3. LUL collapse
4. None of the above

Click here to see the images

Click here to see the answer

Findings: PA radiograph shows a hyperlucent left lung with a small elevated hilum (A, white arrow). The trachea is deviated towards the left and the left main bronchus is curved upward (A, blue arrow). There is a small peak in the left hemidiaphragm (A, red arrow). And there is a triangular-shaped paraspinal opacity (A, circle), better seen in the cone down view (B, white arrow), with two linear metallic opacities inside (B, red arrows).

The lateral view (C) is unremarkable. Although the PA findings suggest loss of volume of the LUL, there are some negative findings: no anterior displacement of the left major fissure and no opacity indicative of LUL collapse.

Analysis of the findings

There are four obvious findings:

1. Hyperlucent left lung with small left hilum
2. Tracheal deviation to the left
3. Upward curving of left main bronchus
4. Juxtaphrenic peak (*)

All these findings are indicative of LUL volume loss with compensatory overinflation of the LLL.

There are two less obvious findings, which are diagnostic:

Paramediastinal opacity with surgical staples
No signs of LUL collapse in the lateral view

The first indicates previous surgery and the second excludes LUL collapse. Taken together, these findings lead to the obvious conclusion that the patient had undergone a previous lobectomy.

(*) The juxtaphrenic peak sign was described by my late friend Kenneth Kattan as an indirect sign of LUL collapse. Semin Roentgenol 1980; 15:187-193

LOSS OF VOLUME OF LUL + SURGICAL STAPLES = LUL LOBECTOMY

In the past, the patient had embryonal carcinoma of the testicle with a metastatic nodule in the LUL (A and B, arrows). He had undergone LUL lobectomy by video-assisted thoracic surgery one year before.

Final diagnosis: LUL lobectomy for metastasis of embryonal testicular carcinoma

I’m showing this case to emphasize the importance of identifying metal sutures in the chest radiograph. Nowadays, most surgical procedures are done by video thoracoscopy which doesn’t leave any telltale signs other than surgical staples. These are difficult to see because of their small size and because high kV “burns” metal density.

Staples are visible as a faint longitudinal ring chain somewhat denser than the surrounding tissues. It’s very important to be familiar with their radiographic appearance because they offer valuable information about previous surgery.
When staples are detected, our interpretation of associated findings may change, as occurred with the case presented.

To familiarize you with the radiological appearance of surgical staples, I’m showing three more cases.

CASE 1:

88-year-o.ld man with dementia and moderate dyspnea. Chest radiographs show a nodule in the RUL (A and B, arrows). PA view shows post-surgical changes at the left 6th and 7th ribs and a hyperlucent left lung with a small hilum. There are surgical clips in the mediastinum (A and B, red circles). These findings suggest a previous LUL lobectomy and a second primary tumor. The patient’s records disclosed a LUL lobectomy for carcinoma twenty years earlier. The second primary tumor was confirmed by needle biopsy.
The radiographic findings are typical of “old” chest surgery.

CASE 2:

PA radiograph of a 23-year-old woman with a nondescript LUL infiltrate (A, arrow). Close-up view reveals a longitudinal ring chain of staples within the infiltrate (B, arrows), pointing to a man-made opacity secondary to video thoracic surgery.

Diagnosis: changes after endoscopic LUL bullectomy for recurrent pneumothorax.

CASE 3:
I saw this case three weeks ago and it is still unproven. A 44-year-old woman from another country came for a routine cardiac checkup. The PA chest radiograph shows a serpiginous opacity in the LLL (A, arrow) with a ring chain of staples in the periphery, better seen in the cone down view (B, arrows). On questioning, the patient mentioned previous endoscopic surgery for a nodule in the left lung two years ago. Enhanced CT shows a solid lesion with staples in the periphery (C, arrow).

As the patient could not provide previous medical records, we were unable to ensure that the changes were attributable to scar tissue. A follow-up CT has been scheduled.

Final words: Staples are difficult to reproduce on the computer screen, and I have done my best. I assure you that they are easily visible on a 14 by 17 reading console, provided that you see and recognize them 🙂


Follow Dr. Pepe’s teaching points:

1. Surgical staples are visible as a faint longitudinal ring chain.

2. They indicate previous surgery and help to interpret the chest findings under a new light.

Cáceres’ Corner Case 205

Dear Friends,

Today I am showing preoperative radiographs for hand surgery in a 53-year-old man.

What do you see?

More images will be shown on Wednesday.

Click here to see the images

Dear Friends,

showing today chest radiographs taken one year earlier.

Do they help?

Click here to see the new images

Click here to see the solution

Findings: PA chest radiograph shows an ill-defined opacity in the left middle lung field (A, arrows). It is located in the anterior clear space in the lateral view and has a stippled appearance (B, arrows). In addition, there is a flat irregularity in the dome of the left hemidiaphragm in the PA view which appears to be calcified (A, red arrow).

Previous radiographs one year earlier show the same findings, unchanged (C-D, arrows).

The clue to the diagnosis lies in the irregularity of the dome of the left hemidiaphragm, that looks like a calcified plaque. This finding suggests that the apparent pulmonary opacity in the PA view may be a pleural plaque see “on face”. It is not seen as a line in the lateral view because the curvature of the anterior thoracic wall does not offer a straight interface to the X-ray beam.

CT confirms calcified anterior pleural plaques in both hemithoraces (E-F, arrows).

Coronal and sagittal CT confirm the calcified plaque in the diaphragmatic dome (G-H, red arrows).

The patient was found to have a history of asbestos exposure.
 
Final diagnosis: Asbestos-related pleural disease simulating pulmonary infiltrate.

Congratulations to S, who was the first to make the diagnosis. Silver medal to VL.
 
Teaching point: remember the deceitful appearance of pleural plaques shown in Diploma case 140. Some of you were fooled by it!

Dr. Pepe’s Diploma Casebook: CASE 141 – SOLVED

Dear Friends,

Today I am showing radiographs of a 47-year-old woman with chronic cough.
What do you see?

Leave your comments here and come back on Friday to see the answer.

Click here to see the images

Click here to see the answer

Findings: PA radiograph shows marked downward displacement of the right hilum (A, white arrow) and verticalization of the intermediate bronchus (A, red arrow). These findings are indicative of marked volume loss of RLL. The lateral view (B) is unremarkable.

Enhanced coronal CT confirms the descended right hilum (C, white arrow), as well as the vertical intermediate bronchus (C, red arrow). A different slice shows a small calcified triangular shadow (D, arrow), which represents a markedly collapsed RLL.

Final diagnosis: severe RLL collapse due to previous TB

In the previous webinar (Diploma case 139), I described the common signs that suggest lobar collapse. In this presentation I want to review atypical forms of lobar collapse and how to recognize them.
The main signs of lobar collapse are volume loss and increased opacity of the lobe. Atypical presentations lack these traits, and the lobe appears to have an increased volume (drowned lobe) or to have collapsed without increased opacity (aerated collapse). A third variant would be a lobe that has lost most of its volume (extreme collapse) and therefore is difficult to identify as such, as occurred in the initial case.

In extreme collapse, the affected lobe is severely decreased in size and may be overlooked, or confused with a different process (Fig. 1). The diagnosis is suggested by secondary findings, such as hilar displacement and/or increased lucency of the unaffected lobe(s) (Figs. 2 and 3).

Fig. 1. 57-year-old man with carcinoma of the RUL bronchus causing severe RUL collapse. The medial displacement of the collapsed lobe simulates mediastinal widening (A, white arrow). The clue to the diagnosis is a small and slightly elevated right hilum (A, red arrow). The lateral view (B) is unremarkable.

Enhanced axial CT image depicts a horizontal sliver of tissue, corresponding to the markedly collapsed RUL, sharply outlined by the minor fissure (C and D, white arrows). Note the obstructed RUL bronchus (D, red arrow). Bronchogenic carcinoma.

Fig. 2. Pre-op film for cataracts in a 72-year-old man. PA chest film shows a lucent left lung. Severe LLL collapse is suspected because of the downward left hilar displacement (A, white arrow) and a triangular-shaped paramediastinal opacity (red arrow). The posterior left hemidiaphragm is blurred in the lateral view (B, arrow).

Enhanced axial CT shows the markedly collapsed lobe (C, arrow). Coronal CT depicts a mass obstructing the LLL bronchus (D, arrow). Final diagnosis: carcinoma.

Fig. 3. 67-year-old woman with extreme LUL collapse secondary to previous TB. The diagnosis is suspected because the collapsed lobe causes haziness of the left mediastinal border in the PA film (A, arrows). The expanded LLL causes increased lucency of the left hemithorax. Lateral view shows marked anterior displacement of the left major fissure (B, arrows).

Coronal and sagittal CT confirm the extreme LUL collapse with bronchiectasis. The major fissure is well depicted in the coronal and sagittal reconstructions (C and D, arrows).

The finding known as drowned lobe is a variant of lobar collapse in which the lobe does not decrease in size but instead, enlarges. It occurs when a slow-growing proximal tumor permits accumulation of distal secretions and infection, causing an increase in size of the lobe (Fig. 4). Bulky tumor masses may contribute to this enlargement (Fig. 5).

Fig. 4. 55-year-old woman with widespread lung disease and a large opacity occupying the upper two thirds of the right lung in the PA radiograph (A, white arrows). The right hilum (A, red arrow) is in a normal position. The lateral view shows that the opacity corresponds to an enlarged RUL (B, arrows).

Enhanced axial and coronal CT shows the enlarged RUL lobe (C and D, white arrows), secondary to central obstruction of the RUL bronchus (C and D, red arrows). Diagnosis: drowned RUL secondary to central carcinoma

Fig. 5. 47-year-old woman with drowned LLL, which appears in the PA radiograph as a uniform mass occupying the lower two thirds of the left lung (A, arrow), recognizable in the lateral view as a swollen LLL (B, arrows).

Enhanced axial CT confirms the swollen LLL (C, white arrow). PET-CT shows that part of the bulk is due to a large tumor mass (D, white arrow), invading the pulmonary veins and left atrium (C and D, red arrows).

In aerated collapse the lobe loses volume, but does not increase in opacity, making the collapse less obvious. This happens because increased opacity is not related with volume loss, but rather with the amount of secretions within the lobe. If the partially collapsed lobe contains air, the lobe will appear to have normal lucency.
In aerated collapse, the diagnosis is suspected by displacement of the hilum, the fissure, or both (Figs. 6-8).

Fig. 6. Aerated RLL collapse in carcinoma. PA chest film depicts a right hilar mass (A and B, red arrows), with a descended hilum. The lowered major fissure is barely visible (A, white arrow). In the lateral view, the collapsed lobe is seen as a faint opacity projected over the spine (B, white arrow). Bronchoscopy confirmed an endobronchial carcinoma.

Fig. 7. Aerated RLL collapse secondary to bronchiectasis. PA radiograph shows a markedly displaced major fissure simulating an inferior accessory fissure (A, white arrow). There is marked downward displacement of the right hilum (A, red arrow). Coronal CT confirms the findings (B, red and white arrow), with bronchiectasis and an open RLL bronchus

Fig. 8. 75-year-old man who had TB in his youth. Chest radiographs show aerated collapse of the LUL, demonstrated in the PA view by the small elevated left hilum (A, arrow) and by the anterior displacement of the major fissure in the lateral view (B, arrows). Note that the LUL is well aerated.


Follow Dr. Pepe’s advice:

1. Common manifestations of lobar collapse are loss of volume and increased opacity.

2. Uncommon manifestations of lobar collapse are extreme collapse, drowned lobe, and aerated collapse.

3. These uncommon manifestations are suspected based on secondary signs: hilar and/or fissure displacement and increased lucency of the unaffected lobe(s).

Cáceres’ Corner Case 203 – SOLVED!

Dear Friends,

Today I am showing radiographs of a 40-year-old man with chest pain.
What do you see?

More images will be shown on Wednesday.

Click here to see the images

Dear Friends,

showing today enhanced CT images of the case.

Do they help?

Click here to see the images

Click here to see the answer

Findings: PA radiograph shows a mediastinal mass (A, arrow) superimposed to the right hilum. In the lateral view the mass is faintly visible behind the distal trachea (B, circle). This location excludes a right hilar mass, because the right hilum is anterior to the trachea.

Enhanced coronal and sagittal CT confirm a posterior mediastinal mass (C-D, arrows) with necrotic areas and marked contrast enhancement. This is an important finding because it limits the differential diagnosis to four conditions: intrathoracic goiter, Castleman’s disease, paraganglioma and hemangioma.
Some of you have mentioned extramedullary hematopoiesis. In my (limited) experience I don’t recall seeing avid contrast enhancement in it. I have asked some friends and searched the web without finding a clear answer. If any of you have better information I am willing to be corrected. At any rate, this patient does not have any bone abnormalities, which makes the diagnosis of extrapulmonary hematopoiesis very unlikely.
 
Final diagnosis: posterior mediastinal paraganglioma surgically proved. A similar case was presented in case 168 of Caceres’ corner.
 
Congratulations to MK, who was the first to suggest the correct diagnosis.
 
Teaching point: remember the four mediastinal processes with avid contrast enhancement: intrathoracic goiter (frequent), Castleman´s disease and paraganglioma (uncommon) and hemangioma (never saw a case).

Cáceres’ Corner Case 202 – SOLVED!

Dear Friends,

Dr. Pepe is busy preparing next week’s webinar (click here to register!) and asked me to present a case this week. The case is provided by my friend Jordi Andreu.

Radiograph belong to  a 83-year-old woman with dementia. A mass was detected in the right lung and a CT was done.

What do you think?

Click here to see the images

Click here to see the answer

Findings: AP chest radiograph shows a well-defined opacity in the right upper hemithorax (A, arrow) which appears to be extrapulmonary. There are calcified granulomas in the left apex with retraction of the left hilum.

Unenhanced axial and coronal CT show an extrapulmonary mass with a calcified rim (B-C, arrows). The mass has a striated appearance, alternating lineal areas of different opacities. This CT appearance is practically pathognomonic of oleothorax (see case 19 of Caceres’ corner).

Instillation of oil in the extrapleural space (oleothorax, plombage) was used to collapse the lungs facilitating healing of TB cavities. It was abandoned in the early fifties after the discovery of effective antimicrobial therapy.
The patient had pulmonary TB in her youth and told us that it was treated by instillation of a substance. A clinical photograph in another patient (D) documents the surgical scar.

Final diagnosis: Oleothorax
 
Congratulations to Diogo, who was the first to make the diagnosis and to Jake, who concurred two days later.
 
Teaching point: this is an uncommon pathology, but it should be known because the appearance is pathognomonic and shouldn´t be confused with other conditions. This patient was seen four weeks ago and diagnosed initially of pleural tumour.

Cáceres’ Corner Case 200 – SOLVED!

Dear Friends,

the first case of Caceres’ corner was published in September 23, 2011. Today, seven years later, we are proud to present case 200. It was not always easy, but it was always fun and worth it. Thank you for your continuous support.

Today’s case was diagnosed by my friend and co-worker Carles Vilá. The PA radiograph was taken as a pre-op exam for renal stones.
Do you see any abnormality?

More images will be shown on Wednesday

Click here to see the images

Dear Friends,

we saw a peripheral opacity in the lower left hemithorax and performed a CT, which showed unexpected findings.
What do you see?

Click here to see the new images

Click here to see the answer

Findings: PA radiograph shows a faint opacity in the periphery of the left lower hemithorax (A, circle). A CT was recommended.

Axial CT shows an unexpected irregular basal opacity (B, arrow). Caudal slices show several parietal nodules (C-D, arrows).

Coronal CT shows the large basal opacity (D, arrow), as well as the small parietal nodules (D-E, red arrows).

The clue to the diagnosis lies in a negative finding: absent spleen in the left upper quadrant of the abdomen (D-E, asterisks), suggesting that the chest opacities may represent accessory spleens.
The patient was interrogated and stated a previous car accident with ruptured spleen and subsequent splenectomy. A test with labelled erythrocytes in another institution confirmed the accessory spleens.
 
Final diagnosis: thoracic splenosis
 
As I am writing this (12:00 PM Thursday), nobody has suggested the right diagnosis. I was expecting many correct answers, since I showed a similar case eight weeks ago (Diploma case 135).
 
Teaching point: remember the importance of negative findings (Diploma cases 135 and 136). In this particular patient, they were crucial to suggest the correct diagnosis.

Congratulations to MK, who made a last-minute diagnosis at 2:08 P.M. on Thursday!

EDiR Question of the Day 2019: #3

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 that will take place at the ECR 2020.

Which of the following imaging findings may be present in tuberculous meningitis?

Please, click here to enter your answer and solve the question before 13:30!

Winner will be announced here, on the EBR blog, at 14:30.

Good luck!