Dr. Pepe’s Diploma Casebook: CASE 144 – SOLVED

Dear Friends,
presenting chest radiograph of a 77-year-old man with malaise and weight loss.
What do you see?

This is the last case before the summer. Will see you again in September. Enjoy your vacation!

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Click here to see the solution

Findings: PA radiograph shows increased opacity of the left hilum (A, arrow), which is due to a mass projected over it, as seen in the lateral view (B, arrows). In addition, there is convexity of the aortopulmonary window (A, red arrow)

The increased hilar opacity (C, arrow) was not visible in a PA radiograph taken six months earlier (D, circle). Convexity of the aortopulmonary window (C, red arrow) was not present at that time.

In the lateral view, the mass (E, arrows) was visible six month earlier, albeit smaller (F, arrow). This progression indicates rapid growth.

Enhanced axial and coronal CT confirms a pulmonary mass invading the aortopulmonary window (G and H, arrows). Lung metastases were present (insert, red arrows)

Diagnosis: lung carcinoma invading the aortopulmonary window

I am presenting this case to discuss the aortopulmonary window (APW), which is a small mediastinal space located between the aortic knob and the pulmonary artery in the PA view (Fig 1A). The APW is normally concave; convexity (Fig 1B) suggests an abnormality that should be studied with enhanced CT.

Fig. 1.

Visibility of the APW is difficult in the elderly, because the superimposed uncoiled descending aorta makes the interpretation more difficult (Fig 2).

Fig 2. 67-year-old man with moderate dyspnea. A calcified lymph node (A-D, red arrows) marks the APW, which is hidden in the PA view by the elongated descending aorta.

Convexity of the APW may be overlooked unless we look specifically at the area (fig 3). The larger the abnormality, the more readily it is detected in the chest radiograph. Subtle changes are more difficult to identify and comparing with previous films is very helpful.

Fig. 3. 55-year-old man consulting for acute chest pain. PA film shows two Hampton humps in the right lower lung (A, white arrows). The left hilum is abnormal (A, red arrow). Enhanced coronal CT confirms the infarcts (B, white arrows), as well as a pulmonary mass (B, red arrow) and lymphadenopathy in the APW (B, yellow arrow). Findings were overlooked in a radiograph taken seven months earlier (C, yellow and red arrows). Proven bronchogenic carcinoma.

Causes that may alter the APW are: tumors, enlarged lymph nodes, aortic aneurysms and increased mediastinal fat. The phrenic nerve crosses this space and a phrenic neurinoma may also grow in the APW, although I have never seen a case.

Enlarged lymph nodes are by far the most common cause of occupation of the APW. They may occur in malignant and non-malignant diseases. They usually coexist with radiographic manifestations of the primary process (Figs 4 and 5).

Fig 4. 59-year-old man with apical LUL carcinoma (A and B, arrows). There is a marked bulge of the APW (A and B, red arrows). Moderate pneumothorax after needle biopsy.

Coronal and axial CT confirm metastatic lymph nodes in the APW (C and D, red arrows)

Fig 5. 33-year-old woman with low-grade fever and malaise. Chest radiographs shows a non-descript infiltrate in the anterior segment of the RUL (A and B, arrows). In addition, there is a prominent bulge in the APW, highly suspicious of lymphadenopathy (A, red arrow). Diagnosis: Hodgkin lymphoma.

In isolated occupation of the APW the etiology cannot be determined in the chest radiograph and enhanced CT should be obtained (fig 6).

Fig 6. Routine check-up in a 60-year-old woman. PA radiograph shows moderate convexity of the APW (A, arrow). Enhanced CT confirms enlarged lymph nodes in the APW (B and C, arrows), mediastinum and hila. Diagnosis: sarcoidosis

Aortic aneurysm is an uncommon cause of convexity of the APW (Fig 7). The abnormality is initially subtle and it becomes more evident as the aneurysm grows (Fig 8).

Fig 7. 78-year-old man without significant symptoms. PA radiograph shows a mediastinal mass protruding at the level of the APW (A and C arrows). The mass is also evident in the lateral view (B and D, arrows).

Radiographs taken five years earlier did not show the abnormality (E and F, circles).

Enhanced axial and coronal CT demonstrate that the mass represents a saccular aneurysm arising from the aortic arch (G and H, arrows).

Fig 8. 78-year-old man after a fall. PA radiograph shows numerous rib fractures (A, white arrows). An additional finding is a mediastinal opacity at the APW (A, red arrow), also visible in the lateral view (B, red arrow).

Comparison with previous films shows a normal APW in 2007 and progression of the opacity over a three-year period (arrows).

Enhanced CT shows that the opacity represents a partially thrombosed aneurysm arising from the inferior aspect of the aortic arch (C-D and E, arrows).

Last but not least, we should remember that mediastinal fat is an innocuous cause of convexity of the APW (Fig 9).

Fig 9. Asymptomatic 57-year-old man with superior mediastinal widening (A, arrow) and discrete convexity of the APW (A, red arrow). Coronal CT shows that the changes are due to mediastinal fat (B and C, arrows).


Follow Dr. Pepe’s advice:

1. Convexity of the APW suggests underlying pathology.

2. Enlarged lymph nodes are the most common cause of a convex APW.

3. Aneurysm and mediastinal fat may also enlarge the APW

Abdominal #2 – Long case

We present the case of a 31-year-old woman with:
* Nausea and vomiting since three days
* Unable to eat or drink without vomiting
* Epigastric pain after eating
* Feels weak

* No prior trauma or illness
* No fever, no diarreha, no hematemesis or bloody stools
* No other family members ill

See below the laboratory findings:

What do you think?

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Signs of dehydration with secondary acute renal impairment and electrolyte disorders

Abdominals X-Ray were performed:

What do you see on the X-Rays?

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Apparent elevation of the right hemidiaphragm with obscuration of the right cardiac border

Air – fluid level at the right upper quadrant: free air?
Absense of gastric air and fluid-air level
Colonic air at the right upper quadrant (Chilaiditi)

Apparent soft tissue mass at the right upper quadrant

Elongated right liver lobe (Riedel lobe)
Instability of the symphysis pubis

Summary

* Apparent elevation of the right hemidiaphragm with obscuration of the right cardiac border
* Air – fluid level at the right upper quadrant: free air?
* Colonic air at the right upper quadrant (Chilaiditi)
* Apparent soft tissue mass at the right upper quadrant

* No apparent dilated bowel loops
* Elongated right liver lobe (Riedel lobe)
* Instability of the symphysis pubis

Differential diagnosis of a large amount of air in the RUQ

* Pneumoperitoneum
* Subphrenic abscess
* Hepatic abscess
* Anterior interposition of colon to the liver

* Loculated pneumothorax (mimick)
* Situs inversus – gastric air (mimick)
* Pneumobilia, portal venous gas (smaller amount)

Images from an abdominal CT-scan:

What do you see on the CT images?

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Anterior defect in the right hemidiaphragm

Partial herniation of stomach (blue arrow) and transverse colon (green arrow)

Gastric outlet obstruction due to compression of the pyloric region (red arrow),with secundary dilatation with fluid (blue arrows)

Normal position of the gastro-esophageal junction and hiatus

Collapse of the right middle lobe (green arrow) and partial collapse of the right lower lobe (blue arrow).

Summary

* Anterior defect in the right hemidiaphragm
* Partial herniation of stomach and transverse colon
* Gastric outlet obstruction due to compression of the pyloric region of the stomach, with secundary dilatation with fluid
* Normal position of the gastro-esophageal junction and hiatus
* No signs of ischemia
* Collapse of the right middle lobe and partial collapse of the right lower lobe.

What is the most likely diagnosis?

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Morgagni hernia of the diaphragm

Patient had a laparoscopic reduction of the hernia with mesh closure of the defect. No signs of ischemia at surgery.
Uneventful recovery with resolution of pain and normal intake the day after.

Morgagni hernia

* Rare congenital diaphragmatic hernia (<5% of all CDH)
* Anterior (retrosternal)
* Right-sided (90%)
* Usually small
* +/- 30% symptomatic: respiratory distress (newborn), recurrent chest infections, abdominal symptoms
* Contents: omental fat, transverse colon (60%), stomach (12%)

* Treatment: surgical repair
> In symptomatic cases, some say also in asymptomatic cases: prevention of strangulation of hernia contents
*Prognosis: good

* Differential diagnosis:
> Traumatic diaphragmatic rupture
> Diaphragmatic eventration / weakness / paralysis (abnormal contour / position of the dome)
> Cardiophrenic angle lesions ( pericardial fat pad, cyst, lipomatosis, tumor)

Cáceres’ Corner Case 207 – SOLVED!

Dear Friends, 

Today I am presenting a case given to me by my good friend José Luis López Moreno. The PA radiograph belongs to a 77-year-old woman with pain in the right hemithorax.
What do you see?

More images will be shown on Wednesday.

Dear Friends,

showing today axial and coronal CT.
What do you think?

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Findings: PA radiographs shows an ovoid opacity in the right lung (A, arrow), that parallels the path of the anterior ribs. Careful observation demonstrates that the third and fifth anterior ribs are visible (B, red arrows), whereas the anterior fourth rib is absent (B, asterisks). An additional finding is moderated flattening of D11 and D12 (A, circle). The findings suggest multicentric bone lesions.

Enhanced axial and coronal CT confirm a lytic expanding lesion of the anterior fourth rib (C and D, arrows), better seen in the 3-D reconstructions (E and F, arrows).

In an adult, lytic expanding rib lesions are usually either metastases (thyroid, renal cell carcinoma) or multiple myeloma. Further studies confirmed a myeloma.
 
Final diagnosis: multiple myeloma affecting the right fourth rib and several thoracic and lumbar vertebrae.
 
Congratulations to Wafaa who suggested the diagnosis in the plain film and to VL who discovered the collapsed vertebrae.
 
Teaching point: remember to look at the underlying rib when facing a pleural/chest wall lesion. An affected rib will narrow down your diagnostic options. And don’t forget satisfaction of search (collapsed vertebrae in this case).

Dr. Pepe’s Diploma Casebook: CASE 143 – The wisdom of Dr. Pepe – SOLVED

Dear Friends,

This case belong to the section “The wisdom of Dr. Pepe”, in which an (useful?) aphorism ends the presentation.

I am presenting a routine PA radiograph in an asymptomatic 79-year-old woman operated on for a breast DCIS five years ago. PA radiograph taken five years earlier is shown for comparison. More images will be shown on Wednesday.

Diagnosis:

1. Granulomas
2. Metastases
3. Primary lung tumor(s)
4. Any of the above

Click here to see the images

Dear Friends,

showing CT images with and without contrast enhancement.

What would your diagnosis be?

1. Carcinoma
2. Active TB
3. Fibrous lung tumor
4. Any of the above

Click here to see the CT


Click here to see the answer

Findings: The PA chest radiograph shows two obvious small nodules in the left middle lung field (A, circle), not present five years earlier (B). In my experience, two nodules close together are usually granulomas. But in this case we have another finding: a subtle bulge in the left hilum (A, arrow), not visible in the previous film, highly suspicious of hilar adenopathy. This changes the diagnostic orientation and makes us think of an active process.

Unenhanced axial CT shows an hourglass-shaped pulmonary lesion (C and D, arrows) that simulated two nodules in the chest radiograph. The lesion enhances after contrast injection and contains a large arterial vessel (E, arrow). Non-enhancing lymph nodes are visible in the left hilum (F, arrow).
Although all three diagnoses offered in the blog can cause hilar adenopathy, the vascularity of the lesion points to a tumor.

PET-CT shows faint uptake of the primary lesion and the hilar lymph nodes (G and H, arrows). A needle biopsy (I, arrow) came back as an atypical small-cell tumor.

The patient was treated with chemotherapy and radiotherapy, with a good response of the primary tumor (J, arrow) and lymph nodes (K, circle).

Final diagnosis: SCLC with hilar metastasis and a good response to QT and RT

Discussion: I just finished reading “The subtle art of not giving a f*ck“ and there is an enlightening (and sadly true) chapter entitled “You are not special”. In this particular case I was feeling special, as I diagnosed a malignant pulmonary fibroma based on a single case seen 20 years ago (see below) because of the similarity of the vascular pattern in the two cases. After 50 years of practice, I forgot a basic principle: common conditions are, well, common. I’m showing this case to remind you that when faced with a diagnostic dilemma you should first consider common options rather than uncommon ones.

To redeem myself, I am showing my only case of fibrous tumor of lung in a 37-year-old woman with hemoptysis. The PA radiograph shows a well-defined paramediastinal nodule (A, arrow). Enhanced coronal and sagittal CT confirms the intrapulmonary location of the nodule, which has a large arterial vessel in the center with an aneurysm at the end (B and C, arrows).

Surgery confirmed a fibrous tumor of the lung.

Two bits of information about fibrous tumor of the lung: It is a very unusual spindle-cell tumor with the same histology as fibrous tumors of pleura, and like them, it has malignant potential. It is usually asymptomatic and is seen as a rounded or ovoid nodule of varying size. Immunohistochemistry is important for the diagnosis.


Follow Dr. Pepe’s pearls of wisdom:

Always consider that what you are seeing is a rare manifestation of a common disease rather than a common manifestation of a rare disease.

Cáceres’ Corner Case 206 – SOLVED

Dear Friends,

Now that Game of Thrones is ending, a new series is planned: Game of Thorax, in which either you diagnose or you die.

As you can see in today’s radiograph, the Iron Throne has been replaced by the Chest Throne.

What would your diagnosis be?

Come back on Friday to see the answer.

Click here to see the answer

Findings: PA chest radiograph show numerous metallic wires spread fan-like throughout the upper two thirds of both lungs.
This appearance is typical of endobronchial coils for lung volume reduction in patients with emphysema. They are used when other therapeutic alternatives are not feasible or as a bridge to lung transplantation.
 
I am showing this case because I have never seen one and wanted to share it with you. And to complain about the last season of Game of Thrones, of course!
 
Congratulations to all of you who made the diagnosis, led by MK, who was the first.

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

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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).