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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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

Cáceres’ Corner Case 208 – SOLVED!

Dear Friends,

Presenting today radiographs of a 65-year-old man with back pain.

What do you see?

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Findings: PA chest radiograph shows an ill-defined opacity in the right middle lung field (A, asterisk), located in the anterior clear space in the lateral view (B, arrows). The anterior arch of the 4th right rib is missing.

A cone down view demonstrates an expanding lytic lesion in the anterior arch of the 4th right rib (C, asterisk), confirmed with CT (D and E, red arrows).

I thought this was an easy case, but I am disappointed because some of you missed a collapsed vertebra (F, circle), not present three years earlier (G, circle). Sagittal CT confirms it as well as additional affectation of L1 and posterior elements of D10 (H, red arrows).

In a patient with a port-a-cath, the presence of multiple lytic lesion suggests metastatic disease as the first possibility.
 
Final diagnosis: Carcinoma of esophagus with bone metastases

Congratulations to Andy, who was the first and to Archana Reddy.t who discovered the collapsed vertebra.

Teaching point: this case is similar to the previous one and the teaching point is the same: look at the underlying rib. And, above all, don’t forget to examine the rest of the bones!

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

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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

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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.

Emergency #9 – Long case

60-year-old female:
* Known with hypertension
* Acute pain on the chest
* X-ray
* Abnormal?
* Differential Diagnosis: No.

What should we think of and do next?

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Clinically suspect for aortic dissection

What protocol?
Non-enhanced chest CT, followed by CT angiography chest-abdomen

No NECT was made:

Imaging findings and key messages

* Soft tissue surrounding ascending aorta from the root, continuing around the aortic arch and descending aorta
* Between the soft-tissue band and the intraluminal contrast, we see intimal calcifications, these are NOT displaced outwards
* At some spots, there is contrast extravasation in the soft tissue
* No intimal tear or dissection flap is seen
* Slight pericardial effusion

What is the diagnosis?

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Aortic intramural hematoma.

Treatment is like an aortic dissection with anti-hypertensive medication. In this case, it is a type A since the mural hematoma is seen proximal to the left subclavian artery, involving the ascending aorta.

Differential Diagnosis

* Thrombosed false lumen in classic aortic dissection: Typically spirals longitudinally around the aorta, whereas an intramural haematoma usually maintains a constant circumferential relationship with the aortic wall

* Aortitis: Typically shows concentric uniform thickening of the aortic wall with or without peri-aortic inflammatory stranding, whereas an intramural haematoma is often eccentric in configuration

Treatment/Prognosis

* If an intramural haematoma involves the ascending aorta (Stanford A), treatment is surgical to prevent rupture and progression to a classic aortic dissection

* Conservative management is indicated for an intramural haematoma of the descending aorta (Stanford B)
* 77% of intramural haematomas regress at 3 years
* Survival of >90% at 5 years

* Untreated, an intramural haematoma can be life-threatening as it can lead to: aortic rupture, aortic dissection, aortic aneurysm.

Dr. Pepe’s Diploma Casebook: CASE 138 – MEET THE EXAMINER

Dear Friends,

in the aftermath of the European Congress of Radiology a have elected to show a new “Meet the Examiner” presentation, with questions and answers similar to a real examination. You will get the final answer at the end of the presentation.

Take your time before seeking the answer.

This case starts with a preoperative PA chest radiograph of a 52-year-old man. No other information was provided in the request. What do you see?

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Findings: PA radiograph shows an obvious convexity of the left paraspinal line (arrow). There is an abnormal opacity in the periphery of the right lung (circle), which may be related to the rib cage.

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After seeing the chest radiograph, we looked into the case further and discovered that the patient was scheduled for biopsy of a collapsed mid-thoracic vertebra, which would explain the bulging of the paraspinal line. Below is the MRI study. What would be your diagnosis?
1. Aggressive hemangioma
2. Metastases
3. Myeloma
4. Any of the above

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Findings: The eighth thoracic vertebra is flattened, impinging on the spinal canal. There is a central lesion in D7 and a smaller one in the anterior aspect of D5. (arrows). The findings were interpreted as an aggressive hemangioma at D8 and smaller hemangiomas at C7 and C5. A CT was requested to obtain more information.

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Axial, coronal and sagittal CT images are shown. What would be your diagnosis?

1. Aggressive hemangioma
2. Metastases
3. Myeloma
4. Any of the above

Click here to see the answer

Findings: axial CT (A) shows the typical “polka dot” appearance of vertebral hemangioma.
Coronal and sagittal views demonstrate the collapsed vertebra (B and C, white arrows) with a soft-tissue mass (B, red arrow) which explains the finding in the chest radiograph. A punched-out cortical lesion in D5 was overlooked (C, yellow arrow).

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In the meantime, we were concerned about the abnormal right peripheral opacity seen in the chest radiograph. Oblique views of the right hemithorax were taken. What do you see?

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Findings: the right oblique view shows what appears to be an old rib fracture accompanied by pleural thickening (A, white arrow). A serendipitous finding is the discovery of lytic lesions in the scapula (A, red arrows). The left oblique view also shows a lytic lesion in the right humerus (B, arrow).

The findings in the oblique chest radiographs prompted a review of the spinal CT. Numerous punched-out cortical lesions that had been overlooked were noted (arrows). This discovery suggested widespread malignant bone infiltration. Given that the patient was in good general condition, multiple myeloma was the first diagnostic choice. Vertebral biopsy provided the final diagnosis of myeloma.

Final diagnosis: multiple myeloma invading a vertebral hemangioma

Vertebral hemangioma is the most common vascular lesion of the spine and is present in about 10% of the population. The favored location is the mid-thoracic spine. In this particular patient we suspect that an unrelated multiple myeloma had invaded a previous vertebral hemangioma, causing collapse of the vertebral body. This responds to the concept of locus minoris resistentia, in this context referring to organs or regions that for some reason are more vulnerable than others. In this case, the wide vascular spaces and increased blood supply of the hemangioma may have facilitated implantation of malignant cells.

The typical appearance of coarse trabeculae (polka dot) of the original hemangioma, plus satisfaction of search were the reasons for the initial misdiagnosis of invasive hemangioma. The findings in the plain films of the chest were decisive to reconsider the diagnosis, leading to a review of the cross-sectional studies and the correct diagnosis.


Follow Dr. Pepe’s advice:

1. Remember Dr. Pepe’s words of wisdom (Diploma case 132): Don’t let one abnormal finding keep you from looking for another

2. Sometimes, plain films have an important role in the diagnosis.