today I am showing preop radiographs for knee surgery of a 71-year-old man.
What do you see?
More images will be shown on Wednesday.
Click here to see new images
Dear friends, showing additional images of the sternum taken six years earlier, in 2014.
What do you think?
Click here to see the answer
Findings: PA chest is unremarkable (A). The lateral radiograph shows an expanding lytic lesion in the sternal manubrium (B, circle).
Cone down view shows the lesion better (C, arrows). Sagittal, coronal and axial unenhanced CT taken six years earlier (2014) demonstrate that the cortical bone is broken in several places, suggesting an aggressive process (D-F, arrows). A soft-tissue mass is not visible.
No other skeletal lesions were found. Biopsy of the sternum confirmed the diagnosis of solitary myeloma (plasmocytoma), that was subsequently treated. The patient remained asymptomatic.
Final diagnosis: Plasmocytoma of the sternum
Congratulations to Priyanka Chhabra and Olena, who made the correct diagnosis. And kudos to all of you who saw the lesion in the lateral chest radiograph.
Teaching point: Remember that a lytic lesion of the sternum in an adult is malignant until proven otherwise. Main etiologies are primary tumors (chondrosarcoma) and metastases.
Reviewing the literature, I found a case report with similar findings: Solitary plasmacytoma of the sternum with a spiculated periosteal reaction: A case report. ONCOLOGY LETTERS 9: 191-194, 2015
This week’s case follows the pattern of a “Meet the Examiner” presentation, with questions and answers similar to a real examination. Take your time before scrolling down for the answer.
The images belong to a 60-year-old man with moderate cough and dyspnea
What would you recommend?
1. Compare with previous films
2. Chest CT
3. PET-CT
4. None of the above
Click here to see the answer
Findings: PA radiograph shows large bullae in both upper lobes. There is a nodule in the RUL projected over one bulla (A, arrow). Two small calcified granulomas are visible in the periphery of the LUL (A, circle). PA film taken five years earlier (B) does not show any nodule in the RUL. The granulomas in the LUL are unchanged.
Report of the chest : bullous emphysema with a nodule not visible in 2014. Given the relationship between bullous disease and carcinoma, it is imperative to do a chest CT.
Enhanced CT was done the next day. What would you suggest?
1. Antibiotic treatment and CXR in one month
2. PET-CT
3. Antibiotic treatment and CT in one month
4. None of the above
Click here to see the answer
Findings: aside form large bullae in both upper lobes, an irregular nodule is evident in the RUL (A-B, arrows). In my opinion, given the appearance of the nodule I would suspect malignancy and request a PET-CT. However CT was reported as: Pseudonodular opacity in RUL that could be related to an infectious/inflammatory process. A neoplasm cannot be excluded. Recommend control after treatment
Click here to see more images
A chest radiograph was taken one month later.
What would you do?
1. PET-CT
2. CXR in three months
3. CT in three months
4. Control in one year
Click here to see more images
The chest radiograph one month later was reported as unchanged and no further suggestions were made by the radiologist. The clinician took no further action.
The patient came back ten months later, and a new radiograph showed an obvious increase in size of the nodule (B, arrow) when compared to the initial film (A, arrow)
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Enhanced CT confirms the increase in size of the nodule (A-B, arrows). Surgery discovered a carcinoma in the wall of a bulla.
Final diagnosis: adenocarcinoma of the lung associated to bullous disease.
Lung carcinoma seems to occur more often in bullous disease, although there is not enough evidence compiled at the present time. Despite the lack of evidence, knowing
this association may prevent misdiagnosis.
A lesser known fact is that the cystic space may disappear after the carcinoma develops, as occurred in a second case (see below). Spontaneous regression of a bulla may be due to non-malignant causes, but carcinoma should be excluded with CT because it may take years for the lesion to be visible in the chest radiograph.
I am showing this case because the opinion given in the chest radiograph was unequivocal, whereas the CT report was vapid, giving the impression that the nodule was infectious, and that malignancy was less likely. The follow-up radiograph was disregarded by the radiologist and clinician and this caused a delay in diagnosis of almost one year.
To complete the information, I am showing a second case of carcinoma developing in the wall of a cystic space
Images of the second case were obtained during routine CT screening in a 72-year-old man, heavy smoker.
Apical axial CT image shows a small nodule in the LUL (A, arrow), with increased uptake on PET-CT (C, arrow). There is a cystic airspace in the LLL (B, arrow) with no PET-CT uptake, interpreted as a non-specific cystic airspace lesion.
At surgery a carcinoma of the LUL was found.
It was decided to continue with yearly follow-up studies. The cystic air space (A, arrow) increased in size in 2008 but still had a thin wall (B, arrow). In 2009 it has decreased slightly in size and the wall is thicker than the previous year (C, arrow). A new PET-CT shows increased uptake in the posterior wall (D, arrow).
Malignancy was suspected. The patient refused further surgery or percutaneous biopsy and it was decided to do a follow up study three months later.
Axial CT shows that the cystic airspace has disappeared and in its place, a solid mass has developed (A and B, arrows) with increased overall uptake on PET-CT (C, arrow). At surgery, an adenocarcinoma was found.
Final diagnosis: adenocarcinoma arising in the wall of a cystic airspace, which disappeared as the tumour progressed.
Follow Dr. Pepe’s advice:
1. Bullous emphysema and isolated cystic spaces may be associated with an increased incidence of carcinomas
2. A poorly worded report may cause an unnecessary delay in diagnosis
Dear friends, Dr Pepe has eloped with Miss Piggy (again) and has let me alone, holding the fort. Hope he will be back in time to give the next webinar.
Today’s radiographs belong to a 60-year-old male with cough and moderate dyspnea.
Diagnosis:
1. Hilar lymphadenopathy
2. Right pulmonary artery aneurysm
3. Mediastinal tumor
4. None of the above
Click here to see the answer
Findings: PA and lateral chest radiographs show a right hilar mass (A-B, arrows). In my opinion, the appearance of the mass and its location in the right hilum in the lateral view rules out a mediastinal mass.
There is a small nodule in the RUL (A, red arrow) that can be overlooked unless we look for it
The nodule is better seen in the cone down view and the axial CT (C-D, red arrows), with high SUV in the PET-CT (E, arrow), accompanied by a metastatic node in the mediastinum (E, circle).
Caudal slices of enhanced CT show multiple lymph nodes in right hilum (F, arrow) and mediastinum (G, circle).
Biopsy of a lymph node returned as metastatic carcinoma.
Final diagnosis: carcinoma of the lung with mediastinal metastases
Congratulations to archanareddyt who was the only one to discover the RUL nodule
Teaching point: this is an interesting case for educational purposes.
1. Knowing the most common causes of unilateral hilar enlargement (lymph nodes vs. enlarged artery) helps the differential diagnosis.
2. We should think of common processes rather than unusual ones (lymph nodes vs. aneurysm).
3. Suspecting unilateral hilar lymph nodes leads to search for the two more common etiologies (TB or carcinoma) leading to the discovery of the RUL nodule.
Dear friends, I am starting a new webinar series entitled “Things that we already know, but are important to remember”. The objective is to refresh basic concepts that often are forgotten.
This week’s webinar title is “Who is afraid of the bad, big lateral chest”. The webinar will take place on Wednesday, September 30 at 12:00 CEST. You can register here.
The initial case is a PA chest radiograph of a 61-year-old man with hemoptysis.
Do you see any abnormality?
1. Yes
2. No
3. I want a lateral chest
Register for the webinar and lear more about this case and others!
Click here to see the answer
Findings: PA radiograph (A) does not show any significant findings. The lateral view shows a posterior pulmonary nodule with irregular contour (B, arrow). A typical donut sign is visible (B, circle), indicative of enlarged subcarinal lymph nodes.
Enhanced axial CT and PET-CT show confirm the pulmonary nodule (C-D, arrows) and the subcarinal lymphadenopathies (C-D, red arrows).
Final diagnosis:
Carcinoma hidden in the PA view behind the right hilum with metastases to subcarinal lymph nodes.
Congratulations to drpeca who was the first to want a lateral view.
Teaching point: remember that about 26% of the lung is hidden in the PA view. A lateral chest radiograph is indispensable to study the chest.
this is the last case of the first semester. Will meet again in September.
Wish all of you a very happy summer vacation!
This is a new “art of interpretation” case. Radiographs belong to a 40-year-old woman with mild cough.
What do you see?
Diagnosis:
1. Chronic TB changes
2. AV malformation
3. Bronchial atresia
4. Any of the above
Click here to see the answer
To refresh your memory, remember that interpreting a chest radiograph involves three basic steps:
1. Gather information. Examine the radiographs carefully and collect all the pertinent information. Remember that overlooking visible findings is the main cause of errors.
2. Analyze the findings. Once collected, the findings should be properly evaluated, and an opinion should be offered.
3. Decide on the next step to reach the diagnosis.
Step 1. Information:
In this patient the lateral view is unremarkable.
All relevant findings are seen in the PA radiograph:
1. Tubular branching opacities in the left upper lung (A, red arrows)
2. Increased lucency of left upper lung (A, circle)
3. Negative finding: the left hilum is in its normal position.
Step 2. Analysis of the findings:
1. Branching tubular opacities have a limited differential diagnosis: either they are pulmonary vessels or mucous-filled dilated bronchi.
2. Hyperlucent lung is a reliable sign of lung disease when complemented with an expiration film to demonstrate air-trapping.
3. The normal position of the left hilum is a negative finding that excludes a fibrotic process in the LUL (I.e. chronic TB), which should cause upper retraction of the hilum.
The combination of a lucent lung lesion with branching tubular opacities points towards an obstructive process of a segmental bronchus with mucous impaction (Obstruction of a lobar bronchus would cause lobar collapse instead of increased lucency).
Once segmental bronchial obstruction is suspected in the chest radiograph, the best procedure to confirm it is an enhanced chest CT with expiratory views. In this case it shows attenuated upper lobe vessels (B, arrows) and obvious mucous impactions (B-C, red arrows).
Axial CT with lung window confirms the increased lucency of the apical-posterior segment of the RUL (D, circle)
Inspiration/expiration axial CT views (E-F) confirm segmental air trapping on the left.
Bronchoscopy did not show any inflammatory or tumoral changes in the LUL bronchus. The orifice of the apical-posterior segment was missing.
Final diagnosis: bronchial atresia of apical-posterior segment of LUL
In my experience, bronchial atresia is the most common congenital lung malformation seen in adults. Congenital bronchial atresia results from proximal interruption of a segmental bronchus, which causes overinflation of the affected segment and secondary mucus impaction. Chest radiography shows a focal hyperlucent area with internal mucus impaction. CT depicts these findings to better advantage. Inspiration and expiration views help to confirm air-trapping. In case of doubt, bronchoscopy excludes other causes of bronchial obstruction.
Congenital bronchial atresia may present different appearances, as shown in the following case of one of our X-ray technicians.
30-year-old female, asymptomatic. PA chest radiograph (A) shows hyperlucent left lung with discrete dextroposition of the heart. Expiration film (B) shows air-trapping on the left with deviation of the mediastinum towards the right. Note a thick tubular shadow in the left lower lung (A-B, red arrows), compatible with bronchial impaction. The findings are suggestive of congenital bronchial atresia
Axial and coronal enhanced CT show increased lucency of the posterior segments of LLL with a central mucous impaction (C-D, red arrows)
Decreased vascularity of LLL and central mucous impaction (E-F, red arrows) are better demonstrated in the MIP reconstruction.
Coronal view eleven years later show that air is now present within the dilated bronchus, confirming the diagnosis (G-H, circles) .
Dr. Pepe’s teaching point:
Hyperlucent lung with mucous impaction are the hallmark of congenital bronchial atresia.
Today’s radiographs belong to a 24-year-old woman with cough and fever. What do you see?
More images will be shown next Wednesday and the answer will be published on Friday.
Click here to see Monday images
Dear Friends,
Showing today CT images of the chest. What do you think?
Click here to see the new images
Click here to see the answer
Findings: Chest radiographs show air-space disease in the right lower lobe (A-B, arrows). There is marked widening of the right paratracheal line (A, red arrow) suggestive of mediastinal lymphadenopathy.
Axial CT with lung window shows RLL air-space disease without cavitation (C, arrow). Mediastinal window at different levels confirms enlarged paratracheal, subcarinal and neck lymph nodes with hypodense center (D-F, red arrows). These findings should suggest active tuberculosis as the first possibility.
Although TB usually affects upper lobes, isolated involvement of lower lobes occurs in about 7% of cases.
Mycobacterium tuberculosis was found in the sputum.
Final diagnosis: active TB.
Congratulations to Archanareddyt who was the first to make the diagnosis.
Teaching point: lymph nodes with hypodense center may occur in several processes (treated tumors, Whipple’s, etc.), but in the appropriate clinical situation, the first diagnostic consideration should be tuberculosis.
The leading case of this week’s Diploma has been provided by my good friend Jordi Andreu. Radiographs belong to an asymptomatic 48-year-old woman.
Diagnosis:
1. Neurogenic tumor
2. Pulmonary hamartoma
3. Pleural fibrous tumor
4. None of the above
What do you think? Come back on Friday to see the answer!
Click here to see the answer
Findings: PA chest radiograph shows a rounded opacity in the left apex (A, arrow). All diagnosis are possible, as the pulmonary apex is a narrow space and it is very difficult to determine the origin of a mass. The clue lies in the nodular opacities in the neck (A, circle) which raise the possibility of superimposed hair braid.
Unenhanced coronal CT (B) does not show any mass, confirming that the finding is artifactual.
Final diagnosis: superimposed hair braid simulating pulmonary disease
The purpose of this presentation is to discuss elements in or about the soft tissues of the chest wall that may simulate lung disease. Those related to the thoracic skeleton were shown in Diploma case # 57.
This Diploma complements the non-significant findings described in webinar eight.
I have classified them into three groups, the first one related to the soft tissues of the chest wall while the other two are external to the body:
Nipple shadows are seen in 3% to 10% of PA chest radiographs. In about 10% of these patients, the identification may raise doubts. Comparison with previous films will confirm the stability of the nodules (Fig. 1). In case of doubt, nipple markers should be placed. Routine use of nipple markers has been proposed in oncologic patients.
Fig. 1. 58-year-old man with typical bilateral nipple shadows (A, arrows), unchanged in comparison with a previous film (B, arrows). Nipples are well seen on axial CT in the same patient (C, arrows). Nowadays, patients may come with their own nipple markers! (D).
Unilateral enlarged nipple shadows are suspicious findings. Visual inspection should be done to confirm that the nipple is indeed enlarged (Fig. 2). Occasionally, a true lung nodule may simulate a nipple shadow, even with nipple markers. In such cases, CT will correct our error (Figs. 3-4)
Fig 2. 61-year-old woman with left pleuritic chest pain. PA chest film shows a small amount of left pleural fluid (A, white arrow) and a nodule at the right costophrenic angle (A, red arrow). Visual inspection showed a large right nipple as the cause of the false nodule. Two weeks later, the pleural effusion has disappeared, and the nipple shadow is no longer seen (B). Fig. 3. 54-year-old man with a renal tumor. PA film shows a nodule in the LLL (A, arrow) that simulates a nipple, even with a nipple marker (B, arrow). Axial CT shows a metastatic nodule in the LLL and a larger one in the RLL, not seen in the PA chest radiograph (insert, arrows).
Skin lesions
Skin lesions may also cause false lung nodules. Visual inspection of the chest will demonstrate them and confirm the diagnosis (Fig. 5). If there is any doubt, a marker can be used.
Fig. 5. Chest wart simulating a lung nodule in the PA film (A, arrow). Lateral film shows the wart in the skin of the anterior chest wall (B, arrow). The wart is higher in this view because the upheld arms elevate it.
Occasionally, a discrepancy in density between both breasts, usually related to previous surgery, may simulate pulmonary pathology (Fig 6).
Fig 6. 65-year-old woman with syncope. PA radiograph shows a rounded opacity in the right lung (A, arrow), suspected to be a pulmonary infiltrate. Axial CT (B) show normal lungs. The opacity is due to a superimposed right breast prosthesis (B-C, arrows).
Hair
In my experience, hair is a common cause of opacities in the lung apices (Fig 7).
Strands of loose hair may project over the upper lung, simulating linear fibrotic infiltrates (Fig 8). Rubber bands at the end of braids may be confused with pulmonary nodules (Fig. 9). A long braid may fool us and consider it intrapulmonary disease (Fig 10).
In most cases, the clue to the diagnosis lies in recognizing that the abnormality extends to the neck.
Fig. 7. Braid simulating an apical pulmonary nodule (A-B, arrows). The rubber band (A-B, red arrows) suggests the correct diagnosisFig. 8. Loose hair simulating a linear infiltrate or fibrosis in the right apex (A, white arrow). Note the same appearance in the lower neck (A, red arrow). The apex looks normal after the hair is lifted (B). The opaque rounded opacity that looks like a hair clasp (A-B yellow arrow) is a cervical disk prosthesis.Fig 9. Two patients with rubber bands at the end of a braid simulating pulmonary nodules (A-B, arrows). In both, the braids are visible in the neck (A-B, red arrows). Despite that, patient B was referred for a CT examination to evaluate a left lung nodule. Fig. 10. 25-year-old man with braided hair simulating a RUL infiltrate (A, arrow). The opacity extends to the neck, giving away the diagnosis (A, red arrow). After raising the braid, the chest looks normal (B). Remember that men also wear their hair long nowadays.
Clothing artifacts
Clothing artifacts occur when the technician does not ask patients to remove garments that have logos or images on them. This usually happens with women, out of respect for modesty (Figs. 11 and 12).
Fig. 11. 27-year-old woman with multiple miliary nodules in both lungs (A, circles). The opacities result from a jeweled panther on the shirt she was wearing (B). Fig 12. 45-year-old woman with previous breast carcinoma. PA radiograph shows small nodules in lower lungs (A, circles). Lateral view proves that the nodules are in a blouse (B, arrow)
Other types of body artifacts may cause dubious opacities in the chest radiograph (Figs 13 and 14)
Fig 13. 29-year-old man with a barely visible non-displaced fracture of the left clavicle (A, arrow), well demonstrated in the 3-D CT reconstruction (B). Components of the support brace for the fracture simulate enlarged upper lobe vessels (A, red arrows).
To end the presentation, in the last two months we have been acquainted with a new artifact: the wire in the face masks (Fig 14)
Fig 14. Routine chest radiograph during the Covid-19 scare. Notice the wire in the face mask (A-B, arrows)
Follow Dr. Pepe’s advice:
1. Unilateral nipple shadows may generate diagnostic problems.
2. If a hair artifact is suspected, look at the soft tissues of the neck.
3. Garments may create weird lung shadows.
Today’s case has been provided by my good friend Victor Pineda. Radiographs belong to a 36-year-old man with cough and fever. For comparison, I am including radiographs taken nine years earlier.
Diagnosis:
1. Chronic TB changes
2. Endobronchial lesion
3. Congenital lesion
4. None of the above
What do you see? More images will be shown on Wednesday. Come back on Friday to see the answer.
Click here to see the images posted on Monday
Showing coronal and axial CT images. What do you think?
Click here to see the CT images
Click here to see the answer
Findings: Pa radiograph shows a left ill-defined opacity that blurs the upper mediastinal contour (A, arrow) and the lower cardiac border (A, red arrow). In the lateral view there is a retro-sternal line that goes from top to bottom (B, arrows). The appearance is typical of marked LUL collapse, which has not changed in the last nine years. Therefore, the most likely diagnosis is a benign condition that occludes the origin of the LUL bronchus.
Enhanced axial and coronal CTs show marked irregularity of the origin of the LUL bronchus (C, arrow) due to a large mass with coarse calcification (C-D, circles) causing distal lobar collapse. The most likely diagnosis is a benign tumor, either carcinoid or hamartoma. Given the size of the mass and the higher frequency of carcinoid, I would favor this diagnosis. It was proved by biopsy and surgery.
Final diagnosis: endobronchial carcinoid with LUL collapse
Congratulations to Ahmed Al Ani who was the first to suggest the correct diagnosis in the plain film.
Teaching point: Detecting LUL collapse in chest radiographs is important because the great majority are secondary to bronchogenic carcinoma. This patient was lucky.
Today I am showing a preoperative PA radiograph in a 72-year-old woman.
Diagnosis:
1. Aortic elongation
2. Aortic dissection
3. Aortic aneurysm
4. Any of the above
What do you see?
Click here to see the answer
Findings: the obvious finding is elongation of the descending aorta. Usually, the diameter of the aorta cannot be determined in the plain film because only the outer wall is outlined by lung air, whereas the medial wall is obscured by the mediastinal structures.
In this case, the tortuous lower aorta projects the medial wall against the lung, allowing to measure the aortic diameter, which is increased (A, red line).
In the other hand, the ascending aorta is not prominent. This a negative finding against aortic elongation, which should involve the whole thoracic aorta.
Therefore, answers 1 and 4 can be excluded. To differentiate between answer 2 and 3 an enhanced CT is needed.
Click here to see more images
Enhanced CT was done. Axial and sagittal images are shown.
What would be your diagnosis?
1. Type B aortic dissection
2. Aneurysm with thrombus
3. Any of the above
Click here to see the answer
Findings: enhanced axial and coronal CT show a normal ascending aorta and a partially thrombosed dilated descending aorta. The fact that the outer wall is calcified (B-C, arrows) indicates that the intima is not displaced and rules out an aortic dissection. The correct diagnosis is aneurysm with partial thrombosis.
Final diagnosis: unsuspected aneurysm of descending aorta
I saw this case three days ago and thought it was a nice demonstration of a negative finding (lack of dilatation of ascending aorta) as mentioned in my last webinar.
As a result of the findings in the plain film, an enhanced CT demonstrated a partially thrombosed aneurysm and the patient was referred for vascular surgery.
This is the last vignette of the season. Since the pandemic is abating, I will resume next week the usual Caceres’ corner cases and Diploma presentations.
Today I am presenting the leading case of a new webinar entitled: “Sherlock Holmes and the curious finding in the chest radiograph”.
AP radiograph belongs to a newborn with respiratory distress.
Diagnosis:
1. Diaphragmatic hernia
2. Lung tumor
3. Pneumonia
4. None of the above
What do you see? Come back on Wednesday to see the answer and the webinar!
Click here to see the answer
Findings: at a first glance, the predominant abnormality is a large bump in the left hemidiaphragm (A, arrow), suggestive of localized eventration or hernia. However, there is and additional important finding: both humeri are not visible (A, circles).
This baby was born with a congenital absence of the arms (amelia).
I am showing this case to stress the importance of discovering so-called negative findings. Our training emphasizes the discovery of positive findings and forgets teaching us to detect structures that are absent, as this case proves.
My apologies for tricking you, but I was trying to prove my point. You can get more information about negative findings in today´s webinar.
