Cáceres’ Corner Case 218 – SOLVED

Dear Friends,

an easy case to celebrate the new year. PA radiograph of a 36-year-old woman with chest pain.

What do you see?

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Findings: PA chest radiograph shows a fracture of the right clavicle (A, arrow). A magnified view of the area raises the possibility of a lytic lesion (B, arrow).

Specific low-Kv images of the clavicle were taken, showing a rounded permeative lesion with a pathological fracture (C, arrow. D, circle). No other lesions were demonstrated in a bone scan. Biopsy followed by surgery came back as chondrosarcoma.

Final diagnosis: chondrosarcoma of clavicle with pathological fracture
 
Congratulations to Archanareddyt, who discovered the pathological fracture
 
Teaching point: when evaluating bone lesions of the chest, take specific views. They allow a better interpretation of the pathologic changes

Dr. Pepe’s Diploma Casebook 151 – All you need to know to interpret a chest radiograph – Fifth Session – SOLVED!

Dear Friends,

Showing today the leading case of the next webinar. PA radiograph belongs to an 86-year-old woman with chest pain.
What do you see?

More images will be shown on Wednesday. You can refresh your memory viewing the older webinars on our youtube channel.

Dear Friends, showing today a lateral film of the case. Hope it helps.

Click here to see the lateral film

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Findings: PA radiograph shows a faint opacity in the left mid-lung field (A, arrow), better seen in the cone down view (B, arrow). The opacity is ill-defined, and my first impression would be an intrapulmonary lesion.

The lateral view shows that the opacity is located in the posterior chest wall. It has a typical pregnancy sign (C, arrow), indicating an extrapulmonary origin.
Enhanced axial CT confirms a low-density chest wall mass (D, arrow). Note the anterior displacement of the intercostal vessel (D, red arrow).

Final diagnosis: lymphoma of chest wall
 
Congratulations to all of you who diagnosed a chest wall lesion. Special mention to MK, who was the first to give the answer.
 
Teaching point: This case documents the importance of the lateral chest to clarify indeterminate findings in the PA radiograph.

Check the full webinar here

Cáceres’ Corner Case 215 – SOLVED

Dear Friends,

Today’s case has been provided by my good friend and former resident Victor Pineda. Radiographs belong to a 56-year-old man with cough and fever.
What do you see?

More images will be shown on Wednesday!

Click here to see the images shown on Monday

Dear friends hope these new images help you with the diagnosis.

Click here to see more images

Click here to see the answer

Findings: PA chest radiograph shows a large paramediastinal lung opacity (A, arrow) that at first glance suggest malignancy. The clue to the diagnosis lies in identifying multiple bronchiectasis in the right and left central lung fields (A, circles).

The lateral view confirms the opacity in the posterior segment of the RUL (B, arrow) and bronchiectasis in the anterior clear space (B, circle).

Central bronchiectasis accompanied by lung opacities are typical of diseases with thick tenacious mucus and are the hallmark of cystic fibrosis o allergic bronchopulmonary aspergillosis. Coronal and axial CT confirm the presence of numerous central bronchiectasis, one of them with a large mucous impaction (C and D, arrows).

In the mediastinal window the impacted mucus is increased in density (E and F, arrows), which is a pathognomonic sign of ABPA.

Final diagnosis: ABPA with central bronchiectasis and dense pulmonary impaction
 
Congratulations to MG who was the first to answer and made a valiant effort to diagnose a difficult case.
 
Teaching point: this case looks difficult, but the diagnosis is easy if we identify basic findings. Discovering central bronchiectasis narrows the diagnosis to two entities and CT confirms one of them.

Dr. Pepe’s Diploma Casebook 149 – All you need to know to interpret a chest radiograph – Third Session – SOLVED

Dear Friends,

I am showing today the leading image of the third webinar. If you haven’t seen them, you can see the first one here and the second one here:

Chest radiograph belongs to a 24-year-old man with occasional episodes of fainting, currently asymptomatic.

What do you see?

Come back on Friday and enjoy the recording of the third webinar with the answer to this case and more information!

Click here to see the answer

Findings: PA chest radiograph shows convexity of the right outline of the middle mediastinum (A, arrow), suggesting dilatation of the ascending aorta. Some of you have mentioned aortic coarctation, which is not a good option because rib notching is not visible, and the aortic knob is unremarkable.
Given the patient´s age, a good possibility is congenital aortic stenosis.

Enhanced sagittal CT reconstruction shows dilatation of the ascending aorta (B, asterisk) and heavy calcification of the aortic valve (B, arrow). Axial CT demonstrated a malformed and calcified aortic valve (C, circle).

Final diagnosis: congenital aortic valve stenosis with post-stenotic dilatation

Congratulations to Renga, who was the first to mention the ascending aorta dilatation.
 
Teaching point: the middle third of the mediastinum is occupied by the aorta and pulmonary artery. Any mediastinal abnormality in this area should be suspected to have a vascular origin.

You can see on our youtube channel the webinar Prof. Cáceres has prepared discussing this case and others.

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!

Click here to see the images


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

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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Click here to see the answer

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?

Click here to see more images


Click here to see the answer

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).