Tag: thorax

Cáceres’ Corner Case 223 – SOLVED

~ Dr. Pepe ~ 9 Comments

Today’s radiographs belong to a 77-year-old man with dyspnea.

Diagnosis:

1.  Allergic aspergillosis
2.  A-V malformations
3.  Chronic changes post-TB
4.  None of the above

What do you see? Come back on Friday to see the answer 🙂

Click here to see the answer

Findings: PA chest radiographs shows elongated opacities apparently arising from the hila (A, arrows). The lack of branching goes against mucous impactions. The clue to the diagnosis lies in the calcified pleural plaque in the right hemidiaphragm (A, red arrow), which is a sign that strongly suggests asbestos exposure.
This diagnosis is corroborated by the lateral view, which shows calcified pleural plaques in the anterior clear space (B, red arrow).

Previous AP and oblique rib radiographs after chest trauma show the undulated calcified plaque in the right hemithorax (C-D, arrows).

Unenhanced coronal CT confirms the plaque in the right hemidiaphragm (E, arrow). Axial CTs demonstrate the anterior plaques (F-G, red arrows), as well as the unaffected lung (F).

Final diagnosis: calcified pleural plaques simulating pulmonary disease.
 
Congratulations to Phi Pham, who was the first to make the correct diagnosis.
 
Teaching point: Remember that superimposed opacities may simulate intrapulmonary pathology.

Dr. Pepe’s Diploma Casebook 154 – All you need to know to interpret a chest radiograph – Eighth Session – SOLVED

~ Dr. Pepe ~ 6 Comments

Dear Friends,

Showing today the leading case of webinar eight. Radiographs belong to 27-year-old with seminoma and pain in the anterior chest wall. What is your opinion about the  clavicular lesion?

1. Metastasis
2. Osteomyelitis
3. Benign bone lesion
4. Any of the above

Check out the last webinar form the series explaining in detail this case on our youtube channel and and catch up on previous ones on the EBR YouTube channel!

Click here to see the answer

Findings: the chest radiograph shows a lytic lesion in the proximal right clavicle (A-B, circles). It has a sclerotic border (A-B, red arrows), indicating a slow-growing process. This finding excludes options 1 and 2 and leaves option 3. Benign bone lesion as the correct diagnosis.

This lytic lesion correspond to a normal variant, called the rhomboid fossa. It represents the insertion site of the costoclavicular ligament( yellow), which extends from first rib (red) to the proximal clavicle (blue).
Is a normal variant and should not to be mistaken for an osteolytic lesion.

It occurs in 30% of males and 5% of females. It is more common in the young and becomes less visible with age.

Final diagnosis: rhomboid fossa of right clavicle

Congratulations to Faelivrin, who made the correct diagnosis

Teaching point: it is important to know the most common normal variants of the chest, to avoid confusing them with pathology.

Cáceres’ Corner Case 222 – SOLVED

~ Dr. Pepe ~ 5 Comments

Dear Friends,

Showing today preoperative radiographs of 57-year-old man with a torn knee cartilage. Sorry about the poor quality of the lateral view.
What do you see?

Come back on Friday to see the answer!

Click here to see the answer

Findings: PA radiograph show widening of the right superior mediastinum (A, arrow), imprinting the tracheal wall (A, red arrow).
In the lateral view there is increased opacity of Raider triangle (B, circle) with slight bowing of the posterior tracheal wall (B, red arrow).

The main causes of occupation of Raider triangle are two: either esophageal disease or congenital malformation of the aortic arch. The last one is the most likely, given the findings in the PA view.
 
Enhanced CT confirms a right aortic arch (C-D, arrows), crossing behind the trachea (C-E, red arrows) and causing the opacity in Raider triangle.

Findings are better seen in the 3-D reconstruction (F).

Final diagnosis: right aortic arch
 
Congratulations to Jolanta who made the correct diagnosis (my initial impression in the plain film was double aortic arch, so I will award another prize to Faelivrin for being wrong with me).
 
Teaching point: this case does not look very exciting, but right aortic arch is very common, and it is important to avoid confusing it with a mediastinal mass.
 
If you want to know more about malformations of the aortic arch, look up the article by Hanneman, Newman and Chan: Congenital variants and anomalies of the aortic arch, RadioGraphics 2017; 37:32–51

Cáceres’ Corner Case 221 – SOLVED

~ Dr. Pepe ~ 20 Comments

Dear Friends,

Today´s images belong to a 76-year-old man with pain in the back. Antecedents of urothelial carcinoma.

PA chest radiograph was normal and radiographs of the dorsal spine were taken.

What do you see?

Come back on Friday to see the solution!

Click here to see the answer

Findings: AP view of dorsal spine shows fixation screws in the lower spine and partial vertebroplasty of D12. The most important finding is that the left pedicle of D8 is absent (A, circle). In the lateral view, the posterior wall of the same vertebra is not seen (B, circle).

The findings are more evident in the cone down views (C-D, circles). In this particular case I was lucky because the superimposed air of the left main bronchus allows an unimpeded view of the missing pedicle.

Review of a recent chest CT demonstrated a lytic lesion in the body and pedicle of D8 (E-G, circles) that were no reported.

Final diagnosis: metastasis to D8 discovered in the plain film of the spine and overlooked in a previous CT.
 
Congratulations to BujarB, who was the only one to discover the missing pedicle (my hero!)
 
You may think that this case is difficult (only one of seven found the lesion). In the old times our routine included looking at the pedicles in the AP view of dorsal and lumbar spine. To familiarize you with the appearance of the normal spine, an AP view is shown below.

Teaching point: remember to look at the pedicles in the AP view. A missing pedicle in a patient with a known primary tumor is highly suspicious of metastasis.

Dr. Pepe’s Diploma Casebook 153 – All you need to know to interpret a chest radiograph – Seventh Session

~ Dr. Pepe ~ 7 Comments

Dear Friends,

Today I am presenting the leading images of the seventh webinar. They belong to a 66-year-old man with vague chest complaints. Chest was read as normal, but there is a visible abnormality, difficult to see.
Can you see it?

Remember, you can see the previous sessions of the webinar in our youtube channel. We will published the answer to this question (and the webinar) on Friday.

Click here to see the answer

Findings: PA radiograph (A) is unremarkable. In the lateral view there is a nodule projected over the mid-thoracic spine (B, arrow). The nodule was overlooked, and the examination was read as normal.

One year later the nodule has increased in size (C, arrow) and has become visible behind the heart in the PA view (D, arrow). It was diagnosed as adenocarcinoma and liver metastases were found.

Two years later, CT and PET-CT show marked progression of the liver metastases.

Final diagnosis: lung adenocarcinoma missed in the first chest radiographs, with widespread metastases two years later
 
Congratulations to Spat, who discovered the initial nodule.
 
Teaching point: remember to look at the dorsal spine in the lateral view. By doing so, you may discover early disease, with great benefit for the patient.

Cáceres’ Corner Case 220 – SOLVED

~ Dr. Pepe ~ 14 Comments


Dear Friends,

I am showing today a case seen last week. Radiographs belong to a 35-year-old man with fever. 

What do you see?

The answer will be published on Friday.

Click here to see the answer

Findings: PA chest radiograph shows widening of the superior mediastinum (A, arrows). There is moderate prominence of both hila (A, red arrows) and two rounded opacities in the inferior aspect of the right hilum (A, yellow arrows). The lateral view shows convex bumps in the left hilum (B, red arrows).
Findings in both views are practically pathognomonic of mediastinal and hilar lymphadenopathies.

Changes in the PA radiograph are more evident when comparing with a previous film taken two years earlier.

In this case, lymphoma is the best possibility. For the sake of the patient I hoped it was infectious mononucleosis. Analysis discovered immature cells in the bloodstream. Further workup confirmed the diagnosis of acute lymphoblastic leukemia.
 
Final diagnosis: acute lymphoblastic leukemia with enlarged hilar and mediastinal lymph nodes.
 
Many of you discovered the enlarged lymph nodes, which makes me very proud.
Kudos for Amal Mahran, who was the first to give a detailed description.
 
Teaching point: I believe this case emphasizes the importance of comparing with previous studies. If I had shown the previous PA chest, I am sure the percentage of correct answers would had been close to one hundred percent.

Cáceres’ Corner Case 219 – SOLVED!

~ Dr. Pepe ~ 15 Comments

Dear Friends,
Today’s images belong to a 67-year-old woman with pain in the chest.
What do you see?

More images will be presented next Wednesday and the answer will be published on Friday, as usual.

Click here to see more images

Dear Friends,

Showing additional axial CT images of the patient.
What do you see?

Click here for the solution

Findings: PA chest radiograph shows a lytic lesion of the 3rd right rib, accompanied by an extrapulmonary sign (A, circle). Lateral view (not shown) is unremarkable.

The lesion is more obvious in the cone-down view (B, circle), specially when compared to a previous study (C, circle).

Axial CT confirms a permeative lesion of the rib (D-E, arrows), as well as lytic lesion in the posterior elements of the 4th thoracic vertebra (E, red arrow). A serendipitous finding is a nodule in the medial quadrant of the left breast (F, arrow), demonstrated in a subsequent mammography (G, arrow) and confirmed to be a carcinoma.

Final diagnosis: carcinoma of the breast with osseous metastases
 
Congratulations to Diogo who saw and described the rib lesion in the plain film.
 
Teaching point:remember that our most common error is missing obvious lesions.
Checklists help to correct oversights. I believe the rib lesion could have been found if you had applied the checklist recommended in webinar one (H).

Cáceres’ Corner Case 218 – SOLVED

~ Dr. Pepe ~ 12 Comments

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?

Click here to see the answer

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!

~ Dr. Pepe ~ 17 Comments

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

Click here to see the answer

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

~ Dr. Pepe ~ 9 Comments

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.