12-year-old boy, asymptomatic:
Lytic lesion on distal fibular metaphysis with well-defined sclerotic borders is seen on both anteroposterior (a) and oblique (b) radiographs
– Most common fibrous bone lesion
– Same as fibrous cortical defect but larger version
– If large enough, may cause pathological fractures
– One of DON’T TOUCH lesions
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.
Dear Friends,
Showing additional axial CT images of the patient.
What do you see?
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).
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!
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.
Dear Friends,
today I am presenting another “Art of interpretation” case. I like them and think they have good teaching value.
Radiographs were taken for preoperative knee surgery in a 21-year-old man.
What is the most likely diagnosis?
Diagnosis:
1. Swyer-James-McLeod syndrome
2. Congenital hypoplasia of left lung
3. LUL collapse
4. None of the above
Findings: PA radiograph shows a hyperlucent left lung with a small elevated hilum (A, white arrow). The trachea is deviated towards the left and the left main bronchus is curved upward (A, blue arrow). There is a small peak in the left hemidiaphragm (A, red arrow). And there is a triangular-shaped paraspinal opacity (A, circle), better seen in the cone down view (B, white arrow), with two linear metallic opacities inside (B, red arrows).
The lateral view (C) is unremarkable. Although the PA findings suggest loss of volume of the LUL, there are some negative findings: no anterior displacement of the left major fissure and no opacity indicative of LUL collapse.
There are four obvious findings:
1. Hyperlucent left lung with small left hilum
2. Tracheal deviation to the left
3. Upward curving of left main bronchus
4. Juxtaphrenic peak (*)
All these findings are indicative of LUL volume loss with compensatory overinflation of the LLL.
There are two less obvious findings, which are diagnostic:
Paramediastinal opacity with surgical staples
No signs of LUL collapse in the lateral view
The first indicates previous surgery and the second excludes LUL collapse. Taken together, these findings lead to the obvious conclusion that the patient had undergone a previous lobectomy.
(*) The juxtaphrenic peak sign was described by my late friend Kenneth Kattan as an indirect sign of LUL collapse. Semin Roentgenol 1980; 15:187-193
LOSS OF VOLUME OF LUL + SURGICAL STAPLES = LUL LOBECTOMY
In the past, the patient had embryonal carcinoma of the testicle with a metastatic nodule in the LUL (A and B, arrows). He had undergone LUL lobectomy by video-assisted thoracic surgery one year before.
Final diagnosis: LUL lobectomy for metastasis of embryonal testicular carcinoma
I’m showing this case to emphasize the importance of identifying metal sutures in the chest radiograph. Nowadays, most surgical procedures are done by video thoracoscopy which doesn’t leave any telltale signs other than surgical staples. These are difficult to see because of their small size and because high kV “burns” metal density.
Staples are visible as a faint longitudinal ring chain somewhat denser than the surrounding tissues. It’s very important to be familiar with their radiographic appearance because they offer valuable information about previous surgery.
When staples are detected, our interpretation of associated findings may change, as occurred with the case presented.
To familiarize you with the radiological appearance of surgical staples, I’m showing three more cases.
CASE 1:
88-year-o.ld man with dementia and moderate dyspnea. Chest radiographs show a nodule in the RUL (A and B, arrows). PA view shows post-surgical changes at the left 6th and 7th ribs and a hyperlucent left lung with a small hilum. There are surgical clips in the mediastinum (A and B, red circles). These findings suggest a previous LUL lobectomy and a second primary tumor. The patient’s records disclosed a LUL lobectomy for carcinoma twenty years earlier. The second primary tumor was confirmed by needle biopsy.
The radiographic findings are typical of “old” chest surgery.
CASE 2:
PA radiograph of a 23-year-old woman with a nondescript LUL infiltrate (A, arrow). Close-up view reveals a longitudinal ring chain of staples within the infiltrate (B, arrows), pointing to a man-made opacity secondary to video thoracic surgery.
Diagnosis: changes after endoscopic LUL bullectomy for recurrent pneumothorax.
CASE 3:
I saw this case three weeks ago and it is still unproven. A 44-year-old woman from another country came for a routine cardiac checkup. The PA chest radiograph shows a serpiginous opacity in the LLL (A, arrow) with a ring chain of staples in the periphery, better seen in the cone down view (B, arrows). On questioning, the patient mentioned previous endoscopic surgery for a nodule in the left lung two years ago. Enhanced CT shows a solid lesion with staples in the periphery (C, arrow).
As the patient could not provide previous medical records, we were unable to ensure that the changes were attributable to scar tissue. A follow-up CT has been scheduled.
Final words: Staples are difficult to reproduce on the computer screen, and I have done my best. I assure you that they are easily visible on a 14 by 17 reading console, provided that you see and recognize them 🙂
Follow Dr. Pepe’s teaching points:
1. Surgical staples are visible as a faint longitudinal ring chain.
2. They indicate previous surgery and help to interpret the chest findings under a new light.
Dear Friends,
Today I am showing preoperative radiographs for hand surgery in a 53-year-old man.
What do you see?
More images will be shown on Wednesday.
Dear Friends,
showing today chest radiographs taken one year earlier.
Do they help?
Findings: PA chest radiograph shows an ill-defined opacity in the left middle lung field (A, arrows). It is located in the anterior clear space in the lateral view and has a stippled appearance (B, arrows). In addition, there is a flat irregularity in the dome of the left hemidiaphragm in the PA view which appears to be calcified (A, red arrow).
Previous radiographs one year earlier show the same findings, unchanged (C-D, arrows).
The clue to the diagnosis lies in the irregularity of the dome of the left hemidiaphragm, that looks like a calcified plaque. This finding suggests that the apparent pulmonary opacity in the PA view may be a pleural plaque see “on face”. It is not seen as a line in the lateral view because the curvature of the anterior thoracic wall does not offer a straight interface to the X-ray beam.
CT confirms calcified anterior pleural plaques in both hemithoraces (E-F, arrows).
Coronal and sagittal CT confirm the calcified plaque in the diaphragmatic dome (G-H, red arrows).
The patient was found to have a history of asbestos exposure.
Final diagnosis: Asbestos-related pleural disease simulating pulmonary infiltrate.
Congratulations to S, who was the first to make the diagnosis. Silver medal to VL.
Teaching point: remember the deceitful appearance of pleural plaques shown in Diploma case 140. Some of you were fooled by it!
Dear Friends,
Today I am showing chest radiographs of a 81-years-old man with chest pain five years after left pneumonectomy for lung carcinoma
Diagnosis:
1. Broncho-pleural fistula
2. Intestinal hernia
3. Empyema
4. None of the above
What do you see?
Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.
Continue reading “Dr. Pepe’s Diploma Casebook: CASE 131 – SOLVED”
Dear Friends,
presenting today chest radiographs of a 70-year-old man with ischemic heart disease and dyspnea.
Diagnosis:
1. Fibrous pleural tumor of major fissure
2. Carcinoma of the lung
3. Loculated fluid in major fissure
4. Any of the above
What do you see?
Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.
Continue reading “Dr. Pepe’s Diploma Casebook: CASE 130 – SOLVED”
