Dr. Pepe’s Diploma Casebook: Case 95 – A painless approach to interpretation (Chapter 2) – SOLVED!

diploma_casebook_case95

Dear Friends,

As you may remember from Diploma Case 94, when I’m facing a chest radiograph I start by asking three questions:

a) Is there any visible abnormality?
b) It is intra- or extrapulmonary?
c) What does it look like?

Today we will discuss the second question, showing chest radiographs in two different patients. Is the abnormality intra- or extrapulmonary? Check the images below, leave your thoughts in the comments and come back for the answer and discussion on Friday.


CASE : 58-year-old man with pain in left hemithorax

CASE 1: 58-year-old man with pain in left hemithorax

CASE 2: Pre-op radiograph for renal carcinoma in a 62-year-old male smoker. A previous study three years earlier was normal.

CASE 2: Pre-op radiograph for renal carcinoma in a 62-year-old male smoker. A previous study three years earlier was normal.

Click here for the answer

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17 Responses to : Dr. Pepe’s Diploma Casebook: Case 95 – A painless approach to interpretation (Chapter 2) – SOLVED!

  1. MK says:

    I am missing the lateral views, but if I have to say something my opinion is:

    Case 1. Extrapleural left lesion
    Case 2: Probably intrapulmonary LLL lesion, but it would be a costal lesion too.

  2. UFTM radiogroup says:

    Dear Professor, we think both are extra pulmonary lesions.
    Case 1: there is pleural base in the lesion with an obtuse angle in the margins.
    Case 2: there are peripheric calcifications in the lesion, in LLL indicating rib origin, since it is in the projection of the anterior costal arch.

  3. genchi bari italia says:

    …scusa se ho “saltato” la lezione precedente….ero al nostro congressso nazionale SIRM a Napoli.Le lesioni sono entrambe extrapolmonari….la prima, con un angolo di raccordo ottuso superiore è un fibroma solitario della pleura….la seconda sono di pertinenza costale….frattura posteriore della 7 sx….riassorbimento litico della 8 e callo osseo della 9…Sempre nel cuore!

  4. Sidra says:

    1st is extrapulmonary
    2nd is intrapulmonary

  5. Mauro says:

    Hello.

    I think the first one could also be a hampton hump, thus intrapulmonary.

  6. ZHW says:

    Dear Professor – you are a real inspiration. Thank you.

    1. First extrapulmonary – but no definite rib erosion. DD – mets myeloma/ plasmacytoma / fibroma. Would CT this to narrow differential.
    2. Second extrapulmonary – Fractured left 7th to 9th rib. The nodule is due to hyperostosis of a healed posterior 9th fracture. Would not CT this.

  7. 19Medicus83 says:

    I think case 1 shows an extrapulmonary lesion with obtuse margins in the left lateral upper lung field, which could be due to an pleural / rib lesion. I suggest rather a malignancy – is there any clinical information, which would be a clue?

    The ovoid lesion of case 2 seems to be intrapulmonary in the LLL with rim calcification, which suggests radiographically a benign entity (harmatoma, calcified granuloma etc.). Healed rip fracture is a differential because there are konsolidated rip fractures of the 7th and 8th rip…

    • Dr Pepe says:

      In case 1 the patient had pain in the upper left hemithorax. Is the lesion well defined throughout?
      Answer case 2 is correct

      • 19Medicus83 says:

        In my opinion the lesion in case 1 is well circumsribed and smooth with obtuse angels, which clearly goes against an intrapulmonary origin. Therefore I would suggest an pleural lesion, the underlying rib seems to be intact. Therefore pleural fibroma, DD: pleural lipoma would be in my differential. Nevertheless a malignant lesion (pleural metastases of CUP, pleural fibrosarcoma etc.) I wouldn`t definitively exclude before CT-scan, knowing they are quite unlikely…

  8. Bujar says:

    Hello dear Professor !

    Case 1 shows extrapulmonary mass ( pregnancy sign). Anterior aspect of 2 and 3 rib is not visible – malignant costal lesion.
    As algoritem – CT

  9. Pingback: Dr. Pepe’s Diploma Casebook: Case 96 – A painless approach to interpretation (Chapter 3) | Blog

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