Today I am presenting chest radiographs of a 60-year-old man with vague chest complaints and mild cough.
What do you see in the images below? Leave your thoughts in the comments section and come back on Friday for the answer.
Findings: PA radiograph shows a lung nodule projected over the anterior left first rib, also visible in the lateral view (Fig 1, arrows).
Fig. 1
The nodule was barely visible in films taken four months earlier (Fig 2, arrows).
Fig. 2
The nodule was missed in both studies. Radiographs taken 18 months later show a large mass in the LUL and a right perihilar mass (Fig 3). Bronchoscopy and biopsy confirmed carcinoma in both locations.
Fig. 3
Final diagnosis: fast-growing bilateral lung carcinoma
Congratulations to all of you who discovered the nodule, with special mention to Genchi Bari, who was the first to mention it.
I am showing this case to emphasise the importance of scrutinising the lung apices. The reported miss rate of nodules in this location reaches up to 50% and many of them are carcinomas.
Teaching point: always look at the apices. This patient is living proof of what happens when a nodule is overlooked.
