This case has been provided by Dr. Oscar Persiva, a former resident and good friend (even though he is a fan of Real Madrid).
The case is a 38-year-old man who came to the Emergency Room with moderate chest pain. Chest radiograph and CT shown.
1. Pleural metastases
2. Neurogenic tumour
3. Fibrous tumour of pleura
4. All of the above
38-year-old man, PA chest
38-year-old man, lateral chest
38-year-old man, axial CT
Click here for the answer to case #27
PA chest film shows a peripheral nodule (arrow). The lateral film shows increased opacity in the anterior clear space (arrow). Axial CT confirms an extrapulmonary nodule (arrow), as well as a rounded anterior mediastinal mass (red arrow).
This combination suggested to the Muppet that this was a malignant thymoma with pleural metastases, as thymomas metastasize along the pleural layers. However, a thymoma with a coincidental chest wall mass could not be excluded.
Therefore, the correct answer should have been: ‘4. All of the above’
The patient was operated on and the final diagnosis was benign thymoma with chest wall schwannoma. The Muppet, thinking he was infallible, is now quite ashamed of himself.
Teaching point: Don’t forget the satisfaction of search/sex! In this patient the discovery of a mediastinal mass in the lateral chest raised interesting diagnostic questions.
Point 2: Always look at the anterior clear space on the lateral film.
For sure it can’t be “4. All of the above”. Fibrous tumour of pleura are usually asymptomatic. Pleural MTS is a remote possibility- the mass seems extra-pleural impinging parietal pleura. I vote for neurogenic tumor because of the chest pain.
Excellent reasoning ! I have nothing to add.
Good reasoning is not always right
What about the second rib counting clockwise from the mass?Is that metastasis?
No. Ribs are normal
Im sure we are missing facts from Chest xrays..
What about the nodular opacity in the retrosternal space? It’s an anterior mediastinum mass hardly visible at the CT. It seems sharply delimitated and quite homogeneous; I would think of thymoma.
The extrapleural right lesion for me seems a neurogenic tumor.
I don’t find the association between them and both can cause mild-moderate chest pain.
I’m worried about the electrodes… Was the cardiac registration normal? Does the patient have fever? The thymoma itself can cause chest pain but it doesn’t look too big and symptoms seems to be related with structures compression…some quite unfrequent associations with thymoma can also cause atypical chest pain but not isolated (myocarditis, pericarditis).
Is there any association between a thymoma and a pleural lesion?
Electrodes are in place because the patient came with chest pain. Don’t worry about them.
Only two ideas.
1. Its not a benign thymoma (thymic carcinoma, malignant thymoma..) and the pleural lesion is a metastasi (I dont like this option at all becausr both lesion are semiologically non agressive).
2. Thats not really a thymoma and both are neurofibromas, what would suggest neurofibromatosis. Also not convinced…
I wll go on thinking…
Of the four answers offered which one would you choose?
Taking in account that I have to choose only one option and I feel I should correlate both findings…I must choose:
1.PLEURAL MET FROM A THYMIC PRIMARY.
Anyway I would prefer a more agressive semiology to reject the benign options (thymoma + neurogenic tumor).
I think of neurogenic tumer due to moderate pain leading to emergnecy
Pueden ser las 3 posibilidades, metástasis,tumor neurogenico y menos probablemente tumor fibroso de la pleura
Very wise choice
Due to the location of the tumor I’d say: 4.All of the above, hence the tumor itself can compress the neurovascular branch of the rib and generate pain, so you can’t exclude 1st and 3rd. 2nd it’s possible too, but in my opinion less likely.
An upper mediastinal mass and a pleural mass. Adult patient. Malign Thymoma or Lymphoma are my best shots.
I thinking about neurogenic pleura tumour and thymoma
I favour neurogenic tumour too
Pleural-based lesion most likely a fibrous tumour of the pleura in a patient of this age. However, thymic carcinoma with a pulmonary metastatic deposit is also a differential diagnosis
Consideramos que la formacion intercostal es extrapulmonar y que desplaza a la pleura. Creemo que probablemente sea un tumor neurogenico, sin embargo la ausencia de realce no genera dudas.
Scusate il ritardo:torno solo ora torno dalle vacanze.Ci sono due patologie:una del mediastino antero-superiore, che tenuemente di impregna di m.d.c.; c’è poi la lesione pleurica, con aspetto benigno. Io penso ad un timoma con un “incidentaloma” rappresentato da un tumore fibroso della pleura; coiè non credo ad un tumore neurogeno(dovrebbe avere rapporto con una costa) nè ad una metastasi, dal momento che non prende contrasto.Sono un fan del BARI( serie B ) e ne sono orgoglioso!
Welcome back! Your diagnosis is well reasoned and I understand your being proud of Bari club.
I have the privilege of being a follower of Barcelona.
Grazie illustre collega:Bari, piccola squadra ma grandi emozioni!!!!
All of the above ? Mmmmm….confusing.
All three possibilities look the same on CT. The mediastinal mass makes metastasis a good possibility. I don’t find it confusing.
In my opinion, CT image clearly suggests chest wall mass (neurogenic tumour), not pleural (metastasis, fibrous tumour).
I respect your opinion, specially since your diagnosis is right!