Caceres’ Corner: Case No. 27 (Update: Solution)

Dear Friends,

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, PA chest

38-year-old man, lateral chest

38-year-old man, lateral chest

38-year-old man, axial CT

38-year-old man, axial CT

Click here for the answer to case #27

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    Jul 2012
    DISCUSSION 30 Comments

    30 Responses to : Caceres’ Corner: Case No. 27 (Update: Solution)

    1. Marius says:

      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.

    2. gmtsalikis says:

      What about the second rib counting clockwise from the mass?Is that metastasis?

    3. gmtsalikis says:

      Im sure we are missing facts from Chest xrays..

    4. jose caceres says:


    5. Albert says:

      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).

      • Jose Caceres says:

        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.

        • Albert says:

          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…

          • Jose Caceres says:

            Of the four answers offered which one would you choose?

            • Albert says:

              Taking in account that I have to choose only one option and I feel I should correlate both findings…I must choose:


              Anyway I would prefer a more agressive semiology to reject the benign options (thymoma + neurogenic tumor).

    6. Dr Hesham says:

      I think of neurogenic tumer due to moderate pain leading to emergnecy

    7. Alejandra says:

      Pueden ser las 3 posibilidades, metástasis,tumor neurogenico y menos probablemente tumor fibroso de la pleura

    8. Arius says:

      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.

    9. Evren says:

      An upper mediastinal mass and a pleural mass. Adult patient. Malign Thymoma or Lymphoma are my best shots.

    10. Vilma says:

      I thinking about neurogenic pleura tumour and thymoma

    11. Olga says:

      I favour neurogenic tumour too

    12. RadLex says:

      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

    13. HIBA says:

      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.

    14. Genchi Bari Italia says:

      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!

      • Jose Caceres says:

        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.

    15. GENCHI BARI ITALIA says:

      Grazie illustre collega:Bari, piccola squadra ma grandi emozioni!!!!

    16. Dr Strangelove says:

      All of the above ? Mmmmm….confusing.

      • Jose Caceres says:

        All three possibilities look the same on CT. The mediastinal mass makes metastasis a good possibility. I don’t find it confusing.

        • Dr Strangelove says:

          In my opinion, CT image clearly suggests chest wall mass (neurogenic tumour), not pleural (metastasis, fibrous tumour).