Caceres’ Corner: Case No. 33 (Update: Solution)

Dear Friends,

Muppet is feeling mean today and wishes to inflict upon you the following case: a 56-year-old woman with a history of respiratory infections. She was operated on for osteogenic sarcoma of the right leg eight years earlier.

1. Metastases from sarcoma
2. Carcinoma of the lung
3. Tuberculosis
4. None of the above

56-year-old woman, PA chest

56-year-old woman, lateral chest

56-year-old woman, CT

Click here for the answer to case #33

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    Sep 2012
    DISCUSSION 33 Comments

    33 Responses to : Caceres’ Corner: Case No. 33 (Update: Solution)

    1. fatima says:

      luftsichel sign.

      2 – carcinoma of the lung

    2. fatima says:

      3 – mets of sarcoma

    3. vinay says:

      mets from sarcoma ..

    4. Marius says:

      The Luftsichel sign + retrosternal opacity projection on profile + diaphragmatic peak indicate LUL atelectasy; Probable cause is some central calcification – maybe broncholiths or calcified ADP (goes well with recurrent infections – maybe tb?). I see no reason to think of mets from osteosarcoma 8 years apart.
      And there’s a small left pleural effusion – dunno why…

    5. Ricardo says:

      4. Seguiré estudiando el caso

    6. pedro manuel gil c ruz says:

      the opacity in lateral projection show thathe cause is one obstruction produced by bonchiolits like i can seein inthe ct of the lung not exist neoplasis causes in this images

    7. Rahul says:

      PA – left upper lobe collapse – veiling density, luftsichel sign, juxtaphrenic peak sign; also a left apical pneumothorax; Lateral – confirms the LUL collapse; CT chest (unenhanced) – calcified lesion causing obstruction of the left upper lobe bronchus likely from an osteosarcoma metastases – these are associated with pneumothoraces

    8. Irene says:

      4.bronchial carcinoid tumor maybe?

    9. Isobel says:

      Lingular atelectasia- intrabronchial mtx ?

    10. Genchi Bari Italia says:

      Atelettasia lobo polmonare da bronco-litiasi del bronco lobare. quale esito di calcificazioni da tappo mucoso.GG

    11. Dr Hesham Al feria I says:

      I would prefer TB if the patient is coming from east Other wise it’s metastatic lesion

    12. Dimitrova says:

      None of the above.Pneumothorax partialis?

    13. pedro manuel gil c ruz says:

      is a bronchiolit whit atelectasis

    14. p.s says:

      Post-obstructive atelectasis of the left upper lobe.
      Unilateral LT pleural effusion.New pulmonary primary.
      It could be osteogenic sarcoma M though, If the time interval in between was less than 5 years.But, endobronchial M are rare.
      So ,I think it is the second choice.

    15. Alice says:

      Bronchial calcifications leading to LUL-atelectasis.

      Singular metastatic lesion of osteogenic sarcoma is unlikely, but possible.
      Broncholiths is another possibility, but the chest-x-ray does not show signs of earlier TB and other causes of bronchioliths are rare.
      Time for another wild guess:
      4. (none of the above) – strongly calcified tracheobronchogenic amyloidosis?

      • Jose caceres says:

        Muppet loves your diagnosis, although is not the right one. Gives you special prize for creativity.

    16. Rami says:

      Allow me to talk loudly, Yes it may look as a Pneumothorax, but there are three against it, 1-the continuation of the vessels(no cut of), & 2- if we compare the two apex we would see them same density! 3- What would be the reason of decreasing transparency of the left side which is seen just ventrally, in compare to the other side. CT answers that with: Pleural effusion(pyo or hemothorax), specially when we see that the bronchus is widely open !
      From lateral view, no Lymph nodes enlargement. Calcification seem to be due chronic process , its maybe TB: unilateral Effusion with central calcification…

    17. olga says:

      There is probably a central calcified endoronchial lesion causing the LUL collapse. A foreign body which is calcified is a likelihood. A calcified endobronchial mass such as a carcinoid is another possibility.

    18. Genchi Bari Italia says:

      PS:tempi supplementari. E’ stata eseguita una biopsia della mucosa nasale? La storia di infezioni respiratorie croniche, potrebbe essere indicativa per una Discinesia ciliare primitiva, con “mucoid impact” e successiva calcificazione.

    19. hassan says:

      There are a signs of LUL atelectasis (Volume loss, Elvation of left hilum, tenting signs of diaphragm and displacement of major fissure anteriorly and the most likely cause is tumour wither mets or primary tumour
      I prefer mets from sarcoma.

    20. Dr. T says:

      My first choice is Mets .

    21. mm says:

      Hard case. I go for a primary endobronchial tumor. Could be an endobronquial hamartoma?

    22. vishal kalia says:

      On chest x-ray PA and lateral views features are typical of left upper lobe collapse(luftsichel sign, pulling up of hilum, veil like opacity). CT confirms the x-ray findings with densely calcified endobronchial growth appearing to be the cause of collapse. The differentials will be bronchogenic CA(points in favor are-common cause of collapse and central endobronchial lesion;points against are very dense calcification, no significant extension outside the bronchus), mets from osteogenic SA(rare, would not think of it without relevant history,but endobronchial mets can occur in osteo SA although rarely; points against are-no metastatic lesions in rest of the lung) tubercular or fungal infections( also commmon cause of broncholiths but there is no evidence of any other calcified mediastinal lymphnode or other sequelae of previous infection),endobronchial carcnoid(can be a differential, calcification seen in only 1/3 of cases) and hamartoma(not fat density seen along the calcification. My first possibility will be bronchogenic CA and 2nd possibility will be mets from osteogenic SA. Carcinoid is a strong d/d.

      • Jose Caceres says:

        Excellent discussion. As a matter of fact, it’s better than the one Muppet is posting tomorrow 🙂

    23. ab says: