Caceres’ Corner: Case No. 42 (Update: Solution)

Dear Friends,

Muppet is seriously considering retirement, seeing your level of expertise! You have nailed the previous two cases. We hope you diagnose the following one just as well: 45-year-old man with vague chest pains.

Diagnosis:

1. Aortic aneurysm
2. Intrathoracic goiter
3. Thymoma
4. None of the above

45-year-old man, PA chest

45-year-old man, lateral chest

Click here for the answer to case 42

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    Nov 2012
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    DISCUSSION 29 Comments

    29 Responses to : Caceres’ Corner: Case No. 42 (Update: Solution)

    1. Artur says:

      I’d go for thymoma rather then thyorid goiter. Great hats!

    2. Jorge says:

      Thyroid goiter.

    3. Jorge says:

      Intrathoracic Goiter

    4. Mm says:

      endothoracic goiter because the trachea is displaced to the right and on the lateral view the pretracheal space is occupied

    5. Xose says:

      Muppet, do not retire, please!
      I’d go for intrathoracic gotier too.

    6. VINCENZO GENCHI says:

      Gozzo intratoracico, che impronta e disloca la trachea verso dx, mentre lo spazio chiaro retrosternale è libero.PS. La pensione è bella se vissuta con gli hobby preferiti: i nipoti e la squadra del cuore( sono anche medico-sportivo:la mia 3 specializzazione)!

    7. Genchi Bari Italia says:

      Gozzo endotoracico che impronta e disloca a dx la trachea ed impegna l’outlet toracico.PS: la pensione è bella, perche si ha più tempo libero per studiare la propria materia, più tempo per la libera professione, più tempo per i propri nipoti e più tempo per la ……squadra del cuore!!!!!Sono in pensione da 10 anni!!!!

      • jose caceres says:

        Muppet congratulates you. Your status is enviable! on the other hand: is goiter the only cause of tracheal displacement? Is Muppet naïve?

    8. genchi bari italia says:

      Il gozzo endo-toracico non è la sola causa di impronta e dislocazione tracheale: ad es. anche una cisti broncogena mediastinica.

    9. MANOLIS SOTIRAKIS says:

      Occupation of the aorto-hilar space from a mass.

    10. MANOLIS SOTIRAKIS says:

      There is occupation of the aorto-hilar space from a mass

    11. jose caceres says:

      Afraid this time you all are not thinking properly. Which should be your first condideration when discovering a mediastinal mass?

    12. Marcy says:

      …when we see a mediastinal mass we should determined from which of the mediastinal spaces arises. In this case it seems that is located in the superior middle mediastinal space, so, considerations for endothoracic goiter,duplication cyst,ganglia,vascular anomaly should be taken into account.

    13. Xose says:

      Thanks for your clues, Dr. Caceres
      I’m reconsidering my first answer. The mass doesn’t surpase the clavicles, so intrathoracic gotier or cystic lymphangioma can be ruled out.
      Possible tumors are timoma, germ cells tumors, etc.
      However, we know Muppet is annoyed so that the case has to be very difficult
      Aneurism?

    14. froso says:

      Hello, I am a new fan of your web corner and I find it very exciting!

      About case 42: Lesion is in the superior mediastinum and has distinct upper borders. That means it is not in the anterior mediastinum.
      Also, according to the “silhouette sign” the lesion not located posteriorly (because aortic arch/descending aorta are posterior structures).

      Therefore, the lesion is in the middle superior mediastinum, with deviation of the trachea to the right. The largest portion of the lesion is left to the midline, and a smaller right.
      In the lateral X-ray there is no deviation of the trachea in the anteroposterior axis (that means that a lesion such a retrotracheal goiter should be excluded, because it would shift the trachea anteriorly). Furthermore, this superior location is not typical for a middle mediastinal mass such a bronchogenic cyst, etc.
      Answers 2 and 3 are out.

      This must be a vascular lesion which occupies the middle mediastinum.
      Possible diagnoses:
      -aneurysm of the aortic arch (BUT considering the patient’a age this is not very likely, since saccular-atherosclerotic aneurysms are more often in the elderly with hypertension).

      So my finally vascular diagnosis would be pseudocoarctation of the aorta ( coarctation should be ruled out because the is no rib notching in the PA chest and in the lateral Xray there are no signs of enlarged collateral vessels in the anterior mediastinum).

      (I hope that Muppet will be not too tired and bored from these long comments of a mainly musculoskeletal radiologist…, but who still loves the classics!)

    15. Genchi Bari Italia says:

      Linfoma!

    16. Kelvin says:

      Cervical aortic arch?

      That’s more common on the right….although obviously it can also present on the left.

      • Kelvin says:

        If this were a cervical aortic arch, it would be left sided…another finding favouring the latter is the anterior tracheal displacement…which in such a case would be displaced anteriorly by the high positioned aortic arch.

        The descending aorta in this case is also left sided.

    17. Albert says:

      There is also a convexity on the right paratracheal. I would think of a right aberrant subclavian artery with a big Kummerell diverticulum.

    18. genchi bari italia says:

      Non avevo mai visto questa patologia e sono grato al ” galattico” per avere colmato questo mio vuoto.La diagnosi finale, dopo i suggerimenti, anche dei colleghi, dovrebbe essere la seguente:Arco aortico cervicale, tipo D sec.Haughton. ” radiologia medica” n.96,630-6333,1998.F.Schiavon e coll.

    19. Dr. T says:

      For me, the answer is intrathoracic gotier

      and I hope, The muppet do not retire!

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