Dr. Pepe’s Diploma Casebook: Case 1 – SOLVED!

Dear diploma fans,

Welcome to the very first entry from my diploma casebook!

This is just the first of many weekly cases I’m going to show here on the ESR blog, to help you prepare for the European Diploma in Radiology. They are all typical of what you might expect to find in the exam and I will guide you through each one and remind you of the key points to consider.

To start off, I’m going to follow in the footsteps of my good friend Jose Caceres (although I will be more compassionate), and show you a chest case. If you have any comments or questions, please leave them in the comments section under this post. The answer will be posted on Thursday.

Good luck!

Case 1: 45 year-old man with pain in the left hemithorax

Fig 1

Probable diagnosis:

1. Myeloma/metastases
2. Fibrous tumour of pleura
3. Extrapleural fat
4. All of the above

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    23 Responses to : Dr. Pepe’s Diploma Casebook: Case 1 – SOLVED!

    1. Mihai Comsa says:

      2. Fibrous tumour of pleura

      • Nora says:

        Fibrous tumor of the pleura
        well defined meduim denisty lesion with obtuse angle with chest wall in one side and acute in the other side and its basee related to the pleural surface confirm its chest wall origin and different shape in both views suggest fibrous tumor of the pleura

    2. Kelvin says:

      The opacity in the projection of the lateral aspect of the midzone of the left lung is definitely extrapulmonary. Since it is forming an obtuse angle with the chest wall, it looks like a pleural based mass.

      No associated pleural effusion.

      No bony abnormalities of the related ribs are seen – making it not typical of a myeloma met.

      It does not look like extrapleural fat (site and appearance not typical).

      So my answer is fibrous pleura of pleura.

    3. Genchi Bari Italia says:

      La massa ha sede extra-pleurica:margini netti e raccordo con angoli ottusi al polomone.In LL essa si sovrappone all’ombra cardiaca, riducendone la opacità per immagini tenuemente rx-trasparenti.Penso allora ad una raccolta adiposa extra-pleurica.

    4. Mm says:

      For me it is an extrapulmonary lesions (well-defined soft- tissue masses,with angles obtuse to the chest wall)

      I think it is located anteriorly because the anterior clear space is occupied.

      I do not clearly see the anterior convexity of the 4th rib in the left hemithorax. So I think it may be a rib lesion

    5. Livia says:

      Fibrous tumour of pleura

    6. Dr. Pepe says:

      So far, three people elcted fibrous tumor. Can you distinguish between tumor and extrapleural fat in the plain film?

    7. Dr Hesham says:

      i think of extraplural fat due the appearnce of seen through the normal lung tissue

    8. Rajani says:

      All of the above…

    9. Marcy says:

      I think is a extrapulmonar lesion. The anterior arch of the 4th left rib is missing, suggesting a extraplumonar lesion that is “destroying” the rib. Furthermore it has obtuses angles, which support the extrapulmonar origin. It may be due to a MM, metastases or another primary bone tumor.

      • Dr. Pepe says:

        Considering that the answer will be posted tomorrow, I have to congratulate you! You made the correct diagnosis, together with Mm.

    10. Lola la Piconera says:

      2. Fibrous tumour of the pleura.
      There is semiology about pleural or extrapleural lesions
      I can´t see any rib lesion.
      Extrapleural fat usually have “water” density on chest radiogrph. Extrapleural fat is usually seen in obese patients or patients with Cushing syndrome. This man doesn´t seem to be it. The “normal” position of extrapleural fat is seen on PA view around 6-7 to 10-11 ribs sometimes in one side some times in both sides. This is a more or less thin lyer. Then if this man had left extrapleural fat it would be “the mother” of extrapleural fats.
      Extrapleural lipomas I´ve seen so far now are usually lesser dense than other extrapleural lesions such fibrous tumour of the pleura or neurogenic tumours.
      Pain is not very usual in patients with non complicated fibrous tumour of the pleura. I could be a “complicated” pleural fibroma because bleeding, torsion or malignancy.

    11. Samorodova Oleksandra says:

      Fibrous tumour of pleura!

    12. Anna says:

      Fibrous tumour of pleura

    13. Alice says:

      The anterior Portion of the 4th rib is missing as mentioned above.
      Together with pain this strongly suggests a rib lesion (metastasis).

    14. vishal kalia says:

      A well defined lesion broad based towards pleura with obtuse angles suggest pleural/extrapleural pathology. There is associated destruction of the left 4th rib anteriorly. No calcification is seen within the lesion.possibilities include-MM/plasmacytoma/mets.Bone destruction is against fibrous tumor of the pleura/extrapleural fat.

      • pedro manuel gil c ruz says:

        i think that i an extrapleural lesion like myelolma muliple, therai’snt any rib destruction an ia the cuae posible , no metastasi no other causes formzs an angle agude in PA in anterio in lateral

    15. Dr. Pepe says:

      Good. Ready to take your Diploma examination

    16. dr.zaid yousif khder al-samak says:

      my ansewr is all of the above and more