Dr. Pepe’s Diploma Casebook: Case 110 – The Wisdom of Dr. Pepe (Chapter 3) – SOLVED!

Dear Friends,

To continue with the third chapter of The Wisdom of Dr. Pepe, I am​ showing radiographs of an asymptomatic 52-year-old man with previous history of asbestos exposure.

Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.

1. Fibrous tumour of pleura
2. Large pleural plaque
3. Pleural fat
4. Any of the above

Click here for the answer

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    15 Responses to : Dr. Pepe’s Diploma Casebook: Case 110 – The Wisdom of Dr. Pepe (Chapter 3) – SOLVED!

    1. MK says:

      Good morning!!

      Calcified left apical pleural plaques; calcified lesions proyected over LUL and LLL probably granulomas. No significant changes in time.

      There is a hight density lesion proyected over medium peripheral lobe (with a well definied medial margin), that is bigger than in the previous x-ray. We have to do a CT to exclude a neoplastic origin (probably pleural location-mesothelioma).

      So, any of the above.

      • Mk says:

        I think the calcification have move downwards because of a soft tissue extrapleural lesion is displacing the right pleural plaque. Now the extrapleural soft tissue component is visible (not present one year earlier) so mesothelioma will be an option

    2. Ren says:

      Bilateral apical pleural caps seen. Calcified foci seen in left middle zone. These could represent healed granulomas. An opacity seen over the right upper/ middle zone having a well defined medial margin and obscured lateral margin. It shows some internal calcification. There is increase in size from previous xray raising concern for neoplasm.(mesothelioma) in a patient with history of asbestos exposure

    3. tr says:

      one nodule over the right mid zone and few smaller over the left mid zone; with no significant change in size over the year interval, but they seem to have slightly different positions when comparing both images.
      the change in position and the complete border make them more likely to be pulmonary nodules.
      I don`t see other abnormalities.
      I think the patient should be followed as a high risk patient with pulmonary nodules.

    4. Dr Pepe says:

      I agree with you about the nodule in the right side not changing in size. I disagree about the location; to me it looks extrapulmonary. Do you think that it is calcified?

      • Mk says:

        Perhaps it seems to be more “white” because it is proyected over the rib

        • tr says:

          they can be located in the anterior or posterior pleura/chest wall, and possibly calcified.
          Should we, generally speaking, recommend CT scan in such cases (small lesions), or its enough to follow with CXR?

          • tr says:

            well, i think i was wrong we i thought the nodules have moved, i gave more attention to the anatomic landmarks, and i think it only a technical issue related to the patient`s position and beam incidence.

    5. genchi bari italia says:

      …illustre Prof …. la formazione adesa alla parete toracica, si raccorda con angoli ottusi al polmone, per la sede extrapleurica…essa dimostra una calcificazione amorfa e grossolana, medialmente…..i nodulini opachi polmonari possono essere da esposizione all’amianto…..penso pertanto ad una placca pleurica, parzialmente calcificata…..sempre con affetto da Bari…..

      • Dr Pepe says:

        Do you think, comparing the two films, that the calcification has moved?

        • genchi bari italia says:

          no….essa deborda dal margine inferiore della 7 costa, posteriormente, nella prima immagine , solo perchè le due immagini non sono esattamente nella stessa fase inspiratoria.

          • Dr Pepe says:

            Draw a line on the margin of the lesion and around the calcification and tell me whether or not the calcification has moved

    6. genchi Bari italia says:

      ….allora la calcificazione può’ essere liquida, come latte calcico. ?…….Dybala è’ a Barcellona insieme a Dani Alves…..cosa significa questo ?

      • Dr Pepe says:

        It probabably means that he is visiting the city. I don’t believe Barça has money for another star player.