Dr. Pepe’s Diploma Casebook: Case 20 – SOLVED!

Diploma_casebook_case20

Dear Friends,

Showing chest radiographs of an 81-year-old male with multiple bone fractures after a car accident. There is a rounded well-defined opacity in the posterior costophrenic sulcus. What do think it is?

1. Carcinoma of the lung
2. Bochladek’s hernia
3. Diaphragmatic cyst
4. All of the above

81-year-old male, PA chest

81-year-old male, PA chest

81-year-old male, lateral chest

81-year-old male, lateral chest

Click here for the answer

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    30 Responses to : Dr. Pepe’s Diploma Casebook: Case 20 – SOLVED!

    1. Wasif says:

      2. Bochladek’s hernia

    2. Hussein Fawzy says:

      Bochdalek hernia

    3. Wasan Abdulhakeem says:

      The answer is carcinoma of rhe lung
      Number 1

    4. Taher arif says:

      Bochdahlik hernia

    5. Bruno says:

      Round opacity in the right posterior costophrenic sulcus. It could be a posterior mediastinal mass (pleural or neurogenic origin). With the options given I think Bochladek’s hernia is the best. It can be discovered in adults as a small herniation of fat tissue in both sides.

    6. NK says:

      Bochdaleks hernia

    7. ana says:

      diaphragma tear

    8. ana says:

      it could be a diaphragma tear

    9. MT says:

      . Bochladek’s hernia

    10. rvinay says:

      It looks like bochdalek hernia with gaseous pockets within

    11. Dr. Pepe says:

      I believe the gaseous pockets may be superimposed bowel

    12. Dr. Pepe says:

      There is a strong opinion in favor of hernia and only one for carcinoma. Anybody goes for diaphragmatic cyst?

    13. Maria says:

      I do not really like the configuration of aorta. Is he hemodynamiicly stable? I desperately need a chest ct.

    14. vijay kumar ichpujani says:

      bochdalek’s hernia vs diaphrammatic cyst.. Given the history of trauma diaprhagm tear with subsequent herniation is more likely.
      However, Age may favour a diagnosis of carcinoma, but there are no other symptoms or xray findings supportive.

    15. Dr Strangelove says:

      Taking into account that:
      1. Muppet is tricky and things could not be what they look at first sight (that is the lesson).
      2. Angle of the mass with diaphragma is acute (lateral view) suggesting a supradiaphragmatic origin.
      I would choose lung carcinoma.

    16. Dr. Pepe says:

      I may even trickier than you imagine. You may be right and still give the wrong answer. Still, I congratulate you.

    17. Dr Strangelove says:

      OK, I give up and wait for the solution.
      Muppet is a twisted mind. If the answer is 4, all of the above, Muppet will be barbecued (calçots time).

    18. Maria says:

      There is also an osteoporotic wedge shape fracture of a thoracic vertebra. I will go with lung carcinoma with paraneoplasm reaction.

    19. Aleesha says:

      I believe it is carcinoma.patient too old for bochdalek hernia.diaphragmatic cysts r usually between liver and diagram .it is in the chest

      • Dr. Pepe says:

        Disagree with you. You are thinking of congenital Bochladek hernia. Old people have adquired B. hernia due to the weakening of diphragmatic fibers. Adquired B. hernias increase with age

    20. Badr says:

      the lesion is round shape , well defined in the left posterior costophrenic sulcus:
      1- despite patient is old age ( goes with tumor), but the lesion is well defined, so this option is unlikely.
      2. Bochladek’s hernia, left sided, more in neonates despite some cases reported in adult but there is no findings of herniated bowel in the chest… so it is unlikely.
      3. Diaphragmatic cyst, also congenital and more in children , so it is unlikely…
      we can noticed that descending aorta is tortuous because of atherosclerotic changes as old age … therefore my differential Dx could be descending aortic aneurysm or hydatid cyst.

    21. genchi bari italia says:

      Crollo somatico, a cuneo anteriore di T5, fratture costali , con callo osseo , a dx, mentre a sx le fratture costali, sono recenti, senza callo osseo, e riferibili pertanto al trauma in atto.La massa dello sfondato costo-frenico posteriore dx, si raccorda ad angolo acuto con il polmone, indicandone una sede intra-polmonare. Penso allora a lesione maligna polmonare, con metastasi ossee: il trauma toracico ha fatto “scoprire” la patologia di base.

    22. Genchi bari says:

      Illustre collega, la tua risposta , ritenuta valida per tutte le opzioni che hai formulato, non mi trovano d’accordo e d’altronde la diagnosi finale è propria quella da me formulata , sulla base della patologia ossea concomitante: vertebrale e costale, dx e sx,con “differente” cronologia nei tempi di comparsa delle fratture costali, con e senza callo osseo. Difronte al caso in esame pertanto la 1 diagnosi è quella da me formulata, salvo a dimostrare la “benignità” delle lesioni ossee concomitanti.Aspetto una tua controreplica.

      • Dr. Pepe says:

        Patient was operated on and a follow-up chest film a few months later showed healing of the rib fractures. I believe a PET -CT was negative for osseous metastases, although I don´t have the images. Will look for them and send them to you, together with the post-op chest film.
        Thank you.

    23. Genchi says:

      Grazie per la risposta.

    24. Justin says:

      The one answer that can be confidently excluded is 4. All of the above. The chance that these 3 pathologies would co-exist is extremely small. I have just looked in PubMed ; it has never been reported.

      Perhaps the author meant 4. Any of the above.

      • Dr. Pepe says:

        You are right. “Any of the above” is the proper wording. My English is getting rusty.
        Thanks. I stand corrected

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