Dr. Pepe’s Diploma Casebook: Case 41 – SOLVED!


Dear Friends,

This year I plan to show only chest cases, emphasising the diagnostic approach to basic patterns in the plain film. Hopefully, this monographic approach will help you with the diploma examination.

Cases will be posted every other Monday and answers will be given on Friday.

Radiographs (below) of the first case belong to a 57-year-old man, asymptomatic. Study them carefully, leave your opinions in the comments section, and look out for the answer on Friday.


1. Thymoma
2. Teratoma
3. Mediastinal fat
4. Can’t tell

57-year-old man, asymptomatic

57-year-old man, asymptomatic

57-year-old man, asymptomatic

57-year-old man, asymptomatic

Click here for the answer

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    18 Responses to : Dr. Pepe’s Diploma Casebook: Case 41 – SOLVED!

    1. genchi bari italia says:

      Opacità nel mediastino anterosuperiore: regola delle 4 T( Tiroide-Timo-Teratoma-T linfoma).Tiroide esclusa perché manca il raccordo con un prolungamento intratoracico di una tiroide).Timoma ,T.da residui embrionari e Linfoma per mancanza di clinica e-o laboratorio).Rimane grasso mediastinico soprattutto se ha fatto terapia steroidea.Farei solo una ecografia perché la sede lo consente(evitando la Tac).

    2. Katerina says:

      I think that the lesion is situated in the anterior mediastinum (not anterosuperior) and that it can be either a thymoma, a teratoma or a thymoma but not a thyroid lesion, because the latter would be situated in the middle mediastinum.
      I choose 1. Thymoma
      because it is the most common tumor in the anterior mediastinum, it is often asymptomatic and the mean age of presentation is 50 years

    3. gus says:

      the mass is in the anterior mediastinum and i think is more dence for mediastinal fat.could be a cystic mass or a mixt density mass. there is not calcified and there is not mass efect on the adjacent structures.
      thymoma is the best choise

    4. TobiBob says:

      I would say thymoma. differential would be teratoma, but the age of the patient doesn’t really fit.

    5. Klodi says:

      I think it’s in the anterior mediastinum, well circumscribed, large. I think a Tymoma, or maybe a pericardial cyst in a less likely location.

    6. genchi says:

      …anche una cisti dermoide, potrebbe essere la risposta giusta.

    7. Dr. Pepe says:

      Before posting the answer tomorrow, I would like to ask you if it is possible to make an specific diagnosis of a mediastinal mass in the plain film.

    8. genchi says:

      ….per me non è possibile….si può dire che la massa è compatibile in prima istanza diagnostica con….e poi confermarla con una TAC( se si ha una sonda ecografica , si può completare con questa)

      • Dr. Pepe says:

        Correct! Therefore, the best answer is 4. Cannot tell
        The message is that any mediastinal mass must be evaluated with cross-sectional imaging (usually, but not only, CT)

    9. genchi bari italia says:

      …corretta la mia diagnosi: Bari-Barcellona 2 a 0. Reti:Casebook Pepe’s 41 e Prof.Caceres casebook 71!!!!

    10. Manu says:

      Nella mia carriera mi era già capitato di vedere un’immagine simile e il medico radiologo lo aveva refertato per massa di grasso a livello mediastinico..consigliando però alcune scansioni TC mirate..

    11. dr. yusra almass says:

      An ant. mediastinal mass, of well-defined outline, I think
      the best answer is 4 , because further evaluation is needed by CT scan.

    12. […] Most mediastinal lesions are discovered in the PA radiograph. Broadly speaking, they look like soft-tissue ‘bumps’ in the mediastinum (Fig. 1), identified by the typical pregnancy sign (Diploma Casebook case 95). Since the great majority have no specific characteristics, the role of the chest radiograph is to place the lesion in one of the mediastinal compartments (see Diploma Casebook case 41). […]