Dr. Pepe’s Diploma Casebook: Case 51 – SOLVED!


Dear Friends,

I am back with radiographs of a 63-year-old woman with malaise and low-grade fever. Check the images below and leave me your thoughts and diagnosis in the comments section. Come back on Friday for the answer.

1. Carcinoma of the lung
2. Pneumonia
3. Thymoma
4. None of the above





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    37 Responses to : Dr. Pepe’s Diploma Casebook: Case 51 – SOLVED!

    1. dominik says:

      dear Dr Pepe,

      thank you for interesting case.

      PA chest x ray :

      – bilateral lungs parenchyma is visible specially i LF like in parenchymal fibrosis changes and scars.
      – there are no visible nodular leasions in PA projection
      – there is no pleura effusion, no pneumotorax.
      – the left diaphragm is a bit to high but it can be subjective
      – the middle part of mediastinum i slightly enlarge withe a smooth relief of the right margine.

    2. dominik says:

      in lateral projection in retrosternal projection is well see, with a sharp margines rounded mass.
      in lateral projection are also seen DJD changes of T spine.

    3. dominik says:

      The CT scan prove a well define mass in retrosternal compartment.
      On the CT scan of upper abdomen anterioly to the upper pole of left kidney is well rounded with sharp margines mass suggest a adrenal TU.
      The right adrenal gland is fainty see, but it has also round not well define margine – Tu susp.

    4. Eugenio Zalaquett says:

      An anterior mediastinal mass is shown in the lateral projection. This finding is confirmed in the CT and it has soft tissue density. Also, a probable adrenal metastases is seen on the lower images.
      Given the age and symptoms of the patient, thymic carcinoma is my first option. Lymphoma is my second one, but I miss the nodal involvement.

      Thanks for the case Doc. Greetings from Chile!!!

    5. dominik says:

      the joint images from an xray and Ct scan suggest a primary Tu with metastasis to adrenal glands, bilateraly wich is not very rare. the pulmonary primary tumor i on the first place metstaic changes to andrenal glands, and it usually bilateral.

      the secound ddx is an rounde pneumonia, which featers in pediatric group of patient, with independed adrenal leasions.
      that doesnt fix with this patient. the bone age show this is an adult patient.

      against thymoma talk the localisation which is usually the anterior mediastinum.4 T rule.

      • Dr. Pepe says:

        Round pneumonias occur in adults. I assume your excluding thymoma because the lesion is not in the anterior mediastinum is a typographical error.

        • dominik says:

          thank you for answer. I was suggesting that round pneumonia ist mostly typical
          for pediatric group of patient. it is also possible in a adult grup of patient.

          thymoma ddx is rather improbable. there are maybe couple of cases describe an ectopic pleural thymoma….and in this case the mass isnt really well rounded. it has small spikules whats suggest that the leasion comes from the lung. when its comes from the lung and we have belateral adrenal leasions, that strongly suggest the lung cancer with metastasis to the lungs….it also has a slightly CE(its hard to say it on one image ).

          but of course in medicine everything is possible and it could be also a round atelektasis with comet tail sign with independent adrenal leasions. such lungs leasions are very often in subpleural localisation.

          dear dr Pepe I hope I become clear with my invastigetion…hopefully:-)

          • Dr. Pepe says:

            How would you differentiate a lung tumor from a round pneumonia?

            • dominik says:

              dear dr Pepe, to ddx lung leasion in the beginning i ll have an interview with the patient. after that i ll compare present images with past imagies of course in realation to time periods.
              I ll also check inflamation morfological markers.

              After that, when the ddx ll be still uknown I ll choose pet ct scan becouse of high sensivity for metabolic leasions. that ll help me to diferentiate.
              Ill also consider biopsy under ct.

              besides i ve one more thought about an ddx lung lesion, namely it is an hampton hump with no related bilateral adrenal leasions?…..:-)

    6. Maria says:

      Apart from the lesion at the anterior mediastinum and the adrenal lesion , there is also a lesion a little bit superior to the first lesion , just anterior to the trachea. So there are multiple mediastinal lesions and the adrenal lesion. Thymic tumors with metastases is an option. Thymic carcinoid tumor does not correlate well with the clinical evidence.

      • Dr. Pepe says:

        The lesion you describe is the upper portion of right pulmonary artery. Of course, you need the whole CT study to be sure.

    7. dominik says:

      squam cell carcinoma with adrenal glands metastases….

    8. Tugba says:

      Carcinoma of lung with adrenal met.

    9. murzin says:

      This case iż a typical coincidence of mediastinal thymoma with adrenal adenoma (Cushing’s perhaps). This requires further blood evaluation for hormones and tests for myasthenia.
      Let me know id tej answer is any food- I have a low self esteem level 😉

      • Murzin says:

        Ok, my lesson is not to review images via cell phone 🙂
        The mass in fact is located in the lung… so probably cancer with metastasis to adrenal adenoma (adrenal collision tumor?)- there are two densities visible fat like and soft tissue in the left adrenal. The right one seems to be enlarged by a tumor- meta?

        • Dr. Pepe says:

          Looking at films in your cell phone will lead to misreadings and will lower your self-esteem.

          • murzin says:

            Naturally I ment the quiz pictures- it would be quite irresponsible for diagnostics…
            Can’t wait for the answer- this one is really good, brings up many doubts…

      • Murzin says:

        OK one more update concerning the lateral projection film where the lung infiltration is seen (correlating with the ct) plus a anterior mediastinal mass is seen that needs further evaluation perhaps a mateastatic lymph node or thymoma.

    10. JHC says:

      Common things being common, this is statistically most likely a thymoma with adrenal adenoma. Ddx would include thymic carcinoma with metastatic disease to the adrenal gland. A fascinating possibility would be a MEN I syndrome, which would make the ant mediastinal mass most likely a thymic carcinoid tumor.

    11. gus says:

      I think dominik is right.
      thymus is normal for the age of patient (fat replacement).
      on CT the mass is intrapulmonary, lateral of thymus with irregular borders.
      On chest x ray also we can see enlargemet hilum lymph nodes on the lateral view.

      lung carcinoma with metastatic disease to the adrenal gland?

    12. genchi bari italia says:

      …cosmico Professore….la prima cosa da interpretare è la sede della opacità, vista all’Rx e TC: non penso che sia mediastinica, ma di pertinenza polmonare( escludiamo il Timoma)…una polmonite “rotonda” può anche essere esclusa, per sede non tipica nel polmone e mancante dei segni dell”angiogramma” alla tc con m.d.c….un cr polmonare primitivo mi sembra strano per la omogeneità della massa e per il fatto che non prende contrasto alla Tac…nel frattempo hai mostrato un espanso surrenalico a sx, che non produce sindrome endocrina…anche su tutti dicono cr polmonare e metastasi surrenalica , io penso ad una ipotesi inversa, molto rara in verità, di Cr surrenalico e metastasi solitaria nel polmone.

    13. magda says:

      Pancoast tu at the right side
      metastatic lymph node in the retrosternal space and in the adrenal gland

    14. maggie says:

      Pancoast tu at the right side
      metastatic lymph node in the retrosternal space and meta in left adrenal gland

    15. Maria says:

      I believe there is some degree of left hilum downwards displacement. Or not?

    16. Maria says:

      Crazy idea! I don’t like aorta’s contour. Is arteritis excluded?

    17. genchi bari italia says:

      …gentile collega….una analisi più attenta delle immagini, mi porta alle seguenti conclusioni: la formazione polmonare, che appare omogenea e non assume m.d.c. ( anche senza il segno dell”angiogramma”, come nelle polmonite classiche) depone per polmonite “rotonda”….mentre l’immagine surrenalica sx, piccola ed a margini regolari, depone per adenoma”non funzionante”…scusa per la “revisione” del referto.

    18. genchi bari italia says:

      ….grazie dr Pepe ma a me, come a tutti i radiologi, piace avere molto fantasia….ed i radiologi sono artisti a cui piace andare “controcorrente”…a volte!!!!

    19. Luigi Cocco says:

      Yours cases are very hard!!!! Compliments!!!!!B 🙂

      • Dr. Pepe says:

        I believe the cases can be diagnosed if we pay attention to the details. The case presented here was suspected of pneumonia and confirmed by waiting. That was hard because the lady’s husband was a VIP!

    20. genchi bari italia says:

      …congratulazioni dal dottor Genchi Bari, che dopo una inceretezza iniziale, ha fatto la corretta diagnosi di plomonite “rotonda” ed adenoma surrenalico “non-funzionante”.