Dr. Pepe’s Diploma Casebook: Case 56 – SOLVED!


Dear Friends,

Today I am presenting radiographs of of 41-year-old woman operated on for Ewing sarcoma of T-12 one year ago. Examine the images below, leave me your diagnosis in the comments and come back on Friday for the answer.

1. Enlarged azygos vein
2. Mediastinal lymph node
3. Mediastinal mass
4. None of the above



Click here for the answer

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    17 Responses to : Dr. Pepe’s Diploma Casebook: Case 56 – SOLVED!

    1. gus says:

      The quality of the films is not so good.
      I think the finding is at the level of aortic arc but on the right side.

    2. Laurens says:

      There is a nodular lesion located in the projection of right tracheobronchial angle. I also see indistinct left tracheal wall ,above aortic arch, I also suspect a lesion there.
      Additionally, lytic lesion of fifth rib on the right? (mid-axillary line). With all mentioned above, I would suspect metastases.

    3. genchi bari italia says:

      ….carissimo dr Pepe…per primo una condiderazione clinica-anamnestica….il soggetto è stato operato di S.Ewing un anno prima,…quindi sono stati fatti dei toraci precedenti….l’immagine era presente nei radiogrammi precedenti o è comparsa dopo? …mi sembra inoltre che , nei campi polmonari, specie a dx, ci siano immagini opache micronodulari….Pertanto , pur essendo quella la sede della v. Azygos, in quella sede ci sono ANCHE linfonodi….In conclusione se l’immagine non era presente nei radiogrammi precedenti e se si confermano , come micrometastasi polmonari quanto visto nei polmoni la conclusione è linfoadenopatia metastatica in sede N2…..

    4. Laurens says:

      If other lesions are excluded (rib and trachea ok) I will go with enlarged azygos vein.

      • Laurens says:

        And I hope for patient’s sake this isn’t because of vertebroplasty material leakage into vascular system.

    5. genchi bari italia says:

      ….carissimo dr pepe…la lesione è quindi connessa con la malattia di base:sarcoma di Ewing…..Se escludiamo l’adenopatia metastatica allora l”opacità è la vena azygos “dilatata”….tenendo presenti le connessioni emodinamiche del vaso, la sua dilatazione potrebbe rappresentare lo “scarico collaterale” di una eventuale occlusione della CVI(vena cava inferiore), occlusa su base trombotica-metastatica….

    6. MP says:

      On the PA view the right hila appears to be elevated with respect to the left. There is also a faint rounded opacification just superior to the right hila. The lateral view seems to show a rounded irregular opacification in the middle mediastinal compartment just anterior to the spine. The patient has a history of Ewing sarcoma which I believe most frequently gives metastases to bone and the lungs. I would consider this a suspicious lesion and follow-up with a CT to rule out metastatic disease.

    7. Dr. Pepe says:

      At this time of the day I can safely congratulate Laurens for being the first to mention the azygos vein and Genchi Bari for giving an explanation of the findings.
      Full answer tomorrow.

    8. genchi bari italia says:

      ..grazie dr.Pepe…..ti prego comunicare al prof. Cáceres quest’altro goal del piccolo Bari…..non sempre si può vincere ….anche i “ricchi”(BARCA), piangono…..!

    9. Laurens says:

      Thank you dr. Pepe!!! 🙂 Just a few more days till a new case! 🙂

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