Dr. Pepe’s Diploma Casebook: Case 78 – SOLVED!


Dear Friends,

Today I’m showing a PA radiograph of a 49-year-old man with cough. Check out the image below, leave your thoughts and diagnosis in the comments section and come back on Friday for the answer.

1. Mediastinal lesion
2. Pulmonary lesion
3. Both
4. Can’t tell


Click here for the answer

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    24 Responses to : Dr. Pepe’s Diploma Casebook: Case 78 – SOLVED!

    1. Fares says:

      A right paramediastinal soft tissue shadow extends above the superior clavicle, positive cervicothoracic sign (lung tissue comes between the mass and the neck).
      It is mostly a mass in the posterior mediastinum.

    2. Giovanni says:


    3. genchi bari italia says:

      …la massa può essere di pertinenza sia del segmento apicale lobo superiore sia del mediastino(risposta è 2 )….nello specifico essa dimostra dislocazione a sx della colonna tracheale nonchè sembra estendersi sul cappuccio aortico….diagnosi finale più probabile linfoma….Saluti da Bari….

      • genchi bari italia says:

        …prego corrige: la risposta , in base a quanto dscritto è 3….entrambe(apice polmonare-mediastino)

    4. Borsuk says:

      I think lesion is mediastinal. There is pregnancy sign – surface is smooth, one angle is obtuse, second isn’t but it’s localise in apex.
      Moreover as was mentioned there is positive cervico-thoracic sign so we could precise location to posterior compartment of mediastinum. Trachea isn’t impacted what also confirms that sugestion.

    5. gus says:

      Posterior mediastinal mass

    6. DrPedro says:

      A right mediastinal soft tissue density is mostly homogenous, but below 1st rib it looks a little inhomogenous. So I think there is two lesions- both pulmonary and mediastinal…

    7. Drbabs says:

      Chest X-ray of a 49 year old man presenting with couch of unknown duration shows a nearly elliptical non-calcific homogenous opacity along the right tracheal border at the thoracic inlet. Lower neck is not photographed and therefore it’s uncertain if it continues with the root of the neck. The lesion forms obtuse angle with the right lung apex and it’s therefore an extrapulmonary lesion. Trachea is neither deformed nor displaced and no convicing evidence of remodelling of adjacent ribs. The lesion most likely originates from the superior mediastinum with nerve sheet tumour( shcwannoma) a major differential. Intrathoracic goitre is also a consideration if the lesion continues with the root of the neck.

    8. Jorgetas says:

      Opaque azigos lobe.

      Increased density of the azygos lobe on frontal chest radiographs simulating disease: CT findings in seven patients.
      J Cáceres, J M Mata, X Alegret, J Palmer, and T Franquet
      American Journal of Roentgenology 1993 160:2, 245-248

      • Jose Caceres says:

        You did your research! But remember that the opaque azygos lobe occurs in older people because it is caused by elongation of supra-aortic vessels.
        Still, I believe congratulations are in order.

    9. Paras says:

      1. Mediastinal mass

    10. Yvette says:

      What about lungs changes? Are there any small nodules with random distribution in both lungs? . This kind of changes are present in hematogenous metastases, tbc, in some cases of sarcoidosis.

    11. Yvette says:

      Tbc with paravertebral abscess? Too far from KISS rule?

      • Jose Caceres says:

        A little too far. And the KISS rule would specify bilateral widening in a vertebral abscess

    12. Lola la Piconera says:

      I would say 2
      It seems to me inside the opacity in the right upper zone there are some tubular branching lucencies that could be readed as bronchogram so lesion would be a lung lesion. The outer sharp outline could be explained by an azygous fissure. A consolidation inside an azygous lobe would fit with this image.

    13. devjani says:

      Right upper mediastinal mass.

      Is there an opacity just below the medial end of the left clavicle?

    14. JLGC says:

      4. Can´t tell

      Probably, an opacified azygos lobe

    15. Jose Caceres says:

      Dear friends this is the last case of the first semester, Will see you again in September.
      Explanation of the findings tomorrow. Congratulations to Dr. Pedro, who was the first to post the correct answer.
      Have a nice summer!

    16. tekwani parmanand says:

      c both

    17. LUCAS says:

      1. Mediastinal lesion