Dr. Pepe’s Diploma Casebook: Case 99 – A painless approach to interpretation (Chapter 6) – SOLVED!


Dear Friends,

We’re moving on to a new chapter of the Painless Approach to Interpretation, and this week I’m showing the routine control radiographs of a 48-year-old woman, surgically treated for carcinoma of the breast ten years ago.
What do you see?

Check the image below, leave your thoughts in the comments section, and come back for the answer on Friday.



Click here for the answer

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    40 Responses to : Dr. Pepe’s Diploma Casebook: Case 99 – A painless approach to interpretation (Chapter 6) – SOLVED!

    1. Mauro says:

      I think there is mild elevation of the right hilum, thickening of the right paratracheal stripe and a triangular shaped opacity in the right upper lung field best seen on profile. These findings are probably due to volume loss of the right upper lobe, or at least one segment of this lobe.

      • Dr Pepe says:

        I believe the triangular opacity in the lateral view is due to the soft tissues of the armpit. Note how the anterior line goes out of the lung.

    2. DrPedro says:

      Left breast implant.

    3. MK says:

      There is a subtle hyperlucency of the LUL, and an asymmetry between both breasts, because of surgical changes.
      I can see an increased vascular right hilum.

    4. Genchi Bari Italia says:

      …..professore stimatissimo……dove. è’ l’arco anteriore della 5 costa di Sx ?….la patologia è’ una probabile metastasi litica ….un augurio per il tuo Barca che non decolla…..il mio Bari ha ancora perso…..un grande saluto…

    5. Marco says:

      Oval hyperlucency in the posterior right 8th rib. Also round hyperlucencies in the 8th and 11th thoracic vertebra. The right hilum also appears slightly elevated.

      • Marco says:

        The left upper lung zone appears slightly more lucent compared to the right. I also noticed a round focal lucency between the 7th and 8th left posterior ribs.

      • Dr Pepe says:

        Lucencies may be due to superimposition of scapula. There were no bone lesions.

        • Marco says:

          There seems to be widening of the upper mediastinum on the right side appearing as a soft tissue density. May be associated with enlarged mediastinal lymph nodes.

          • Dr Pepe says:

            Now you are using your knowledge! 😉

            • tuan huy says:

              Dear my Prof, how can we distinguish the widening of right paratracheal from real lesion to widening of SVC, especially in rotation patient, I always worry about variant in rotation patient, more important when we have a CXR with wrong technique, low KVp. Thanks

    6. MK says:

      Right upper paratracheal líne is thickened, perhaps because of mediastinal lymph node secundary to breast neoplams

    7. MK says:

      And right hilar adenopathy

    8. Yvette says:

      Dear dr Pepe, according to your previous lecture, we can say that both hila are the same density and lay on the same level so they are normal. Both main bronchi have a proper angulation.
      There is no hidden masses in apices and in costophrenic angles.Mediastimum isn’t widened, nie fluid in both c-p angles. Bones have low density probably because of anti estrogenic theraphy, but no signs of maetastatic disease. Round opacity at the level of Th8-Th9 is probably the scapula’s angle.
      I would say it’s normal

    9. sht says:

      The left upper(AP) and lower(Lat) hyperlucencies are probably due to prior surgery.
      Both the right paratracheal and left apical shadows look within normal limits.
      Cant really see added hilar opacity in the lat view.
      So will have to say normal images.

    10. Pepita says:

      Micronodular spread

    11. Gabriel says:

      Left inferior lobe nodule pa-retrocardiac ll-projects over the dorsal body

    12. Ren says:

      there is sight hyperlucency of left hemithorax probably post surgery.
      Some of the thoracic vertebrae show hyperdensities. Comparison with previous and follow up X-ray’s required to rule out Mets Vs being lesion

    13. Jolanta says:

      widening of the upper mediastinum and two small nodules in Lateral view

    14. Olena Hural says:

      There is small nodular opacity on lateral view on the level of thoracic vertebrae

      • Olena Hural says:

        This opacity is near the vessels.
        And in lingular segment it seems to be also opacity, which join with heart shadow

        • Olena Hural says:

          A little bit higher above that small opacity on the vertebrae level, there is bigger opacity which is connected with vessels

    15. Nacer says:


    16. sht says:

      Round lucency Rt hilum?

    17. Maria says:

      Lateral view – abnormal opacity in subcutanneous tissue, at upper part of sternum.

    18. ania says:

      right hilum at the same level as left?

    19. sztyga says:

      Right paratracheal line is thickened (enlargment mediastinal lymph nodes?), and on the lateral view behind the heart (at the level of Th9/10) is round opacity, probably vessel but it also could be metastatic nodule, so CT should be performed:)

    20. Mahmoud says:

      Left hilar increased density with lobular outline, may represent hilar lymphadenopathy or medially located lung nodule

    21. Dr Pepe says:

      Before the answer is posted I want to congratulate MK, who saw the abnormality and made a correct evaluation.

    22. genchi bari italia says:

      …grazie Professore per la bellissima lezione !

      • Dr Pepe says:

        Thank you. I believe this case emphasizes the importance of checklists. And of playing well against Real Madrid 😉

    23. ZHW says:

      Beautiful presentation thank you

    24. Fabian says:

      Excelente trabajo. Muchas gracias profesor.