Hola amigos: El caso de hoy corresponde a un hombre de 58 años con dolor en hemitórax derecho.
Podéis dar vuestra opinión hasta el viernes, día en el que se publicará la solución.
Hallazgos: La radiografía localizada muestra una lesión extrapulmonar (A, flecha) con destrucción de la costilla subyacente (A, asterisco). En la radiografía lateral se observa una amputación parcial del húmero izquierdo (B, flecha roja), rodeado por el muñón de tejidos blandos (B, flechas):
Diagnóstico: Metástasis costal de fibrosarcoma de húmero izquierdo (intervenido).
El objetivo de esta presentación es discutir lesiones periféricas extrapulmonares. Dichas lesiones se caracterizan por tener unos bordes bien definidos y ángulos obtusos en su periferia. Se diferencian de las lesiones intrapulmonares periféricas porque éstas presentan ángulos agudos (Fig. 1).
Fig. 1A: Aspecto típico de una lesión extrapulmonar con bordes bien delimitados y ángulos obtusos (A, flechas). B: La imagen muestra una lesión con ángulos agudos (B, flecha) y, por consiguiente, intrapulmonar.
Las lesiones extrapulmonares periféricas pueden originarse en la pleura o en la pared torácica. Aquellas que proceden de la costilla pueden descubrirse fácilmente en la radiografía de tórax si identificamos la lesión costal. Ello nos permite sugerir un diagnóstico de malignidad. Las dos causas más frecuentes de masas con efectación costal in adultos son las metástasis y el mieloma (Fig. 2):
Fig. 2: Varón de 45 años con dolor en hemitórax izquierdo. La radiografía PA muestra una lesión periférica extrapulmonar (A, flecha), apenas visible en la proyección lateral (B).
La radiografía localizada muestra que la costilla subyacente no es visible (C, asterisco). Un TC axial muestra una gran lesión destructiva costal con masa de partes blandas (D, flecha). Biopsia demostró una metástasis de hepatocarcinoma.
Si no se observa lesión costal en la radiografía, es preciso hacer un TC para determinar la densidad de la lesión. Las más frecuentes son tejidos blandos o grasa.
La densidad de tejidos blandos identifica una lesión sólida tumoral, que habrá que investigar. Las etiologías más frecuentes son los tumores fibrosos de pleura, neurofibromas y metástasis (Fig. 3):
Fig. 3: Típica lesión extrapulmonar en un paciente operado de timoma maligno (A, flecha). No se ven alteraciones costales. TC muestra una lesión pleural sólida (B, flecha), que correspondía a una metástasis pleural del timoma.
Los lipomas de pared torácica no son infrecuentes. No pueden distinguirse en la radiografía convencional de tumores sólidos, ya que tienen una densidad similar. Son fácilmente demostrables por TC, que evidencia la densidad grasa y confirma la inocuidad de la lesión (Figs. 4-5 ):
Fig. 4: Varón de 52 años asintomático, en el que se descubrió accidentalmente una lesión extrapulmonar (A, flecha). TC demuestra que la lesión corresponde a grasa parietal (B, flecha).
Fig. 5: Varón de 57 años con carcinoma broncogénico. La radiografía PA de tórax muestra un hilio tumoral (A, flecha) y una lesión extrapulmonar (A, flecha roja). TC confirma un colapso parcial de LII (B, flecha). La masa visible en la placa PA corresponde a grasa parietal (C, flecha roja) y por tanto, carece de significado.
El líquido pleural encapsulado puede dar también lesiones extrapulmonares. No suele dar problemas diagnósticos, ya que la evolución clínica suele ser suficiente. En caso de duda, un TC confirma la densidad agua del líquido (Fig. 6):
Fig. 6: Varón de 35 años con empiema encapsulado. La radiografía PA muestra una colección extrapulmonar (A, flechas) con densidad líquida en el TC coronal (B, flechas). Como en la gran mayoría de líquido encapsulado pleural hay pinzamiento del seno costofrénico.
El consejo de Dr. Pepe:
- El signo de la embarazada diferencia las lesiones extrapulmonares de las pulmonares periféricas.
- La destrucción de la costilla subyacente apunta a una lesión maligna.
- La TC nos permite identificar lesiones sólidas y excluye la grasa extrapleural, que carece de significado patológico.
opacity of the apex of the right lung
parietal mass
Tumor pleural
Imagen compatible con lesión pleural compatible con derrame pleural lo cuñado va mesotelioma
La costilla está destruída, lo que sugiere en primer lugar una lesión costal con masa acompañante.
Más información mañana.
Buen fin de semana!
Mesotelioma
metástasis.
Esta lesion fue resecada quiurgicamente?
LESIÓN EXTRA PLEURAL , LA LESION PUEDE SER UNA OSTEOLISIS COSTAL.
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