Hola amigos, bienvenidos al blog “Los casos de Dr. Pepe”. Mi objetivo es presentar imágenes que ayuden en la preparación del Diploma Europeo de Radiología. Se alternarán radiografías de tórax, presentadas por el Dr. José Mata y yo mismo (Casos de tórax), junto con casos docentes de todas las especialidades recopilados por un grupo de radiólogos expertos (Casos para Diploma).
Los casos aparecerán semanalmente. Os animo a participar y enviar vuestras opiniones.
Sin más dilación, os presento el primer caso. Se trata de una mujer de 57 años con dolor torácico agudo. Analítica normal. A continuación se muestran radiografías de tórax y un corte axial de TC. Cuál sería vuestro diagnóstico?
1. Liposarcoma de pared costal
2. Grasa mediastínica
3. Infarto pulmonar
4. Nada de lo expuesto
Podéis enviar vuestra opinión hasta el viernes, en que se dará la solución.
Haz click aquí para ver la respuesta
Hallazgos: Las radiografías de tórax muestran una opacidad mal definida paracardíaca izquierda (A,B flechas rojas) y un mínimo pinzamiento del seno costofrénico (A,B flechas).
El TAC con contraste i.v. muestra una lesión paracardíaca ovalada con interior graso (C, flecha roja). La lesión tiene un borde denso y en su interior se ven zonas lineales. Se observa una pequeña cantidad de líquido pleural (flecha). El aspecto radiológico de la lesión, junto con la sintomatología, es altamente sugerente de una necrosis grasa epipericárdica (NGE). En esta entidad se produce un infarto de la grasa adyacente al pericardio, igual que ocurre con la apendagitis epiploica en el abdomen. El tratamiento es conservador y el diagnóstico se confirma con un TAC de control que demuestra la desaparición de los hallazgos (D, círculo).
C – TAC inicial; D – Tres semanas más tarde
La NGE se consideraba infrecuente; pero en los últimos años han aumentado los casos reportados. En mi opinión, es mucho más frecuente de lo que se cree y debe incluirse en el diagnóstico diferencial del dolor torácico agudo.
Felicidades a Cocotet y Diana, que hicieron el diagnóstico correcto
Para ampliar el tema: Epipericardial fat necrosis. AJR 2005;185: 1234-1236
Grasa mediastínica
Por la clínica de la paciente y la presencia de pequeños septos en la lesión con densidad predominantemente grasa yo creo que se trata de liposarcoma de la pared costal, aunque por las técnicas de imagen es difícil diferenciarlos a veces.
Quería decir que es difícil difernciar el liposarcoma del lipoma
Otra alternativa grasa no neoplásica?
liposarcoma
Radiografías de tórax la semana previa no mostraban alteraciones. Cambia eso su diagnóstico?
Liposarcoma
Absceso….da la impresion que estuviera entre las pleuras..
En caso de ser liposarcoma ….no habria causado ya erosion osea o por el tamaño lesion a tejidos blandos o infiltracion a pericardio???? La grasa mediastinica noes mas frecuente de lado derecho?
La grasa puede estar en ambos lados. En mi experiencia es más frecuente en el lado izquierdo, en la punta del corazón
Podría tratarse de una necrosis de la grasa epicárdica? Cursan con dolor y densidad grasa, cuadraría bastante.
pericárdica
Infarto de la grasa pericardica.
Diagnóstico correcto! Siento no darte crédito en la respuesta de mañana, que está ya editada.
Tendrás crédito
almohadilla grasa .
grasa mediastinica
infarto graso
liposarcoma de pared costal
cojinete o almohadilla grasa
….che piacere vedere una lingua “latina “….riesco a capire tutto non usando il traduttore….liponecrosi …..l’importante non è partecipare ma….. vincere!!!!….forza Barca e forza Bari!!!!
Benvenuto!
Infrecuente verlo en tórax, mucho más frecuente en abdomen.
Infarto graso. La clínica manda. Los liposarcimas de ese tamaño no duelen. Deben crecer mucho lara infiltrar.
la imagen corresponde a contenido lipidico, podria ser grasa pericardica, la ubicación del liposarcoma no es habitual
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Sin más dilación, os presento el primer caso. Se trata de una mujer de 57 años con dolor torácico agudo. Analítica normal. A continuación se muestran radiografías de tórax y un corte axial de TC. Cuál sería vuestro diagnóstico?
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Chest X-rays, presented by Dr. José Mata and myself ( Chest Cases ), will alternate with teaching cases from all specialties compiled by a group of expert radiologists ( Diploma Cases ).
Could that opacity be liposarcoma? I’ve seen one case present similarly, though much larger, and it turned out to be high-grade. What about mediastinal fat? Slim chance. Let us know what the final diagnosis is! I hope the patient gets well soon. Pacman 30th Anniversary was great!
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Muy interesante el caso, Dr. Pepe. Creo que se trata de grasa mediastínica (opción 2); gracias por este excelente material educativo.
It took me a little while to read all of the comments, but I found the article to be quite intriguing.
This case is a great way to test radiology skills!
This thorax case is an excellent example of how subtle imaging findings can guide diagnosis. I really appreciate the step-by-step presentation — it makes complex radiology more approachable.
I love how the images are presented alongside clear clinical context — it really helps in understanding differential diagnoses.
What a thorough case! The discussion encourages thinking beyond the obvious and improves analytical skills.
Really appreciate the clear explanations and high-quality images — makes learning radiology much more engaging.
It’s impressive how these cases are structured to mimic real exam situations.
The detail in the PA, lateral, and CT images really helps visualize the case.
I really appreciate how Dr. Pepe’s Cases combines structured teaching with real radiology scenarios. The alternating chest X-rays and multidisciplinary cases make it an excellent resource for EDiR preparation.
Thanks for sharing
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Siempre me pongo nervioso cuando veo diagnósticos que dependen tanto de sutilezas visuales. Mencionas específicamente que “el tumor de Pancoast suele invadir la primera y segunda costilla” y destruir las raíces nerviosas. Eso me recuerda a un paciente que vi hace años, donde confundimos una sombra apical con un simple engrosamiento pleural hasta que el dolor de hombro se volvió insoportable. Me pregunto, ¿en tu práctica usas la RM de entrada para cualquier opacidad apical sospechosa, o sigues confiando primero en la TC para ver esa destrucción ósea?
¡Vaya caso! Me llamó mucho la atención cuando mencionas que **”el paciente no presentaba síntomas respiratorios previos”** a pesar de la magnitud de la lesión. Me recuerda a un paciente que tuve hace años, un fumador empedernido que llegó caminando como si nada y traía un desastre en los pulmones. A veces la clínica nos engaña totalmente. ¿Sueles pedir TC de alta resolución de entrada en estos casos asintomáticos o prefieres esperar a la radiografía simple primero para no radiar de más?
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This blog is an excellent resource for radiology enthusiasts, providing valuable cases to enhance diagnostic skills. The first case is intriguing—great for learning!
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Further, thoracic radiograph and an axial TC corte are displayed. What could be our diagnosis?
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