Sample Teaching Cases

Thoracic Imaging

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Thoracic imaging includes assessment of the respiratory system and chest wall. Cardiac imaging is covered in a dedicated section.

Case TI.1

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History

The patient is a 69-year-old male who presents with right-sided chest pain and shortness of breath after falling from a horse.

Questions

1. After this chest radiograph was obtained, how appropriate are detailed rib radiographs? Should an alternative study be performed?

2. How should the interpreting radiologist communicate the findings demonstrated in this case?

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Case TI.2

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1. In a premenopausal female, what abdominal mass is associated with the demonstrated pulmonary finding(s)?

2. What autosomal dominant syndrome presents with similar pulmonary finding(s)?

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Case TI.3

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1. What is the differential diagnosis for the salient finding?

2. In the setting of joint pain and rash, what is the diagnosis?

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Case TI.4

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1. What complications/sequelae are seen in asbestos-related disease? What are their latency periods?

2. What are the most common locations for metastatic malignant mesothelioma?

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Case TI.5

This case has two sets of images.

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Image TI 5.1

History

Afebrile, 36-year-old male presents with worsening chest pain and shortness of breath for 3 weeks

Questions

1. Define “tension hydrothorax”.

2. What etiologies cause tension hydrothorax?

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Image TI 5.2

Questions

3. What features of this mass delineate its location?

4. What is the differential diagnosis for a mass in this location?

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Answers


Case TI.1

History

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The patient is a 69-year-old male who presents with right-sided chest pain and shortness of breath after falling from a horse.

Diagnosis

Infra-pulmonic pneumothorax, subpleural hematoma, rib fractures and subcutaneous emphysema.

Findings

Increased lucency of the lung base at the right diaphragm delineates the inferior pleural space and is suspicious for infra-pulmonic pneumothorax. Additionally, soft tissue density projecting along the internal chest wall, subcutaneous emphysema along the right chest wall and multiple bilateral rib fractures are seen.  

Answers

1.  After this chest radiograph was obtained, how appropriate are detailed rib radiographs? Should an alternative study be performed?

Based on the Appropriateness Criteria of the American College of Radiology, a ribs series in this patient scores a rating of 5, out of a possible 9. The presence or absence of a rib fracture would not change the clinical management for most patients. The presence of more than three rib fractures is associated with increased morbidity and mortality. In this case, the presence of a hemopneumothorax is of significantly greater concern. If additional imaging is considered, the rib series would not be the appropriate choice to further evaluate this finding. CT of the chest and possibly the abdomen should be considered to evaluate vascular and internal organ injury. 

2. How should the interpreting radiologist communicate the findings demonstrated in this case?

The presence of a hemopneumothorax warrants “non-routine” communication in this case, meaning that we should not depend on the normal methods of communication, such as the PAC system or digital media. When radiologists see an emergent or urgent finding, they should make direct verbal contact with the primary care provider to ensure timely receipt of the findings.  Furthermore, the radiologist should document the name of the person who was notified of the finding as well as the time and date of the communication and the route of communication (phone call, face-to-face conversation, HIPPA-compliant digital message with affirmation of receipt, etc).

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Case TI.2

CaseTI10ii.pngDiagnosis 

Lymphangioleiomyomatosis (LAM)

Findings

Present in nearly all cases, findings in LAM include thin-walled pulmonary cysts, usually with a uniform, random distribution. Small cysts on radiographs were seen as diffuse, coarse interstitial markings (not shown). 

Answers

1. In a premenopausal female, what abdominal mass is associated with the demonstrated pulmonary finding(s)?

Renal angiomyolipomas, characterized by extra-cellular fat on CT, are the most frequent abdominal masses identified in LAM occurring in more than 70% of cases. Cystic retroperitoneal lymphangioleiomyomas, which occur in approximately 20% of cases, are due to a proliferation of smooth muscle in lymphatic vessels, causing obstruction and lymphatic dilatation. Lymphangiomas are only distinguishable from lymphangioleiomyomas by histological evaluation; therefore, on radiologic imaging cystic retroperitoneal masses are considered lymphangioleiomyomas.

2. What autosomal dominant syndrome is associated with similar pulmonary finding(s)?

The pulmonary findings in LAM include increased lung volume and thin-walled (< 3 mm) cysts as demonstrated on this high-resolution CT. Tuberous sclerosis (TS), an autosomal dominant syndrome, presents with findings similar to LAM and shares similar genetic markers. Findings in TS include renal angiomyolipomas and cysts, cardiac rhabdomyomas, pulmonary lymphangioleiomyomatosis, rectal polyps, bone islands and cysts, thyroid adenomas, and renal cancers.

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Case TI.3

Diagnosis

Lofgren's syndrome

Findings

Bilateral hilar mass-like lesions (red arrows) are seen on the frontal radiograph, surrounding and outlining the main bronchi.

Answers

1. What is the differential diagnosis for the salient finding?

The bilateral hilar mass-like lesions could be lymphadenoathy or pulmonary artery enlargement. The differential diagnosis includes the following:

Lymph Node Enlargement

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  • Malignancy
  • Infection
  • Sarcoidosis
  • Berylliosis
  • Silicosis

Pulmonary Artery Enlargement

  • Pulmonary arterial hypertension
  • Left to right shunt
  • High output state
  • Cystic fibrosis

2. In the setting of joint pain and rash, what is the diagnosis?

The finding of bilateral hilar lymphadenopathy in conjunction with joint pain and rash is consistent with Lofgren's syndrome, which is a clinical variant of sarcoidosis. The triad of findings in Lofgren's syndrome includes bilateral hilar adenopathy, erythema nodosum, and migratory polyarthralgias.

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Case TI.4

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Diagnosis

Asbestos-related pleural disease with development of mesothelioma

Findings

CT of the chest without contrast revealed bilateral pleural-based calcified plagues and a soft tissue mass, eroding into a left-sided rib. Subsequently, contrasted CT demonstrated a chest wall mass with moderate enhancement. Incidental note was made of a hepatic cyst.

Answers

1. What sequelae are seen in asbestos-related disease? What are their latency periods?

Benign pleural effusion is the earliest sequelae occurring in less than 10 years, usually resolves but may recur. Subsequently pleural thickening, round atelectasis, and noncalcified pleural plaques can be seen after approximately 15 years. “Late” sequelae include asbestosis (> 20 years), calcified pleural plaques (20 – 30 years), bronchogenic adenocarcinoma (variable with increased risk after 30 years), and malignant mesothelioma (35– 40 years).

2. What are the most common locations for metastatic malignant mesothelioma?

Malignant mesothelioma metastasizes by (1) direct spread into the pericardium, contralateral pleura, and peritoneum, (2) lymphatic invasion to regional lymph nodes and (3) hematogenous spread lungs, liver, kidneys, and adrenal glands.

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Case TI.5

Castlemans Disease.pngDiagnosis

Castlemans Disease

Findings

The frontal radiograph demonstrates complete opacification of the left hemithorax and contralateral midline shift of mediastinal structures (red arrows).

Coronal MR images demonstrate a posterior mediastinal, mixed signal mass abutting the spine and lifting the pleura, creating an oblique angle with the pleura.

Answers

1. Define "tension hydrothorax".

A tension hydrothorax is due to pressure from fluid in the pleural space causing contralateral midline shift. The sequelae of midline shift in a tension hydrothorax are comparable to those in a tension pneumothorax.

2. What etiologies cause tension hydrothorax?

Tension hydrothoraces are related to pleural-based infections (empyema), trauma (hemothorax, chylothorax) and pleural-based malignancies (malignant pleural effusion). 

3. What features of this mass delineate its location?

The oblique margins between the lung (visceral pleura) and the mass indicate that the mass is extrapleural and outside of the lung. Since the lesion abuts the spine, the lesion is within the posterior mediastinum.

4. What is the differential diagnosis for a mass in this location?

The differential for posterior mediastinal masses includes esophageal lesions, hiatal and diaphragmatic hernias, duplication cysts, descending aortic aneurysms, neurogenic tumors, abscesses, lateral meningoceles, and extramedullary hematopoiesis.

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