Radiology corner

Case 1

1. c) Right middle lobe. There is consolidation within the right lower zone and given the clinical history an infective aetiology is most likely. The abnormality affects the right middle lobe as it is limited superiorly by the horizontal fissure (red arrow) and there is loss of clarity of the right heart border (yellow arrow). The horizontal fissure as a general rule runs from the lateral aspect of the right sixth rib to the level of the right hilar point and may be visualised on a normal chest radiograph.

   

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   The axial CT correlate confirms the dense consolidation with air bronchograms evident (blue arrows). The axial CT image also identifies ground-glass and dense parenchymal opacification within the right lower lobe.

2. a) Yes. The dual lumen catheter is appropriately positioned with its tip located at the junction of the SVC and right atrium.

Case 2

1. b) Bony abnormality. The main abnormality is the presence of inferior rib notching. This patient had aortic coarctation and on the chest radiograph the appearances are suggestive of a high aortic knuckle. It is difficult to assess for the “figure 3” sign of aortic coarctation on this radiograph due to the prominent manubrium. The bilateral inferior rib notching is due to enlarged intercostal arteries due to collateral flow from the internal mammary arteries (these arise from the subclavian vessels bilaterally). This results in pressure erosion on the inferior aspect of ribs 3–9 bilaterally.

The differential diagnoses for inferior rib notching are listed in the table below.

Case 3

1. c) Lung parenchymal abnormality. There is a round soft tissue mass projected behind the anterior aspect of the right first rib (red arrow), which was confirmed on subsequent axial computed tomography (CT) imaging. This was confirmed to represent a bronchial adenocarcinoma on tissue biopsy. Remember to assess the “check” areas on a chest radiograph for hidden masses, i.e. apices, hilar regions, retrocardiac region, adjacent to the lateral chest walls and below the diaphragm.

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The differential diagnoses for a solitary pulmonary nodule are listed in the table below.

Case 4

1. e) Bony abnormality. There is a destructive lesion of the left humeral head, which is dislocated inferiorly on this single AP view. This is an aggressive process as there is an ill-defined zone of transition with cortical destruction. Given the nature of the film it is difficult to assess for subtle periosteal reaction.

Given the age of the patient metastases and multiple myeloma are the most likely causes of these findings. The primary cancers to particularly consider are breast, bronchus, thyroid and renal.