Dense hilum sign

Case contributed by Dr Ian Bickle

Presentation

New wheeze and one episode of hemoptysis associated with shortness of breath. Former smoker, smoked for 30 years. Currently on oral antibiotics. Infection or other cause?

Patient Data

Age: 70 years
Gender: Female
X-ray

The left hilum is dense.

Heart size normal. Lungs clear.

CT

5.2 cm left hilar soft tissue mass infiltrating the mediastinal fat and encroaching on the esophagus, surrounding the left main bronchus bifurcation and narrowing the LUL and LLL bronchi emanating from it, and surrounding and narrowing many left pulmonary artery branches.

No adenopathy. No metastases.

Fatty liver. 34 mm left renal angiomyolipoma.

Case Discussion

A good plain radiograph to assess the skill of a reporter, not least when reporting high volumes of radiographs per hour as is typical in professional practice rather than professional exams.

This was a T4 lung cancer, so advanced in local staging but easily missable in a stack of 500 unreported plain radiographs.

The hilum is a review area for a reason: it can be very tricky.

The contemporary radiologist should act with prudence, separating potentially concerning radiographs requiring CT and not flooding the CT scanner with endless unnecessary investigations with all that it entails in terms of radiation exposure, anxiety to the patient, practical inconvenience, and cost. 

I use this in a fellowship rapid reporting or viva exam every time.

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