The images demonstrate a frontal and lateral projection of a barium swallow examination. The oesophagus is dilated proximally to an irregular narrowing concentric stricture with only minimal contrast seen beyond the level of obstruction. These appearances alone suggest malignancy. Oesophageal malignancy could cause these appearances, however, as we will see, there are further findings which exclude this diagnosis and confirm the correct diagnosis. The bronchial tree is particularly well visualized in this case due to senescent cartilage calcifications. However, it is noted on the frontal projection that there is an abrupt cutoff of the left main bronchus. The left hemithorax is opaque and contracted with herniation of right-sided lung parenchyma across the anterior mediastinum. The findings could be due to prior pneumonectomy or bronchial neoplasm. In the absence of surgical clips or featuers of thoracotomy the latter should be considered more likely.
The additional film provided demonstrates the collapsed left lung, this image having been performed following visualization of the abnormalities on the images provided. In order to combine the findings into one malignancy diagnosis, the best unifying diagnosis is lung carcinoma with mediastinal extension or malignant nodal disease secondarily infiltrating the oesophagus. The reverse process is less likely, as mediastinal adenopathy from oesophageal carcinoma would be unlikely to peripherally extend into the left hilum without obvious abnormality on the right side. Lymphoma could bridge the anatomical distance between the oesophagus and the left main bronchus but such infiltrative disease of the oesophagus would be unusual.
The findings in this case were not individually difficult, however, our eyes are conditioned to observing certain findings according to the clinical indication or examination. When presented with the findings individually it is easy to reach the correct diagnosis, yet in combination they may prove more difficult. It is always important to look at the entire film on every case. For CT this would also imply visualization of all window levels and settings.
The additional film provided demonstrates the collapsed left lung, this image having been performed following visualization of the abnormalities on the images provided. In order to combine the findings into one malignancy diagnosis, the best unifying diagnosis is lung carcinoma with mediastinal extension or malignant nodal disease secondarily infiltrating the oesophagus. The reverse process is less likely, as mediastinal adenopathy from oesophageal carcinoma would be unlikely to peripherally extend into the left hilum without obvious abnormality on the right side. Lymphoma could bridge the anatomical distance between the oesophagus and the left main bronchus but such infiltrative disease of the oesophagus would be unusual.
The findings in this case were not individually difficult, however, our eyes are conditioned to observing certain findings according to the clinical indication or examination. When presented with the findings individually it is easy to reach the correct diagnosis, yet in combination they may prove more difficult. It is always important to look at the entire film on every case. For CT this would also imply visualization of all window levels and settings.
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