Chest X-Ray breakdown: assessing the azygos contour

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A female in her 50s presents with a history of weight loss and cough. What does the Chest X-Ray show?

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MEDIASTINAL LYMPH NODE ENLARGEMENT
👨🏽‍💻This is a tricky film...hopefully you noticed that the left base is abnormal - we can see blunting of the costophrenic angle meaning a small pleural effusion and there is loss of volume of the left hemithorax.

👨🏽‍💻There was another problem here however - the azygos vein contour was abnormal reflecting mediastinal node enlargement. This is such an important review area on a Chest X-Ray! Be careful not to overcall this on AP films as things can get magnified but on a PA film you should be seeing a much smaller contour as in the normal example

👨🏽‍💻You may also realise the trachea is deviated a little to the right due to mediastinal nodes on the left side of the mediastinum. The raised left hemidiaphragm may be in part due to phrenic nerve palsy due to the node enlargement in the mediastinum

👨🏽‍💻PET-CT is used in the staging of lymphoma. We usually stage using the Ann Arbor staging system:
Stage 1️⃣ one nodal site
Stage 2️⃣ two nodal sites on the same side of the diaphragm
Stage 3️⃣ nodal sites on both sides of the diaphragm
Stage 4️⃣ extralymhatic organ involvement eg lung or liver

We add on a ‘B’ if there are B symptoms (fever, weight loss of more than 10 percent body weight, night sweats) or ‘S’ if the spleen is involved

▫️Hopefully this case will help you in the future if you come across nodal enlargement in the azygos region

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