Teaching Case

A case of the first rib mimicking a mass or tumour is presented. The significance of identifying the structure as a rib is stressed to avoid subjecting patients to unnecessary procedures.

An 80-year-old man with a known history of asthma and chronic bronchitis was brought into Accident and Emergency after having been found on the floor of his home. He was thought to have been there for two days. A chest x-ray was requested to rule out a chest infection. The chest x-ray demonstrated a large mass in the right upper zone, which was initially thought to be a Pancoast Tumour. On closer inspection however, this was not the case.

In the study by Ichinohe K et al., it was shown that Pancoast tumour can be easily missed and care must be taken when considering this as a possible diagnosis. Treatment delay for Pancoast tumours was relatively long, and approximately two-thirds of the delay was due to doctors, mainly because of errors in radiology. However, in a new study from the National Cancer Institute (NCI), part of the National Institutes of Health, it was shown that chest X-rays can detect early lung cancer but also can produce many false-positive test results, causing needless extra tests. Radiographic interpretation is a systematic search for disease patterns, regardless of the image display or noise in the image. In this case, even though the initial thought was that of a tumour, a second look with careful comparison of the opposite side revealed the true diagnosis. The significance of this finding is that the patient was not exposed to any unnecessary tests.