Incidentally Detected Malignancies in Lung Explants.

Introduction: Incidentally detected malignancies in lung explants portend risk of early cancer recurrence and metastases with posttransplant immunosuppression. We present a series of lung transplant recipients with previously unverified malignancies in native lung explants. Design: We reviewed the histopathology, radiographic imaging, and management of lung explant malignancies at our institution over 10 years (2011-2020). Endpoints were survival and allograft rejection. Results: An explant malignancy was found in 1.3% (11/855) of lung transplant recipients (6 [55%] men; median age 68 years; 6 [55%] ex-smokers [median pack-years, 25]). Nine (82%) were adenocarcinoma, 1 (9%) was squamous cell carcinoma (SCC), and 1 (9%) was follicular lymphoma. Three patients (27%) had multifocal involvement (≥3 lobes), 4 (36%) had nodal involvement, and the median (range) tumor size was 2.7 (0.4-19) cm. The median interval between last imaging and transplant was 58 (29-144) days. Mycophenolate mofetil was discontinued or reduced in all; everolimus was used in 2 patients, and cisplatin-pemetrexed chemotherapy was used in 2 patients. The prevalence of acute cellular rejection and chronic rejection was 27% and 9%, respectively. Lung recipients with cancer had significantly lower survival than those without (36.4% vs 67.3%, p = 0.002); median survival was 27 (17, 65) months in 4 recipients who were alive and cancer-free at the end of the study period. Conclusions: Unidentified malignancies, commonly adenocarcinoma, can be detected in explanted native lungs. Pneumonectomy may be curative in SCC, lymphoproliferative disorders, and stage I adenocarcinoma. Modulating immunosuppression to prevent allograft rejection and tumor proliferation is warranted.

Association of Bolus Transit Time on Barium Esophagram With Esophageal Peristalsis on High-resolution Manometry and Nonobstructive Dysphagia.

GOAL: The goal of this study was to correlate upright and prone bolus transit time (BTT) on barium esophagography (BE) with esophageal peristalsis on high-resolution manometry (HRM) and self-reported dysphagia in patients with normal lower esophageal sphincter parameters on HRM. BACKGROUND: BTT on BE could be the gold standard for assessing the effectiveness of esophageal peristalsis if it can be quantified. MATERIALS AND METHODS: Patients with normal lower esophageal sphincter parameters and standard-protocol BE from 2017 to 2020 were included. Patients were divided, based on the number of normal swallows (distal contractile integral >450 mm Hg-s-cm), into 11 groups (10 normal swallows to 0 normal swallows). Liquid barium swallows in prone position were objectively evaluated for prone BTT. Patients reported difficulty in swallowing on a scale from 0 (none) to 4 (very severe). Fractional polynomial and logistic regression analysis were used to study the association (along with the rate of change) between BTT, peristalsis, and dysphagia. RESULTS: A total of 146 patients were included. Prone BTT increased as the number of normal swallows decreased ( P <0.001). Two deflection points were noted on the association between peristalsis and prone BTT at 50% normal swallows, 40 seconds and 30% normal swallows, 80 seconds, after which peristaltic function declined independently of prone BTT. Patients with prone BTT>40 seconds had nearly 6-fold higher odds of 0% normal swallows on HRM than patients with prone BTT<40 seconds ( P =0.002). Increasing prone BTT was associated with increasing dysphagia grades 1 and 2 ( P ≤0.036). CONCLUSIONS: Esophageal motility can be quantified by BE. Prone BTT correlates with the proportion of normal esophageal swallows and dysphagia.

Pneumatosis Intestinalis in Adult Bilateral Lung Transplant Patients: A Single Institution Experience and Literature Review.

Pneumatosis intestinalis (PI) is a radiologic finding which is characterized by the accumulation of gas within the bowel wall. This radiologic finding is traditionally thought of in the sense of intestinal ischemia. An uncommon cause of this finding is post organ transplantation. We did an institutional and literature review of this finding to demonstrate its distinct imaging features and benign nature. It was observed to occur in approximately 5.2% of patients post lung transplant (23/442). On imaging, it displays an expansile/bubbly appearance of gas within the bowel wall that is distinct from the traditional findings seen in intestinal ischemia. Clinical review showed that posttransplant patients with PI can be successfully managed conservatively with early enteral nutrition, oxygen, antibiotics, and limited follow-up imaging. With the increasing use of organ transplantation, PI is being diagnosed with increased frequency. It is important to let clinicians know of this entity and its potential outcomes.

Pneumomediastinum in blunt trauma: If aerodigestive injury is not seen on CT, invasive workup is not indicated.

BACKGROUND: Pneumomediastinum following blunt trauma is often observed on CT imaging, and concern for associated aerodigestive injury often prompts endoscopy and/or fluoroscopy. In recent years, adoption of multi-detector CT technology has resulted in high resolution images that may clearly identify aerodigestive injuries. The purpose of this study was to evaluate the utility of multi-detector CT in the identification of blunt aerodigestive injuries. METHODS: Over five years, patients with pneumomediastinum following blunt trauma were identified from the registry of a level 1 trauma center. All CT imaging of trauma patients during this time period was accomplished with 64-slice scanners. RESULTS: 127 patients with blunt traumatic pneumomediastinum were identified. Five airway injuries were identified, and all injuries were evident on CT imaging. No patient was found to have airway injury by endoscopy that was not evident on CT. No patient had an esophageal injury. CONCLUSION: Multi-detector CT imaging identifies aerodigestive injuries associated with pneumomediastinum following blunt trauma. The absence of a recognizable aerodigestive injury by CT effectively rules out the presence of such injury.

To reduce routine computed tomographic angiography for thoracic aortic injury assessment in level II blunt trauma patients using three mediastinal signs on the initial chest radiograph: a preliminary report.

PURPOSE: CTA is routinely ordered on level II blunt thoraco-abdominally injured patients for assessment of injury to the thoracic aorta. The vast majority of such assessments are negative. The question being asked is, Does the accurate interpretation of the three mediastinal signs permit reliable determination of which patients need CTA for aortic assessment? The purpose of this investigation was to evaluate the role of three specifically selected mediastinal anatomic signs on the initial supine chest radiograph (CXR) of adult level II blunt thoraco-abdominally injured patients for the presence or absence of a mediastinal hematoma. The presence of a mediastinal hematoma is typically used as an indicator for computed tomographic angiography (CTA). The three mediastinal signs are the right para-tracheal stripe (RPTS), left para-spinal line (LPSL), and the left apical extra-pleural area (LAPA). MATERIALS AND METHODS: The patient triage designation (level II trauma) was made by the attending physician at the time of admission. The initial CXR image and the CTA report of the 197 adult blunt level II thoraco-abdominally injured patients obtained on the day of admission were compared. The CXR of each of the 197 patients was independently assessed by each of four observers specifically for the status of the three mediastinal signs. Each observer was blinded to the CTA report until after the status of the three mediastinal sign evaluation had been determined. Two or three of the mediastinal signs being positive were required to determine that the CXR was positive for a mediastinal hematoma. RESULTS: Two or three of the selected mediastinal signs were normal in 192 (97.5%) patients. None of these patients had either a mediastinal hematoma or a major aortic injury on CTA. In each of the remaining five (2.5%) patients, two or three of the mediastinal signs were abnormal. Each of these patients had a mediastinal hematoma and a major thoracic aortic injury on CTA. CONCLUSIONS: This preliminary study suggests that the accurate interpretation of the three specifically selected mediastinal signs on the initial supine CXR of adult level II blunt thoraco-abdominally injured patients could reduce the need for routine CTA for thoracic aortic injury assessment, and requires verification by an additional study.