Cardiac and Pericardial Neoplasms in Children: Radiologic-Pathologic Correlation.

Primary cardiac and pericardial neoplasms are rare in the pediatric population and can include both benign and malignant lesions. Rhabdomyomas, teratomas, fibromas, and hemangiomas are the most common benign tumors. The most common primary cardiac malignancies are soft-tissue sarcomas, including undifferentiated sarcomas, rhabdomyosarcomas, and fibrosarcomas. However, metastatic lesions are more common than primary cardiac neoplasms. Children with primary cardiac and pericardial tumors may present with nonspecific cardiovascular symptoms, and their clinical presentation may mimic that of more common nonneoplastic cardiac disease. The diagnosis of cardiac tumors has recently been facilitated using noninvasive cardiac imaging. Echocardiography is generally the first-line modality for evaluation. Cardiac MRI and CT are used for tissue characterization and evaluation of tumor size, extension, and physiologic effect. The varied imaging appearances of primary cardiac neoplasms can be explained by their underlying abnormality. Treatment of these lesions varies from conservative management, with spontaneous regression of some lesions such as rhabdomyomas, to surgical resection, particularly in patients with associated heart failure. With adequate imaging techniques and knowledge of the pathologic basis of the neoplasm, it is often possible to differentiate benign from malignant tumors, which can greatly affect adequate and timely treatment. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Mediastinal Masses in Children: Radiologic-Pathologic Correlation.

Most pediatric masses in the chest are located in the mediastinum. These masses are often initially detected incidentally on chest radiographs in asymptomatic children, although some patients may present with respiratory symptoms. At chest radiography, the mediastinum has been anatomically divided into anterior, middle, and posterior compartments. However, with the International Thymic Malignancy Interest Group classification scheme, which is based on cross-sectional imaging findings, the mediastinum is divided into prevascular, visceral, and paravertebral compartments. In the prevascular compartment, tumors of thymic origin, lymphomas, germ cell tumors, and vascular tumors are encountered. In the visceral compartment, lymphadenopathy and masses related to the foregut are seen. In the paravertebral compartment, neurogenic tumors are most common. Using the anatomic location in combination with knowledge of the imaging and pathologic features of pediatric mediastinal masses aids in accurate diagnosis of these masses to guide treatment and management decisions. An invited commentary by Lee and Winant is available online. ©RSNA, 2021.

Screening for Lung Cancer: Lexicon for Communicating With Health Care Providers.

OBJECTIVE: The effectiveness of lung cancer screening with low-dose CT (LDCT) has been shown by multiple clinical trials, particularly the National Lung Screening Trial. Accurate communication of LDCT results to health care providers is critical to optimal patient care. CONCLUSION: The Lung CT Screening Reporting and Data System (Lung-RADS), a structured decision-oriented reporting system designed to minimize the rate of false-positive results and developed by the American College of Radiology, is recommended for use with all LDCT examinations.

Primary Lung Tumors in Children: Radiologic-Pathologic Correlation From the Radiologic Pathology Archives.

Primary lung tumors in children are rare, with a narrow range of diagnostic considerations. However, the overlapping imaging appearances of these tumors necessitate attention to key discriminating imaging and pathologic features. In the neonate and infant, the important considerations include pleuropulmonary blastoma (PPB), infantile fibrosarcoma, and fetal lung interstitial tumor. Among these tumors, imaging findings such as air-filled cysts in type 1 PPB and homogeneously low attenuation of fetal lung interstitial tumors are relatively specific. Key pathologic and genetic discriminators among this group of tumors include the DICER1 germline mutation found in PPB and the t(12,15)(p13;q25) translocation and ETV6-NTRK3 fusion gene seen in infantile fibrosarcoma. Primary lung tumors in older children include inflammatory myofibroblastic tumors (IMTs), carcinoid salivary gland-type tumors of the lung, recurrent respiratory papillomatosis, and other rare entities. IMT, a spindle-cell proliferation with inflammatory elements, is the most common lung tumor in children. Anaplastic lymphoma kinase, a receptor-type protein tyrosine kinase, is present in 50% of these tumors, and this finding may support an imaging diagnosis of IMT. Carcinoid tumors account for a substantial portion of childhood lung tumors, and their characteristic avid enhancement on images corresponds to the compressed fibrovascular stroma histologically. Furthermore, novel imaging agents used with somatostatin receptor analogs have an emerging role in the evaluation of carcinoid tumors. Although less common than mucoepidermoid carcinoma, adenoid cystic carcinoma tends to recur given the perineural spread seen histologically. Integrating radiologic and pathologic knowledge is critical to accurate diagnosis, treatment planning, and surveillance of primary lung tumors in children.

Revisions to the TNM Staging of Lung Cancer: Rationale, Significance, and Clinical Application.

Lung cancer remains the leading cause of cancer-related mortality worldwide. To formulate effective treatment strategies and optimize patient outcomes, accurate staging is essential. Lung cancer staging has traditionally relied on a TNM staging system, for which the International Association for the Study of Lung Cancer (IASLC) has recently proposed changes. The revised classification for this eighth edition of the TNM staging system (TNM-8) is based on detailed analysis of a new large international database of lung cancer cases assembled by the IASLC for the purposes of this project. Fundamental changes incorporated into TNM-8 include (a) modifications to the T classification on the basis of 1-cm increments in tumor size; (b) grouping of lung cancers that result in partial or complete lung atelectasis or pneumonitis; (c) grouping of tumors with involvement of a main bronchus irrespective of distance from the carina; (d) reassignment of diaphragmatic invasion in terms of T classification; (e) elimination of mediastinal pleural invasion from the T classification; and (f) subdivision of the M classification into different descriptors on the basis of the number and site of extrathoracic metastases. In response to these revisions, established stage groups have been modified, and others have been created. In addition, recommendations for classifying patterns of disease that result in multiple sites of pulmonary involvement, including multiple primary lung cancers, lung cancers with separate tumor nodules, multiple ground-glass/lepidic lesions, and consolidation, as well as recommendations for lesion measurement, are addressed. Understanding the key revisions introduced in TNM-8 allows radiologists to accurately stage patients with lung cancer and optimize therapy. ©RSNA, 2018.

Metastasis to the Heart: A Radiologic Approach to Diagnosis With Pathologic Correlation.

OBJECTIVE: Evaluating metastatic disease to the heart and pericardium, from detection to diagnosis, often requires a multimodality imaging approach. A radiologist's ability to evaluate cardiac metastases hinges on an understanding of the epidemiology, anatomy, and imaging features of this disease process. CONCLUSION: On surveillance imaging of patients with cancer or when metastatic disease is suspected, detection of metastatic disease may be greatly enhanced by an understanding of which primary tumors metastasize to the heart and the most common routes of spread.

Imaging of Thoracic Neurogenic Tumors.

OBJECTIVE: Thoracic neurogenic neoplasms may be a diagnostic challenge both clinically and radiologically, ranging from benign, incidentally discovered tumors to aggressive, symptomatic malignancies. These tumors may originate from any nervous structure within the chest and are derived from cells of the nerve sheath, autonomic ganglia, or paraganglia. The nervous anatomy of the thorax is complex, and neurogenic tumors may be found in any mediastinal compartment or in the chest wall. Furthermore, neurogenic tumors may indicate one of many syndromes, particularly when they are multiple. CONCLUSION: This article illustrates the complex anatomy of the nervous system within the chest and details important epidemiologic and pathophysiologic features as an approach to neurogenic tumors of the thorax. Key imaging features of neurogenic tumors occurring in the chest are identified, focusing on distinguishing characteristics and the relative advantages of available imaging modalities to further refine a differential diagnosis.

Imaging Evaluation of Malignant Chest Wall Neoplasms.

Neoplasms of the chest wall are uncommon lesions that represent approximately 5% of all thoracic malignancies. These tumors comprise a heterogeneous group of neoplasms that may arise from osseous structures or soft tissues, and they may be malignant or benign. More than 50% of chest wall neoplasms are malignancies and include tumors that may arise as primary malignancies or secondarily involve the chest wall by way of direct invasion or metastasis from intrathoracic or extrathoracic neoplasms. Although 20% of chest wall tumors may be detected at chest radiography, chest wall malignancies are best evaluated with cross-sectional imaging, principally multidetector computed tomography (CT) and magnetic resonance (MR) imaging, each of which has distinct strengths and limitations. Multidetector CT is optimal for depicting bone, muscle, and vascular structures, whereas MR imaging renders superior soft-tissue contrast and spatial resolution and is better for delineating the full extent of disease. Fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT is not routinely performed to evaluate chest wall malignancies. The primary functions of PET/CT in this setting include staging of disease, evaluation of treatment response, and detection of recurrent disease. Ultrasonography has a limited role in the evaluation and characterization of superficial chest wall lesions; however, it can be used to guide biopsy and has been shown to depict chest wall invasion by lung cancer more accurately than CT. It is important that radiologists be able to identify the key multidetector CT and MR imaging features that can be used to differentiate malignant from benign chest lesions, suggest specific histologic tumor types, and ultimately guide patient treatment. (©)RSNA, 2016.

Imaging of pediatric pathology during the Iraq and Afghanistan conflicts.

United States Armed Forces radiologists deployed to Afghanistan and Iraq in modern military conflicts may encounter pediatric patients as a casualty of war or when providing humanitarian assistance to the indigenous population. Pediatric patients account for 4-7% of admissions at U.S. military hospitals during the Iraq and Afghanistan conflicts. It is pertinent for radiologists in the humanitarian care team to be familiar with imaging pediatric trauma patients, the pathology endemic to the local population, and delayed presentations of congenital and developmental disorders to adequately care for these patients. The radiological manifestations of various pediatric disorders seen in the setting of the Iraq and Afghanistan conflicts will be explored.

Multimodality imaging for characterization, classification, and staging of malignant pleural mesothelioma.

Malignant pleural mesothelioma (MPM) is the most common primary malignancy of the pleura and is associated with asbestos exposure in approximately 80% of patients. The patient prognosis is poor, with a median survival of 9-17 months after diagnosis. However, improved survival and decreased morbidity and mortality have been demonstrated when the diagnosis is made in the early stages of disease and specific treatment strategies are implemented. A staging system that focuses on the extent of primary tumor (T), lymph node involvement (N), and metastatic disease (M) has been devised by the International Mesothelioma Interest Group and emphasizes factors related to overall survival. Radiologists should recognize the manifestations of MPM across multiple imaging modalities, translate these findings into the updated staging system, and understand the effects of appropriate staging on treatment and survival. Computed tomography (CT) remains the primary imaging modality used to evaluate MPM and efficiently demonstrates the extent of primary tumor, intrathoracic lymphadenopathy, and extrathoracic spread. However, additional imaging modalities, such as magnetic resonance (MR) imaging of the thorax and positron emission tomography (PET)/CT with fluorodeoxyglucose, have emerged in recent years and are complementary to CT for disease staging and evaluation of patients with MPM. Thoracic MR imaging is particularly useful for identifying invasion of the chest wall, mediastinum, and diaphragm, and PET/CT can accurately demonstrate intrathoracic and extrathoracic lymphadenopathy and metastatic disease.

Beyond milestones and percentiles: Revisiting non-cognitive and non-interpretive skills in radiology.

While there is no precise formula for a great radiology resident, certain attributes and achievements may herald success during training. We briefly review prior works exploring predictive factors and evaluation metrics of top resident performance, noting that those focusing on non-cognitive attributes are over twenty years old. As radiology practice and education has substantially evolved in the interim, we revisit this topic from a contemporary perspective. Inspired by the literature and our own personal experiences, we suggest that the following non-cognitive traits are invaluable for radiology trainees: communication expertise, workplace adaptability, self-awareness, tech savvy and genuine interest in one's individual work and greater community. These characteristics should be highlighted by applicants, sought by selection committees, cultivated by mentors, evaluated by programs and valued by colleagues.

Cryptococcal pneumonia and meningitis in a renal transplant recipient with a false negative serum cryptococcal antigen due to postzone phenomenon.

Cryptococcal infection can cause significant morbidity and mortality in immunocompromised patients. We present a patient who was diagnosed with cryptococcal meningitis and pulmonary disease in the setting of a history of renal transplantation. The diagnosis was made based on growth of Cryptococcus neoformans in blood cultures and identification of cryptococcal antigen (CrAg) in cerebral spinal fluid (CSF) using a lateral flow assay (LFA). Our case is unique since the initial serum CrAg was falsely negative due to excess cryptococcal antigen preventing the formation of antigen-antibody complexes, referred to as the postzone phenomenon. This phenomenon has been reported on CSF samples but rarely reported on serum samples in patients without an HIV diagnosis.

What a differential a virus makes: a practical approach to thoracic imaging findings in the context of HIV infection--part 2, extrapulmonary findings, chronic lung disease, and immune reconstitution syndrome.

OBJECTIVE: The Centers for Disease Control and Prevention reported more than one million people with HIV infection in the United States in 2006, an increase of 11% over 3 years. Worldwide, nearly 34 million people are infected with HIV. Pulmonary disease accounts for 30-40% of acute hospitalizations of HIV-seropositive patients, underscoring the importance of understanding the range of cardiothoracic imaging findings associated with HIV infection. This article will cover extrapulmonary thoracic diseases, chronic lung diseases, and immune reconstitution inflammatory syndrome in HIV-infected patients. Our approach is focused on the radiologist's perspective by recognizing and categorizing key imaging findings to generate a differential diagnosis. The differential diagnosis can be further refined by incorporating clinical data, such as patient demographics, CD4 count, and presenting symptoms. In addition, with prolonged survival of HIV-infected patients in the era of highly active antiretroviral therapy, radiologists can also benefit from awareness of imaging features of a myriad of chronic cardiopulmonary diseases in this patient population. Finally, the change of imaging findings and clinical status in response to treatment provides important diagnostic information, such as in immune reconstitution syndrome. CONCLUSION: Developing a practical approach to key cardiothoracic imaging findings in HIV-infected patients will aid the radiologist in generating a clinically relevant differential diagnosis and interpretation, thereby improving patient care.

What a differential a virus makes: a practical approach to thoracic imaging findings in the context of HIV infection--part 1, pulmonary findings.

OBJECTIVE: The Centers for Disease Control and Prevention reported more than one million people with HIV infection in the United States in 2006, an increase of 11% over 3 years. Worldwide, nearly 34 million people are infected with HIV. Pulmonary disease accounts for 30-40% of acute hospitalizations of HIV-infected patients, underscoring the importance of understanding the pulmonary manifestations in this population. When presented with a chest radiograph or CT image of a patient with the clinical history of HIV infection, one approach is to start by identifying and categorizing key imaging findings. In some instances, the key findings may be further subcategorized to narrow the differential diagnosis, such as distinguishing between perilymphatic distribution and the random distribution of micronodules. The differential diagnosis of these key imaging findings can also be further refined by incorporating clinical data, such as patient demographics, CD4 count, and presenting symptoms. Finally, the change of thoracic disease and clinical status in response to treatment provides important diagnostic information. The purpose of this article is to discuss pulmonary findings in patients with HIV. CONCLUSION: By developing a systematic and practical approach to key pulmonary imaging findings in HIV-infected patients, radiologists can generate clinically relevant and succinct differential diagnoses and thereby improve patient care.

Imaging of the Posterior/Paravertebral Mediastinum.

A wide variety of abnormalities may be encountered in the paravertebral mediastinum, ranging from congenital lesions to malignant neoplasms. A combination of localizing mediastinal masses to the paravertebral compartment, characterizing them with cross-sectional imaging techniques, and correlating the imaging findings with demographics and other clinical history typically enables the development of a focused differential diagnosis. Radiologists must be familiar with these concepts in order to help guide subsequent imaging and/or intervention and, when appropriate, treatment planning for neoplasms and other abnormalities.

Thymic Epithelial Neoplasms: Radiologic-Pathologic Correlation.

Thymic epithelial neoplasms, as classified by the World Health Organization, include thymoma, thymic carcinoma, and thymic carcinoid. They are a rare group of tumors and are often diagnosed incidentally in the work-up of parathymic syndrome, such as myasthenia gravis, or when mass effect or local invasion causes other symptoms. In each of these scenarios, understanding the radiologic-pathologic relationship of these tumors allows clinical imagers to contribute meaningfully to management decisions and overall patient care. Integrating important imaging features, such as local invasion, and pathologic features, such as necrosis and immunohistochemistry, ensures a meaningful contribution by clinical imagers to the care team.

Cardiac Neoplasms: Radiologic-Pathologic Correlation.

Cardiac neoplasms are a diagnostic challenge on many levels. They are rare, their clinical presentation may mimic other much more common cardiac diseases, and they are at an uncommon intersection of oncologic and cardiac imaging. The pathology of primary cardiac neoplasms explains their varied imaging features, for example, calcification in primary cardiac osteosarcomas and T2 hyperintensity in myxomas. Integrating the imaging and pathologic features of cardiac tumors furthers our understanding of the spectrum of appearances of these neoplasms and improves the clinical imager's ability to confidently make a diagnosis.

Esophageal Neoplasms: Radiologic-Pathologic Correlation.

The epidemiology and clinical management of esophageal carcinomas are changing, and clinical imagers are required to understand both the imaging appearances of common cancers and the pathologic diagnoses that drive management. Rare esophageal malignancies and benign esophageal neoplasms have distinct imaging features that may suggest a diagnosis and guide the next steps clinically. Furthermore, these imaging features have a basis in pathology, and this article focuses on the relationship between pathologic features and imaging manifestations that will help an informed imager maintain clinical relevance.