Imaging of therapeutic airway interventions in thoracic oncology.

Tracheobronchial obstruction, haemoptysis, and airway fistulas caused by airway involvement by primary or metastatic malignancies may result in dyspnoea, wheezing, stridor, hypoxaemia, and obstructive atelectasis or pneumonia, and can lead to life-threatening respiratory failure if untreated. Complex minimally invasive endobronchial interventions are being used increasingly to treat cancer patients with tracheobronchial conditions with curative or, most often, palliative intent, to improve symptoms and quality of life. The selection of the appropriate treatment strategy depends on multiple factors, including tumour characteristics, whether the lesion is predominately endobronchial, shows extrinsic compression, or a combination of both, the patient's clinical status, the urgency of the clinical scenario, physician expertise, and availability of tools. Pre-procedure multidetector computed tomography (MDCT) imaging can aid in the most appropriate selection of bronchoscopic treatment. Follow-up imaging is invaluable for the early recognition and management of any potential complication. This article reviews the most commonly used endobronchial procedures in the oncological setting and illustrates the role of MDCT in planning, assisting, and follow-up of endobronchial therapeutic procedures.

COMPARISON BETWEEN THORACIC RADIOGRAPHIC FINDINGS AND POSTMORTEM DIAGNOSIS OF THORACIC DISEASES IN DYSPNEIC COMPANION RATS (RATTUS NORVEGICUS).

Companion rats are often presented to veterinarians for respiratory difficulties. Dyspnea in rats is most commonly due to infectious pneumonia, and thoracic neoplasia can go undiagnosed ante mortem due to a mistaken interpretation of pneumonia. In domestic carnivores, pulmonary nodular patterns have been shown to correlate with lung neoplastic diseases and infectious diseases. The main objective of this retrospective case series study was to determine whether certain radiographic criteria could be correlated with the presence of thoracic infectious disease and neoplastic disease in companion rats. A secondary objective was to determine whether the patient's sex and age were different between rats diagnosed with infectious versus neoplastic disease. Medical records and thoracic radiographs of dyspneic companion rats presented to the University of California at Davis, William R. Pritchard Veterinary Medical Teaching Hospital during the time period from January 2000 to December 2014 were reviewed. Rats with postmortem confirmation of thoracic lesions were included in the study. Thoracic radiographs were evaluated for positioning, lesion distribution, lung lobe involved, pulmonary pattern, mediastinal and pleural lesions by three observers blinded to diagnosis. Thirty rats were included in the study, including 23 rats with an infectious disease and seven with neoplasia. Mediastinal lesions were significantly more prevalent in the group diagnosed with thoracic neoplasia (P = 0.031), in particular cranially (P = 0.048). Although there was an overlap between the two groups, findings indicated that the presence of cranial mediastinal lesions may be helpful for differentiating neoplastic from infectious disease in rats.

Narrow band imaging for early diagnosis of epithelial dysplasia and microinvasive tumors in the upper aerodigestive tract.

The various stages of tumor growth are characterized by typical epithelial, vascular, and secondary connective tissue changes. Narrow Band Imaging (NBI) endoscopy is a minimally invasive imaging technique that presents vascular structures in particular at a higher contrast than white light endoscopy alone. In combination with high-resolution image recording and reproduction (high-definition television, HDTV; ultra-high definition, 4K), progress has been made in otolaryngological differential diagnostics, both pre- and intraoperatively. This progress represents an important step toward a so-called optical biopsy. Flexible endoscopy in combination with NBI allows for a detailed assessment of areas of the upper aerodigestive tract that are difficult to assess by rigid endoscopy. Papillomas along with precancerous and cancerous lesions are characterized by epithelial and connective tissue changes as well as by typical perpendicular vascular changes. Systematic use of NBI is recommended in the differential diagnosis of malignant lesions of the upper aerodigestive tract. NBI also offers a significant improvement in the pre- and intraoperative assessment of superficial resection margins. In particular, the combination of NBI and contact endoscopy (compact endoscopy) facilitates excellent therapeutic decisions during tumor surgery. Intraoperative determination of resection margins at an unprecedented precision is possible. In addition, assessment of the form and extent of the perpendicular vessel loops stimulated by epithelial signaling enables differential diagnostic decisions to be made, approximating our goal of an optical biopsy.

Computed tomography virtual bronchoscopy: normal variants, pitfalls, and spectrum of common and rare pathology.

A broad spectrum of pathologies that involve the laryngotracheobronchial airway and imaging plays a crucial role in evaluating these abnormalities. Computed tomography with virtual bronchoscopy has been found to be very helpful in defining the location, extent, and nature of these lesions, and is increasingly being used even in patients with contraindications for fiberoptic bronchoscopy and laryngoscopy. Ionizing radiation, associated with virtual bronchoscopy, can be minimized by using low-dose multidetector computed tomography and hybrid iterative reconstruction techniques. Furthermore, retrospectively generated virtual bronchoscopy from a routinely acquired computed tomography data set eliminates additional cost and radiation. In the future, virtual bronchoscopy assisted with advanced navigational techniques will broaden the diagnostic and therapeutic landscape. This article presents the characteristic features of common and rare laryngotracheobronchial pathologies seen with virtual bronchoscopy.

Differentiation between mucus secretion and endoluminal tumors in the airway: analysis and comparison of CT findings.

OBJECTIVE: The objective of our study was to suggest CT features that help differentiate transient mucus secretion from airway tumors in the evaluation of soft-tissue nodular lesions confined within the airway lumen. MATERIALS AND METHODS: Forty-two patients with airway tumors (mean age, 57.6 ± 14.9 [SD] years) and 48 patients with secretion (mean age, 67.8 ± 13.4 years) were included. Two observers analyzed the following features on contrast-enhanced CT in consensus readings: shape (round, ovoid, lobulating, or complex); margin (circumscribed or uncircumscribed); size (including change in size between mediastinal and lung window images); location (anterior, posterior, or unclear); angle between the lesion and contacting airway wall (acute, obtuse, or unclear); attenuation (quantitative and qualitative analyses); and presence of air, fat, or calcification within the lesion. The positive predictive value (PPV) of each CT finding was calculated for secretion and tumor, respectively. RESULTS: Round (90.0%) or lobulating (92.9%) shape, uncircumscribed margin (100.0%), unclear location (87.5%), unclear angle (87.5%), a CT number of 21.7 HU or more (91.7%), and internal features such as fat (100.0%) or calcification (100.0%) showed high PPVs for tumors. Complex shape (100.0%), change in size of more than 15.9% (96.8%), a CT number of less than 21.7 HU (83.3%), and internal air density (100.0%) showed high PPVs for secretion. CONCLUSION: On contrast-enhanced CT, the evaluation of shape, change in size between mediastinal and lung window images, the measurement of CT number, and internal features such as air, fat, or calcification might help differentiate secretion from tumors.

Malignant transformation of a highly aggressive human papillomavirus type 11-associated recurrent respiratory papillomatosis.

OBJECTIVE: The objective is to present an uncommon case of squamous cell carcinoma (SCC) arising from extensive recurrent respiratory papillomatosis (RRP) involving the upper and lower airway and temporal bone. STUDY DESIGN: This is a case report and a review of the literature. METHODS: We describe a case of a 24-year-old woman with a history of human papillomavirus (HPV) type 11 since childhood originating in the larynx and trachea, then progressing to involve the distal pulmonary alveoli and right middle ear through the eustachian tube. Papillomatous growth was treated with multiple surgeries including laser cytoreduction of laryngotracheal papillomatosis and radical mastoidectomy, followed by a trial of chemotherapy. Despite this aggressive treatment regimen, papillomatous growth progressed with recurrence in the right eustachian tube, middle ear, and mastoid eventually extending to involve the calvaria and scalp. RESULTS: The patient underwent a composite resection of involved tissues, including the scalp, auricle, and lateral temporal bone, with reconstruction using a latissimus dorsi free flap. Final pathologic analysis revealed an extensive infiltrative well-differentiated SCC arising from the papilloma. A review of the literature on aggressive respiratory papillomatosis suggests that malignant transformation of juvenile-onset RRP occurs exclusively in cases positive for HPV-11. CONCLUSIONS: We report an unusual case of SCC originating from extensive RRP involving the airway, temporal bone, and scalp and describe the medical and surgical management. Although the incidence of juvenile-onset RRP transformation to SCC is very low, the presence of HPV-11 as a risk factor for malignant transformation of RRP is becoming evident.

Is investigation of patients with haemoptysis and normal chest radiograph justified?

BACKGROUND: Haemoptysis is a common clinical symptom. A small proportion of patients present with haemoptysis and normal chest radiograph. The investigation strategy for this group of patients is unclear. The aim of this study is to see whether further investigations for this group of patients are justified. METHODS: A retrospective analysis was conducted of consecutive patients presenting with haemoptysis and normal chest radiograph over a period of 56 months irrespective of their smoking status. These patients were investigated by CT of the thorax and fibreoptic bronchoscopy. RESULTS: 275 episodes of haemoptysis with normal chest radiograph were investigated further in 270 patients (60% males). The median age was 60 years. Twenty-six patients were diagnosed to have respiratory tract malignancies (larynx, 1; trachea, 1; lung, 22; carcinoid, 1; and leiomyoma, 1). Eight (31%) of the 26 patients with respiratory tract malignancy had radical treatment. Fibreoptic bronchoscopy was diagnostic of cancer in 14 (54%) of the 26 patients with malignancy. CT of the thorax was suggestive of cancer in 24 (96%) of the 25 patients with malignancy. CONCLUSION: It is concluded that further investigation of haemoptysis in smokers is justified regardless of the amount or frequency of haemoptysis based on a 9.6% rate of malignancy in this consecutive series. It is recommended that these patients are investigated with CT of the thorax followed by fibreoptic bronchoscopy.

[Kystic pleuropulmonary blastoma fortuitly discovered in an infant]. / Pleuropneumoblastome kystique de découverte fortuite chez un nourrisson.

Pleuropulmonary blastoma is a rare childhood intrathoracic neoplasm, associated with a poor outcome. We report the case of a 7 week-old boy with a pleuropulmonary blastoma classified as type I. Disease was discovered at a chest X-ray performed as a work-up for a benign acute viral bronchiolitis. The final diagnosis was brought by pathology: a bronchopulmonary malformation had not been ruled out by clinical, radiological and macroscopic findings. Pleuropulmonary blastoma is a rare childhood intrathoracic neoplasm, for which the poor outcome and tough diagnosis justify a surgical attitude when an intrathoracic bullous lesion is found in an infant.

Bronchoscopic and radiologic features of Kaposi's sarcoma involving the respiratory system.

In a group of 61 patients admitted to New England Deaconess Hospital, Boston, with a diagnosis of acquired immune deficiency syndrome (AIDS), 25 were found to have Kaposi's sarcoma involving the skin and mucous membranes. Of these 25 patients, eight had lesions involving the respiratory system. Radiographically, patients with Kaposi's sarcoma had hilar and mediastinal adenopathy with perihilar parenchymal infiltration which progressed to diffuse bilateral infiltrates over a period of months. This pattern and the tempo of its evolution were distinctly different from the diffuse infiltrates seen in patients with Pneumocystis carinii pneumonia. Bronchoscopy was performed in seven of the eight patients, revealing characteristic lesions of Kaposi's sarcoma in the airways. We propose that parenchymal pulmonary Kaposi's sarcoma can be strongly suspected in a patient with AIDS who has the following features: a characteristic radiologic pattern; endobronchial Kaposi's sarcoma at bronchoscopy; and no evidence of opportunistic infection. In this subset of patients, further diagnostic intervention such as open lung biopsy, a procedure with potential morbidity in these ill individuals, may be unnecessary.

Clinical applications of tumor volume measurements for predicting outcome in patients with squamous cell carcinoma of the upper aerodigestive tract.

Gross tumor volume (GTV) at the primary site, as derived from pretreatment CT findings, can help predict local control of squamous cell carcinoma at different head and neck subsites after treatment with nonsurgical organ preservation. Local recurrence is more likely with large tumors than with small lesions in the same anatomic subsite, and GTV is often more strongly associated with local control than is tumor stage. This review discusses tumor volume calculation-technique, current literature, and potential clinical applications-and aims to help the reader to understand the role of GTV calculations and to integrate this knowledge into clinical practice.

Primary diaphragmatic schwannoma with a typical target appearance: correlation of CT and MR imagings and histologic findings.

A rare case of benign diaphragmatic schwannoma in a 38-year-old female is reported. Precontrast computed tomography (CT) showed an encapsulated well-defined round homogeneous tumor with central calcification, measuring approximately 5 cm in diameter, arising from the left diaphragm. Contrast-enhanced CT and gadolinium-enhanced T1-weighted magnetic resonance (MR) imaging showed focal enhancement in the central portion of the tumor. The tumor showed a typical target appearance of increased peripheral signal intensity and decreased central signal intensity on unenhanced T2-weighted images. Pathological examination of resected specimens of the tumor showed two zonal histological components: a hypercellular portion of spindle cells with nuclear palisading (Antoni A tissue) and a hypocellular portion of cells with cystic degeneration, together with focal calcification and hemangeomatous vascular changes (Antoni B tissue). We consider the radiological characteristics of diaphragmatic schwannoma on CT and MR imagings to represent the geographic difference between the histologic zones of the tumor.

Malignant transformation in non-irradiated recurrent respiratory papillomatosis.

The clinical, radiographic and post mortem findings occurring in a 6-year-old female with a four-year history of recurrent respiratory papillomatosis (RRP) are described. At autopsy, there were two separate foci of malignant transformation (malignant degeneration) in the bronchioloalveolar papillomata. This patient is the youngest in whom such changes have been described. Malignant transformation is a rare occurrence and is usually seen in older patients with longstanding papillomatosis, therapeutic irradiation, or a history of smoking. Pulmonary spread represents the majority of cases with "spontaneous" malignant transformation.

Isotretinoin therapy for recurrent respiratory papillomatosis.

Retinoic acid has been advocated for use in several premalignant and malignant epithelial lesions of the head and neck, including benign recurrent respiratory papillomatosis, with varying results. We describe a 24-year-old man with extensive tracheoesophageal and bronchoalveolar papillomatosis that degenerated into squamous cell carcinoma. Multiple endoscopic carbon dioxide laser excisions, at one point performed on a weekly basis, as well as a prolonged trial of interferon, failed to control the progression of his disease. Isotretinoin (13-cis-retinoic acid) therapy (1 mg/kg per day) was instituted, with dramatic clinical, radiographic, and functional improvement. The patient experienced no significant toxic effects and required no endoscopic procedures over a 6-month period. We propose that isotretinoin may be an effective adjuvant therapy for aggressive respiratory papillomatosis.

Clinical applications of 2D and 3D CT imaging of the airways--a review.

Hardware and software evolution has broadened the possibilities of 2D and 3D reformatting of spiral CT and MR data set. In the study of the thorax, intrinsic benefits of volumetric CT scanning and better quality of reconstructed images offer us the possibility to apply additional rendering techniques to everyday clinical practice. Considering the large number and redundancy of possible post-processing imaging techniques that we can apply to raw CT sections data, it is necessary to precisely set a well-defined number of clinical applications of each of them, by careful evaluation of their benefits and possible pitfalls in each clinical setting. In diagnostic evaluation of pathological processes affecting the airways, a huge number of thin sections is necessary for detailed appraisal and has to be evaluated, and information must then be transferred to referring clinicians. By additional rendering it is possible to make image evaluation and data transfer easier, faster, and more effective. In the study of central airways, additional rendering can be of interest for precise evaluation of the length, morphology, and degree of stenoses. It may help in depicting exactly the locoregional extent of central tumours by better display of relations with bronchovascular interfaces and can increase CT/bronchoscopy sinergy. It may allow closer radiotherapy planning and better depiction of air collections, and, finally, it could ease panoramic evaluation of the results of dynamic or functional studies, that are made possible by increased speed of spiral scanning. When applied to the evaluation of peripheral airways, as a completion to conventional HRCT scans, High-Resolution Volumetric CT, by projection slabs applied to target areas of interest, can better depict the profusion and extension of affected bronchial segments in bronchiectasis, influence the choice of different approaches for tissue sampling by better evaluation of the relations of lung nodules with the airways, or help to detect otherwise overlooked slight pathological findings. In the exploration of the air-spaces of the head and neck, targeted multiplanar study can now be performed without additional scanning by retro-reconstructed sections from original transverse CT slices. Additional rendering can help in surgical planning, by simulation of surgical approaches, and allows better integration with functional paranasal sinuses endoscopic surgery, by endoscopic perspective rendering. Whichever application we perform, the clinical value of 2D and 3D rendering techniques lies in the possibility of overcoming perceptual difficulties and 'slice pollution', by easing more efficient data transfer without loss of information. 3D imaging should not be considered, in the large majority of cases, as a diagnostic tool: looking at reformatted images may increase diagnostic accuracy in only very few cases, but an increase in diagnostic confidence could be not negligible. The purpose of the radiologist skilled in post-processing techniques should be that of modifying patient management, by more confident diagnostic evaluation, in a small number of patients, and, in a larger number of cases, by simplifying communication with referring physicians and surgeons. We will display in detail possible clinical applications of the different 2D and 3D imaging techniques, in the study of the tracheobronchial tree, larynx, nasal cavities and paranasal sinuses by Helical CT, review relating bibliography, and briefly discuss pitfalls and perspectives of CT rendering techniques for each field.

Recurrent respiratory papillomatosis: cytopathological findings in an unusual case.

Recurrent respiratory papillomatosis (RRP) primarily is a disease of children and adolescents. Most patients experience spontaneous regression at a later age, while others continue to be affected throughout their lives. Here, we present the case of a 26-yr-old man who presented with persistent cough, worsening dyspnea, and development of pneumothorax. Eight years prior, he had presented with similar complaints and an evaluation at that time had showed RRP. Follow-up since that time showed recurrent disease managed by multiple surgical procedures. At the most current admission, an ultrasound-guided fine-needle aspiration (FNA) of the lung showed numerous papillary tissue fragments and single atypical squamous cells consistent with recurrent RPR. To our knowledge, morphological findings of RRP have been reported rarely.