CT imaging features of thin-walled cavitary squamous cell lung cancer.

Primary lung cancer manifesting as a thin-walled solitary cavity, occurs relatively infrequently. The most common histologic type presenting such a pattern is squamous cell cancer, followed by adenocarcinoma, and finally - large cell cancer. Cavitation is typically not seen in small cell lung cancer. Entities indicating malignancy of such lesions include irregular cystic wall, wall nodule formation, nodular septa or increased standard uptake on positron emission tomography (PET). We are presenting a case of a squamous cell lung cancer manifesting on chest CT as a thin-walled septated cavity with irregular margins mimicking a cyst. The lesion was reported unchanged in a follow-up computed tomography after 3 months. A follow-up scan obtained 2 years after initial examination showed thickening of a cyst wall, solid structures within its lumen and thoracic lymph nodes enlargement.

Atypical manifestations of granulomatosis with polyangiitis: the diagnostic challenge for pulmonologists.

This is a review considering atypical manifestations of granulomatosis with polyangiitis (GPA). Virtually any organ can be affected, and in some patients, GPA can manifest unusually. Since thoracic involvement of GPA often predominates, the first who might be expected to establish a diagnosis are pulmonary specialists. We would like to familiarize pulmonary specialists with several extra-ELK (E: ear-nose-throat; L: lung; K: kidney) involvements of the disease. We describe sites rarely affected by GPA like the breast, skeletal system, orbit and eye, heart and vessels, central nervous system, urogenital system as well as endocrine and gastrointestinal tract involvement.

Pulmonary tuberculosis mimicking lung cancer progression after 10 years of cancer remission.

Differentiation between pulmonary tuberculosis and lung cancer is often challenging for clinicians, especially that both conditions can coexist. This is due to the fact that the clinical and radiological symptoms of both diseases can be similar. Our case report presents a patient who was treated for advanced lung cancer 10 years earlier and currently has been hospitalized again because of a strong clinical and radiological suspicion of the cancer progression, but whose final diagnosis was tuberculosis.

Diagnostic Difficulties in Bone Sarcoidosis Imaging. A Cases Study.

Sarcoidosis is a multiorgan inflammatory disease that rarely involves the musculoskeletal system. A typical radiographic presentation is only noted with phalangeal lesions in the hands and feet, and other skeletal sites of sarcoidosis are a diagnostic imaging challenge [1]. We describe two cases of patients with sarcoidosis in whom pathologic bone marrow lesions were diagnosed on MRI scans. The magnetic resonance findings were non-specific and metastatic lesions or multiple myeloma were suspected. The case analysis serves to point to limitations of imaging studies in diagnosing bone sarcoidosis and underline the importance of cooperation between the radiologist and the clinician. The role of magnetic resonance imaging in the diagnostic algorithm for bone sarcoidosis should mostly focus on locating lesions, indicating biopsy sites and follow-up of abnormalities.

Pulmonary hypertension in the course of diffuse parenchymal lung diseases - state of art and future considerations.

Lung diseases are one of the most frequent causes of pulmonary hypertension (PH). The development of PH influences the course of lung disease, worsening the clinical symptoms and prognosis. According to the most recent publications, PH in the course of lung diseases develops as a result of both "parenchymal" and vascular pathology, in the patients with genetic predisposition. Prolonged infection (especially viral one) may be an additional promoting factor. Right heart catheterization (RHC), which is an invasive procedure, is the only objective method of diagnosing PH. According to the latest recommendations, the management algorithm of PH and coexisting interstitial lung disease is based on RHC and the results of pulmonary function tests. Majority of the patients develop mild PH in the course of advanced lung disease. Best treatment of underlying lung pathology combined with long term oxygen treatment is recommended in this group. In case of severe PH (mean resting pulmonary artery pressure (mPAP) ≥ 35 mm Hg) the alternate cause of PH has to be sought. PAH-specific drugs use should be limited to patients with severe PH participating in clinical trials. In this review, the value of various non-invasive methods (echocardiography, radiological examination, exercise capacity and brain natriuretic peptides assessment) in the process of screening for PH is presented, and the results of recent randomized clinical trials with PAH-specific drugs in patients with diffuse parenchymal lung diseases are discussed.

Accuracy of FDG PET/CT in the evaluation of solitary pulmonary lesions - own experience.

INTRODUCTION: In recent years, positron emission tomography (PET) has been increasingly applied in the diagnosis of neoplastic lung diseases. In contrast to conventional imaging studies, PET-CT enables the visualisation of not only the morphology of the suspicious lesion, but also its metabolism. The aim of the present study was to investigate the role of PET-CT in the initial assessment of patients with indeterminate solitary pulmonary lesions. MATERIAL AND METHODS: The study was conducted on a group of 82 patients with indeterminate lung nodule diagnosed at the National Institute of Tuberculosis and Lung Diseases in the period from January 2008 to May 2011. CT and PET-CT were performed in all of the patients. Histological or cytological examination of the biopsy specimens obtained from bronchoscopy, mediastinoscopy and intraoperatively were the reference tests. RESULTS: Malignancy was documented in 40 patients (48.8%). Histopathological analysis of all tumours revealed 12 cases of squamous cell carcinoma, 18 cases of adenocarcinoma and 1 case of carcinoid, whereas in 9 patients the diagnosis of "non-small cell cancer not otherwise specified" was made. All lesions except one were of solid character on chest CT. SUV(max) values exceeding 2.5 were found in 38 cancer patients (true positives, TP). The mean value of SUV(max) was 9.1 (1-26.8). Forty-two lesions were documented as benign (51.2%). SUV(max) values equal to or less than 2.5 were found in 37 patients (true negatives, TN). The mean value of SUV(max) in this group was 1.9 (0.5-8.6). The diagnostic value of PET-CT SUV(max) exceeding 2.5 in the prediction of neoplastic origin of solitary pulmonary lesions was: sensitivity - 95% (95% CI 84-99%), specificity - 88% (95% CI 75-95%) and accuracy - 91.5% (95% CI 83-96%). Positive predictive value (PPV) was 88.4% (95% CI 76-95%), and negative predictive value (NPV) was 94.8% (95% CI 83-99%). False negative results concerned two patients, with final diagnosis of carcinoid and adenocarcinoma; false positive results were obtained in 5 patients with various inflammatory lesions. CONCLUSIONS: In the present study, PET-CT appeared to have high sensitivity (95%), but lower specificity (88%) for predicting the malignant character of solitary pulmonary lesions. Overall diagnostic value of PET-CT SUV(max) > 2.5 was high - PPV was 88.4%, NPV was 94.8%. In the authors' opinion, the PET-CT value may increase when clinical data as well as other radiological documentation (with retrospective assessment) are taken into consideration.

The application of MDCT in the diagnosis of chest trauma.

INTRODUCTION: Traumas are the third most common cause of death worldwide, after cardiovascular diseases and neoplasms, and the main cause of death of patients under 40 years of age. Contemporary image diagnosis of chest trauma uses chest X-ray (CXR), multidetector computed tomography (MDCT), transthoracic and transoesophageal ultrasound (USG), X-ray angiography and magnetic resonance. The aim of the present study was to evaluate MDCT results in the examination of posttraumatic chest injuries and to compare the results of CXR and MDCT in chosen chest traumatic injuries. MATERIAL AND METHODS: The sixty patients with chest trauma included in the study were diagnosed at the Department of Radiology of the Institute of Tuberculosis and Lung Diseases between May 2004 and October 2007. MDCT was performed in all patients. Two groups with different types of injury (blunt or penetrating chest trauma) were distinguished. The analysis of injuries in both groups was conducted depending on the mechanism of trauma. The detection of 20 selected injuries at CXR and MDCT was compared. Moreover, the compatibility of MDCT with the results of intraoperative assessment and bronchoscopy was analysed. The influence of MDCT on the treatment modality was also assessed. RESULTS: History of blunt chest trauma was found in 51 patients (group 1) and of penetrating trauma in 9 patients (group 2). The most frequent injuries among group 1 were lung contusion and rib fractures, and among group 2 it was pericardial hematoma. Compared to MDCT, the sensitivity and specificity of CXR were 66.7 and 58%, respectively. Change of treatment modality was observed after MDCT in 83% of patients. The sensitivity and specificity of MDCT in diagnosing tracheobronchial injury, compared to bronchoscopy, were 72.7% and 100%, respectively. Compatibility of MDCT results and intraoperative assessment was observed in 43% of patients, and the main reason for discrepancy was underdiagnosis of diaphragm injury in MDCT. CONCLUSIONS: MDCT was a valuable diagnostic method in recognition of chest trauma, characterized by high sensitivity and specificity in the assessment of life-threatening injures and for depicting tracheal and bronchial injuries. The diagnostic value of CXR was low. The compatibility of MCTD and intraoperative assessment was confirmed, with the exception of diaphragm injures and lung laceration. Change of treatment modality was certified after MDCT in 83% of patients.

[A surprising diagnosis in a male with a tumour of the chest wall--not always lung cancer]. / Zaskakujace rozpoznanie u mezczyzny z guzem sciany klatki piersiowej--nie wszyscy choruja na raka pluca.

Lung cancer is the most frequent malignant tumour in men. Advanced disease may produce metastatic tumours in subcutaneous tissue and also infiltrate the chest wall. We present a history of a man referred to our department suspected of lung tumour infiltrating the chest wall. Additionally, bone metastatic disease was diagnosed (ribs, vertebral bodies and skull). Thanks to a wide diagnostic approach, ductal cancer of the breast was finally diagnosed, a neoplasm that is extremely rare in male patients, usually presenting as a definite nodule in the nipple area of the breast. This case shows the importance of careful histological evaluation of the chest wall tumour.

[Diffuse alveolar hemorrhage as the only manifestation of antiphospholipid syndrome]. / Rozlane krwawienie pecherzykowe jako jedyna manifestacja zespolu antyfosfolipidowego.

The antiphospholipid syndrome is characterized by the presence of antiphospholipid antibodies and the association of protean clinical manifestations as a result of both venous and arterial thrombosis. While pulmonary embolism (secondary to deep vein thrombosis) is common and well-known disturbance in antiphospholipid syndrome, recently there are growing number of case reports describing nonthrombotic lung pathologies in APS. We present here a young male with antiphospholipid syndrome, whose the only manifestation was diffuse alveolar hemorrhage.

Assessment of recurrence of non-small cell lung cancer after therapy using CT and Integrated PET/CT.

INTRODUCTION: Non-small cell lung cancer (NSCLC) has become the leading cause of cancer-related deaths in Poland. Follow-up of patients with NSCLC is aimed at early detection of local recurrence, metastatic process, treatment-related complications or second primary lung cancer. We investigated the diagnostic accuracy of FDG-PET-CT in the detection of recurrence of NSCLC after treatment. MATERIAL AND METHODS: Seventy-two NSCLC patients (19 females, 56 males), stage I to IV, who had undergone surgery and/ /or radiation therapy, occasionally associated with chemotherapy, were retrospectively included in our study. Chest radiographs and thoracic computed tomography (CT) were performed to localize the abnormality prior to PET-CT. All the patients underwent CT and PET-CT in the period from January 2008 until January 2012. All PET images were interpreted in conjunction with thoracic CT. PET-CT and CT diagnoses were correlated with pathological diagnoses. RESULTS: Forty-five patients had recurrent tumour. Tumour recurrence was observed more often in men than in women and also in case of neoplastic cell emboli in lymphatic or blood vessels. In three patients second primary lung cancer was diagnosed. False positive diagnosis of relapse based on PET-CT was obtained in 4 patients, mainly due to inflammatory lesions. The accuracy of PET-CT for diagnosis of recurrence was 94.4% (95% CI 91; 100). CONCLUSIONS: FDG PET-CT was the best method to differentiate recurrent bronchogenic carcinoma from inflammatory lesions, especially at post-therapeutic sites. It has been shown that PET-CT is more accurate method than CT in recurrent NSCLC. PET-CT results had a further impact on the clinical management and treatment planning.

[Fibrosing mediastinitis with pulmonary hypertension as a rare complication of sarcoidosis]. / Wlóknienie sródpiersia z nadcisnieniem plucnym jako rzadkie powiklanie sarkoidozy.

Fibrosing mediastinitis is a rare disease, mostly associated with previous granulomatous diseases, such as histoplasmosis, tuberculosis, or sarcoidosis. We present a case of 42-year-old woman with sarcoidosis, who had developed fibrosing mediastinitis and pulmonary hypertension. Contrast-enhanced computer tomography showed abnormal, bilateral, solid tissues surrounding the hila and mediastinum. Magnetic resonance imaging showed: abnormal, intermediate signal tissue in the mediastinum, surrounding hila, narrowing both lower lobe arteries and both lobe bronchi, left upper lobe atelectasis, and contrast enhancement of mediastinal infiltration. The patient was treated with steroids for 14 months (initial dose of prednisone was 1 mg/kg/day, then tapered) with clinical and radiological improvement. We reviewed the literature concerning fibrosing mediastinitis. The various causes of that disorder, the radiological manifestation, and possible treatment modalities are discussed. The causes of pulmonary hypertension in our patient are another aspect of the article. It could be associated with both the fibrosing mediastinitis and the sarcoidosis.

[Staging of non-small cell lung cancer using CT and integrated PET-CT]. / Ocena zaawansowania niedrobnokomórkowego raka pluca metodatomografii komputerowej i pozytonowej tomografii emisyjnejskojarzonej z tomografia komputerowa

INTRODUCTION: Lung cancer is the leading cause of death from cancer in developed countries. Radiological imaging methods are the basic methods in early diagnosis of this disease. TNM classification is a very important tool for optimal treatment in non-small lung cancer (NSCLC). Conventional radiological techniques allow the evaluation of the stage on the basis of anatomical changes only, while PET-CT provides information about the biochemical processes that may precede anatomical changes. The aim of this study was to compare the accuracy and sensitivity of CT and PET-CT in the staging of NSCLC. MATERIAL AND METHODS: The study was conducted on a group of 99 patients with NSCLC diagnosed at the Institute of Tuberculosis and Lung Diseases in the period from January 2008 to May 2010. CT and PET-CT were performed in all patients. Histological or cytological examination of the material obtained from biopsy, bronchoscopy, mediastinoscopy, and intraoperatively was the reference test. TNM classification was performed independently after CT and PET-CT. RESULTS AND CONCLUSIONS: It has been shown that PET-CT is a more accurate and sensitive method than CT in the staging process in NSCLC. PET-CT allowed the correct classification of the T, N, M, and total TNM in, respectively, 97%, 95%, 99%, and 89% of cases, while for CT it was, respectively, 95%, 84%, 84%, and 68% (p = 0.0002).

Diagnosis of malignant pericarditis: a single centre experience.

BACKGROUND: Malignancy is the most common cause of effusive pericarditis with a haemodynamically significant amount of pericardial fluid. Early diagnosis and management of malignant pericarditis may significantly improve outcomes. AIM: To evaluate retrospectively the rate and clinical presentation of malignant pericarditis among patients undergoing invasive treatment, with a view to identification of optimal diagnostic modalities to distinguish this group among other patients. METHODS: We studied 191 patients (100 men and 91 women, median age 57 years, range 19-88 years) with effusive pericarditis who underwent invasive treatment in the National Institute of Tuberculosis and Lung Diseases in Warsaw in 1982- -2008 due to a significant amount of pericardial fluid and/or echocardiographic evidence of cardiac tamponade. Pericardiocentesis was performed in 93 cases, pericardioscopy in 61 cases, and substernal pericardiotomy in 37 cases. Pericardial fluid was sent for examination in all patients, and a pericardial specimen was obtained in 96 patients. The patients were divided into 3 groups: Group 1 included patients with malignant pericarditis (malignant cells found in the cytological examination of the pericardial fluid and/or neoplastic infiltration in the histological examination of the pericardial specimen), Group 2 included patients with probable malignant pericarditis (pericardial fluid without malignant cells with histologically confirmed malignancy at some other location), and Group 3 included patients with non-malignant pericarditis (negative cytological examination of pericardial fluid and histological examination of the pericardial specimen, with no evidence of malignancy during hospitalization and one-year follow-up). RESULTS: Malignancy was found in 111 (58%) of 191 patients, including 66 (35%) patients with definite malignant pericarditis and 45 (23%) patients with probable malignant pericarditis. Lung cancer, including adenocarcinoma, was the most common type of malignancy, present in 44 (67%) patients. Non-malignant pericarditis was found in 80 (42%) patients. Among patients with the diagnosis of malignancy (Groups 1 and 2), a positive result of the cytological examination of the pericardial fluid was obtained in 52 cases (sensitivity of 46%). Among patients without malignancy, a negative result of the cytological examination of the pericardial fluid was obtained in all 80 cases (specificity of 100%). Malignant infiltration was found in 20 of 44 patients with the diagnosis of malignancy (sensitivity of 46%) and in none among 52 patients without malignancy (specificity of 100%). Compared to patients with non-malignant pericarditis, patients with malignant pericarditis significantly more commonly presented with tachycardia of >100 bpm in a resting electrocardiogram (ECG) (in 77% of patients with malignant pericarditis vs. 43% of patients with non-malignant pericarditis, p = 0.01), low QRS amplitude (52% vs. 34%, respectively, p = 0.03), electrical alternans (19% vs. 3%, respectively, p = 0.001), echocardiographic evidence of cardiac tamponade (67% vs. 34%, respectively, p = 0.0001), enlarged mediastinal lymph nodes by chest computed tomography (CT) (90% vs. 29%, respectively, p <0.00001), pericardial thickness >8 mm by chest CT (62% vs. 16%, respectively, p <0.0001), and bloody pericardial effusion (94% vs. 43%, respectively, p <0.0001). Levels of carcinoembryonic antigen (CEA) and cytokeratin fragment-19 (CYFRA 21-1) in the pericardial fluid were higher in patients with malignant pericarditis compared to patients with non-malignant pericarditis, with median values of 40.8 ng/mL vs. 0.9 ng/mL, p <0.0001, and 162.85 ng/mL vs. 13.35 ng/mL, p <0.0001, respectively. CONCLUSIONS: 1. Malignancy was found in 58% of patients undergoing invasive treatment due to large pericardial effusion. 2. Cytological examination of the pericardial fluid and histological examination of a pericardial specimen showed high specificity (100%) but low sensitivity (46%) in the diagnosis of malignant pericarditis. 3. The most important predictors of malignant pericarditis included tachycardia of >100 bpm as revealed by the physical examination and ECG, echocardiographic evidence of cardiac tamponade, presence of enlarged mediastinal lymph nodes (>1 cm) and thickened pericardium (>8 mm) by chest CT, bloody pericardial effusion, and elevated levels of CEA (>5 ng/mL) and CYFRA 21-1 (>50 ng/mL) in the pericardial fluid.

[Tuberculosis of shoulder bone]. / Gruzlica kosci ramiennej.

We present a case of 39-year old man in whom after one year of corticotherapy due to suspicion of lung sarcoidosis, pathologic changes in left shoulder bone were diagnosed. Bone biopsy was carried out with subsequent development of skin fistula with matter drainage. Based on histological examination of bone specimen and bacteriological tests - tuberculosis was diagnosed. Patient received typical antituberculous therapy for 6 months resulting in healing of the fistula. After next 6 months new fistula developed within the muscles of the left arm. Examination by magnetic resonance revealed changes suggestive of tuberculosis of the left shoulder bone with the presence of two fistulas and abscess in the muscle. The patient received another course of antituberculous treatment and the content of fistula was removed. After 8 months of therapy fistula was healed while changes in shoulder bone regressed only partially, so the therapy was prolonged until 12 month.

Intraosseous lipomas: A report of six cases and a review of literature.

BACKGROUND: Intraosseous lipoma is a very rare lesion, which constitutes not more than 0.1% of bone tumors. The introduction of cross-sectional imaging, especially MRI, seems to have increased the detection rate of these lesions. CASE REPORT: The authors presented 6 cases of intraosseous lipomas in bones of the lower extremities. All lesions were detected incidentally and presented radiographically as radiolucent lesions with sclerotic borders and internal trabeculations. One lesion caused bone expansion. CT and MRI identified fatty tissue in all lesions. Cystic degeneration was present in one lesion and dystrophic calcifications in two. DISCUSSION: The radiographic appearance of intraosseous lipomas is not characteristic and requires differential diagnostics conducted for a long time. However, CT and MRI allow for a tissue-specific diagnosis. The detection of a predominant fatty component in a lesion confirms its benign character and no further diagnostic work-up is required.

Fibrosing mediastinitis as an untypical complication of tuberculosis: case report.

Fibrosing mediastinitis (FM) is a rare benign disorder caused by proliferation of acellular collagen and fibrous tissue within the mediastinum. In the United States, most cases are thought to be caused by an abnormal immune response to Histoplasma capsulatum infection. Some cases of FM are related to tuberculosis. In most patients the cause of FM is unknown. The affected patients are typically young and present with signs and symptoms of obstruction or compression of the superior vena cava, pulmonary veins or arteries, central airways or esophagus. Computed tomography and magnetic resonance imaging are central to the diagnosis and management of this disorder. We present a rare case of FM as a sequela of tuberculosis.