Patrones radiológicos en la aproximación diagnóstica a la neumonía organizativa / Radiographic patterns in the diagnostic approach to organizing pneumonia

Una mujer de 56 años, no fumadora, que presentaba tos irritativa y disnea de medianos esfuerzos desde hacía un mes acudió a urgencias por aumento de su disnea. En la radiografía de tórax se apreciaban zonas de incremento de densidad mal definidas, bilaterales, por lo que fue diagnosticada de bronconeumonía con insuficiencia respiratoria parcial. Durante el ingreso empeoró su disnea y se realizó una tomografía computarizada torácica donde se observaron áreas de atenuación en vidrio deslustrado con engrosamiento de septos interlobulillares («patrón en empedrado»), de predominio en lóbulos inferiores. Requirió ventilación mecánica en la Unidad de Cuidados Intensivos. Posteriormente se realizó una biopsia pulmonar abierta. Se plantean las cuestiones siguientes: ¿Es posible realizar el diagnóstico de neumonía organizativa (NO) exclusivamente mediante las manifestaciones clínicas?. ¿Son patognomónicos los hallazgos en las pruebas de imagen?. ¿Se requiere la realización de una biopsia pulmonar para confirmar el diagnóstico de NO?. ¿Es necesario esperar a la confirmación histológica para iniciar el tratamiento ante la sospecha de NO? (AU)

A 56-year-old woman, non-smoker, who complained of dry cough and dyspnea during the last month came to the emergency department due to increased dyspnea. The chest X-ray showed areas of poorly defined, bilateral alveolar opacities, leading to the diagnosis of bronchopneumonia with partial respiratory failure. During admission, she experienced an exacerbation of the dyspnea. A high-resolution computed tomography scan was performed, showing areas of ground glass opacities with interlobular septal thickening («crazy-paving» pattern), predominantly in lower lobes. She required mechanical ventilation and she was admitted to the intensive care unit. Subsequently, an open lung biopsy was performed. The following questions should be proposed: Is it possible to make the diagnosis of Organizing Pneumonia (OP) only by clinical findings?. Are the imaging test findings pathognomonic?. Is a lung biopsy required to confirm the diagnosis of OP?. Is it necessary to wait for histologic confirmation to start treatment when OP is suspected? (AU)

Radiographic patterns in the diagnostic approach to organizing pneumonia.

A 56-year-old woman, non-smoker, who complained of dry cough and dyspnea during the last month came to the emergency department due to increased dyspnea. The chest X-ray showed areas of poorly defined, bilateral alveolar opacities, leading to the diagnosis of bronchopneumonia with partial respiratory failure. During admission, she experienced an exacerbation of the dyspnea. A high-resolution computed tomography scan was performed, showing areas of ground glass opacities with interlobular septal thickening ("crazy-paving" pattern), predominantly in lower lobes. She required mechanical ventilation and she was admitted to the intensive care unit. Subsequently, an open lung biopsy was performed. The following questions should be proposed:

[Treatment of lung lesions by stereotactic body radiation therapy after computed tomography guided placement of a Visicoil(®) marker: initial experience]. / Tratamiento de lesiones pulmonares mediante radioterapia estereotáxica extracraneal tras colocación guiada por tomografía computarizada de marcador Visicoil(®): experiencia inicial.

OBJECTIVE: To describe the technique of stereotactic body radiation therapy (SBRT) of lung lesions after the computed tomography (CT) guided placement of an internal fiducial marker and to assess the results, complications and secondary effects of these procedures. MATERIAL AND METHOD: A series of 39 lesions (8 primary and 31 metastases) in 25 patients treated using this procedure were analysed. A CT-guided percutaneous transthoracic puncture was performed for placing the internal marker in the lesion or near to it. The procedure did not require sedation. The marker serves as a guide for the treatment of the lesion using SBRT with respiratory synchronism, which allows the movement of the tumour to be controlled and to decrease the radiation volume, giving high doses with precision to the tumour, and minimal to the surrounding healthy tissue. RESULTS: The only complication of the percutaneous fiducial placement was a pneumothorax in 6 (24%) patients. A pleural drain had to be placed in 3 patients. Local control was achieved in 96.7% of the lesions. The radiation produced a grade 1 asthenia in 1 patient, a grade 2 pneumonitis in one patient and a grade 1 pneumonitis in the remainder. CONCLUSIONS: The CT-guided placement of internal markers in lung lesions is a safe technique that may be performed as ambulatory procedure. SBRT with respiratory synchronism allows the dose to the tumour to be increased, and reduces the volume of healthy lung treated, with few secondary effects.