Positron emission tomography in the diagnosis and management of primary pediatric lung tumors.

Primary pediatric lung tumors are uncommon and have many overlapping clinical and imaging features. In contrast to adult lung tumors, these rare pediatric neoplasms have a relatively broad histologic spectrum. Informed by a single-institution 13-year retrospective record review, we present an overview of the most common primary pediatric lung neoplasms, with a focus on the role of positron emission tomography (PET), specifically 18F-fluorodeoxyglucose (FDG) PET and 68Ga-DOTATATE PET, in the management of primary pediatric lung tumors. In addition to characteristic conventional radiographic and cross-sectional imaging findings, knowledge of patient age, underlying cancer predisposition syndromes, and PET imaging features may help narrow the differential. While metastases from other primary malignancies remain the most commonly encountered pediatric lung malignancy, the examples presented in this pictorial essay highlight many of the important conventional radiologic and PET imaging features of primary pediatric lung malignancies.

Altitudinal variation in organ mass from three mountain systems: The case of mesquite lizard Sceloporus grammicus.

High altitude environments provide a fertile ground for investigating the benefits of phenotypic adjustments at several levels of biological organization. Low oxygen partial pressure and low environmental temperature are the main limiting factors that promote phenotypic variation in different organs, such as the lung and heart. Although high-altitude environments act like natural laboratories, most morphological studies conducted to date lack replication. Here, we evaluated organ mass variation in nine populations of Sceloporus grammicus, throughout three altitudinal gradients (mountains) from the Trans-Mexican volcanic belt. A total of 84 individuals from three different altitudes at three different mountains were collected. Then, we used generalized linear models to analyze the pattern of variation in internal organs mass as a function of altitude and temperature. We observed a striking pattern of altitudinal variation in the size of cardiorespiratory organs: while heart mass increased with altitude and decreased with temperature, the lung showed a significant statistical interaction between mountain transect and temperature. Overall, our results support the hypothesis that cardiorespiratory organs should be bigger in populations occurring at higher altitudes. Moreover, the study of different mountain systems allowed us to observe some differences in one mountain in relation to the other two.

Primary pulmonary lymphoepithelial-like carcinoma : A rare childhood malignancy.

Lymphoepithelial-like carcinoma (LELC) usually presents as a head and neck tumor with a close resemblance to nasopharyngeal carcinoma. We present an extremely rare case of Primary Pulmonary lymphoepithelioma in a 14-year-old female patient. The patient presented with a right-sided lung mass, which on biopsy revealed to be a lymphoepithelioma. There was no evidence of any mass elsewhere in the body, including the nasopharynx, as evidenced by PET CT. The IHC was positive for both cytokeratin and lymphoid cell markers. Hence, we conclude that lymphoepitheliomas can present as a primary lung mass in a young nonsmoking female, of which only two case reports are available from the Indian subcontinent till date.

Sequential Minimally Invasive Fetal Interventions for Two Life-Threatening Conditions: A Novel Approach.

INTRODUCTION: In utero interventions are performed in fetuses with "isolated" major congenital anomalies to improve neonatal outcomes and quality of life. Sequential in utero interventions to treat 2 anomalies in 1 fetus have not yet been described. CASE PRESENTATION: Here, we report a fetus with a large left-sided intralobar bronchopulmonary sequestration (BPS) causing mediastinal shift, a small extralobar BPS, and concomitant severe left-sided congenital diaphragmatic hernia (CDH). At 26-week gestation, the BPS was noted to be increasing in size with a significant reduction in right lung volume and progression to fetal hydrops. The fetus underwent ultrasound-guided ablation of the BPS feeding vessel leading to complete tumor regression. However, lung development remained poor (O/E-LHR: 0.22) due to the left-sided CDH, prompting fetal endoscopic tracheal occlusion therapy at 28-week gestation to allow increased lung growth. After vaginal delivery, the newborn underwent diaphragmatic repair with resection of the extralobar sequestration. He was discharged home with tracheostomy on room air at 9 months. DISCUSSION/CONCLUSION: Sequential in utero interventions to treat 2 severe major anomalies in the same fetus have not been previously described. This approach may be a useful alternative in select cases with otherwise high morbidity/mortality. Further studies are required to confirm our hypothesis.

Fetal Sclerotherapy for Hydropic Congenital Cystic Adenomatoid Malformations of the Lung Refractory to Steroids: A Case Report and Review of the Literature.

Microcystic congenital cystic adenomatoid malformations (CCAM), when associated with hydrops, carry a dismal prognosis. Options for treatment are limited and experimental, including antenatal corticosteroids, open fetal surgery, laser ablation and, more recently, sclerotherapy. We describe a case of a large, predominantly microcystic CCAM in a hydropic fetus treated successfully with direct interstitial injection of a sclerosant agent (3% sodium tetradecyl sulfate) at 23+3 weeks gestation, after multiple failed courses of steroids. Elective thoracoscopic right lower lobectomy was performed at 1 year of life and there have been no respiratory or other medical morbidities since. A literature review of fetal lung masses treated with sclerosants antenatally reveals that sclerotherapy may represent a novel treatment option for large hydropic microcystic CCAMs, which are unresponsive to corticosteroids. Further studies are required to evaluate the utility and safety of fetal sclerotherapy, as this may represent an alternative minimally invasive treatment option to fetal lobectomy.

Systemic air embolism after percutaneous computed tomography-guided lung biopsy due to a kink in the coaxial biopsy system: a case report.

BACKGROUND: Systemic air embolism is a rare but potentially life-threatening complication of percutaneous computed tomography (CT)-guided lung biopsy. The incidence might be underestimated because of failure to diagnose this adverse event in asymptomatic patients; early recognition is difficult. CASE PRESENTATION: We report the case of a 73-year-old man with systemic air embolism, a complication of percutaneous CT-guided lung biopsy, due to a kink in the coaxial biopsy system. Serial post-procedure CT scans demonstrated the causal relationship. CONCLUSIONS: Sequential post-biopsy CT scans demonstrated a causal relationship between this systemic air embolism and percutaneous biopsy, and allowed the radiologist to track the course of the emboli and their resolution. Awareness of air entry via the introducer needle and an early post-biopsy CT scan are crucial for early detection of systemic air embolism. If air embolism occurs in an asymptomatic patient, we recommend performing a delayed chest CT scan to follow the air's course.

Cryptococcus gattii Infection Presenting as an Aggressive Lung Mass.

Cryptococcus gattii is an endemic fungus predominantly isolated in the tropical and subtropical regions, causing predominantly pulmonary disease with a predilection for the central nervous system. Herein, we report a case of rapidly progressing C. gattii pneumonia in an immune-deficient but virologically suppressed host with underlying human immunodeficiency viral (HIV) infection, exhibiting various fungal morphologies from bronchoalveolar lavage (BAL) cytological specimens. A 51-year-old Chinese male with known HIV disease was admitted to the Singapore General Hospital for evaluation of functional decline, febrile episodes, and a left hilar mass on chest radiograph. Computed tomography (CT) showed consolidation in the apical segment of the left lower lobe. He underwent bronchoscopy and BAL. Positron emission tomography-computed tomography done 10 days after the initial CT showed approximate doubling of the pulmonary lesion. Cytological examination of the fluid revealed yeasts of varying sizes. Subsequent fungal culture from BAL fluid grew C. gattii 10 days later.

Thoracic Changes after Full Laser Ablation of the Feeding Artery in Fetuses with Bronchopulmonary Sequestration.

OBJECTIVE: To assess longitudinal intrathoracic changes after fetal laser surgery in fetuses with bronchopulmonary sequestration (BPS) with hydrops and/or hydrothorax. STUDY DESIGN: The presence of intrafetal fluid effusions, the lung mass volume ratio (congenital pulmonary airway malformation volume ratio [CVR]), and the observed/expected lung-to-head circumference ratio (O/E-LHR) of both lungs were evaluated in a cohort of BPS fetuses with hydrops and/or hydrothorax treated with full laser ablation of the feeding artery (FLAFA). The longitudinal changes in intrafetal fluid effusions, lung mass volume, and pulmonary growth were analyzed by survival and multilevel analysis against days after FLAFA. RESULTS: FLAFA was successfully performed in 15 cases at a median gestational age of 26.9 weeks. A complete disappearance of the hydrops and hydrothorax was observed a median interval of 7.5 and 21 days after the fetal intervention, respectively. A progressive decrease in the CVR and an increment in the size of both lungs were observed after FLAFA. The O/E-LHR of the lung contralateral and ipsilateral to the side of the BPS became normal on average 8 and 10 weeks after FLAFA, respectively. CONCLUSION: Fetal laser surgery with FLAFA promotes disappearance of all fetal fluid effusions, a lung mass regression sequence, and a normalization of pulmonary growth.

In Utero Diagnosis of Unilateral Bronchial Atresia: One Pathologically Proven and 2 Presumed Cases With Similar Sonographic Findings at Presentation.

Unilateral bronchial atresia is a rare prenatal diagnosis that can be confused with other congenital lung abnormalities, particularly congenital pulmonary airway malformation. Accurate distinction between these entities is important for appropriate clinical care and prognosis. Familiarity of the key imaging and clinical features of unilateral bronchial atresia in comparison to other fetal lung abnormalities should increase the likelihood of achieving a timely and accurate diagnosis.

Pleural Fibroma; A meandering path to surgical removal.

A 52 Year old male was admitted with respiratory distress. Radiological examination revealed a large mass in patient's right hemi thorax with mediastinal shift and partial lung collapse. Biopsies previously done conferred the diagnosis of solitary fibrous tumor; however, in order to avoid a surgical resection, patient didn't follow the adviced procedure. After thorough counseling, surgical resection was done with few post operative complications and patient recovered well with ability to perform his daily activities with partial support. The histopathology results showed solitary fibrous tumor. Apart from pneumonia and local wound infection, patient status was well for the next six week follow-up.

A rare case of solitary fibrous tumor of the lung parenchyma: case report.

Solitary fibrous tumor (SFT) of the lung is a rare neoplasm, usually originating from lung pleura. We present a case report of a 57-year-old male with no significant medical history who was incidentally diagnosed with an SFT of lung parenchyma on chest computed tomography scan. Radiological imaging revealed a well-defined mass in the left lower lobe of the lung. Biopsy and histopathological examination confirmed the diagnosis of solitary fibrous tumor. This case highlights the importance of considering SFT in the differential diagnosis of lung masses, as its clinical presentation and radiological features can mimic those of more common pulmonary malignancies.

Pulmonary Spindle Cell Carcinoma: As Rare as a Hen's Teeth.

This case is about a 70-year-old man who presented with symptoms and laboratory reports that indicated differentials toward an infectious disease (pneumonia and tuberculosis). A lung mass was found in his chest X-ray and in the computerized tomography (CT) scan of his thorax. A biopsy was taken from the lung mass, and histopathological examination and immunohistochemical staining of the biopsy were done. The results revealed the presence of spindle cell carcinoma (SpCC) with vimentin and cytokeratin positivity. Spindle cell lung cancer is a rare type of non-small cell lung carcinoma, for which all available research indicates a poor prognosis. Due to the rarity of diagnosis, there is a dearth of information about the epidemiology and overall survival of affected patients.

Intrapulmonary mature cystic teratoma: A case report with literature review.

Background: Mature intrapulmonary cystic teratomas are rare. The clinical manifestations are nonspecific and may mislead to other diseases. The radiographic findings are often perplexing. There are few complete reports on intrapulmonary teratomas, including patient history, radiologic and pathologic findings, patient management, and outcomes. We present a case report of an intrapulmonary mature cystic teratoma diagnosed at our hospital, along with an extensive review of the relevant literature. Case presentation: A 47-year-old non-smoking female patient presented with hemoptysis and intermittent dyspnea for 5 months without fever or weight loss. Chest computed tomography revealed an inhomogeneous, hypodense, lobulated mass with internal fat, calcification, and soft tissue components. The patient underwent a left thoracotomy and left upper lobe lobectomy. Pathological examination revealed a cystic tumor containing various components, including fat, keratin debris, teeth, and hair. A diagnosis of intrapulmonary mature cystic teratoma was made. Three months after the operation, no recurrent tumor was identified, and the patient was scheduled for follow-up next year. Conclusion: Intrapulmonary mature cystic teratomas are unusual. Owing to its general clinical symptoms and radiographic findings, it was misdiagnosed before surgery. After surgery, pathological and radiological findings confirmed the diagnosis. Therefore, intrapulmonary mature cystic teratomas should be considered in the differential diagnosis, and sufficient examinations should be conducted to rule out the condition.

Hybrid Pulmonary Sequestration, Cystic Pulmonary Adenomatoid Malformation, and Dextrocardia: A Triple Whammy.

Pulmonary sequestration and cystic pulmonary adenomatoid malformation are rare congenital cystic disorders of the lungs. The presence of both the diseases in the same individual is therefore very uncommon. Pulmonary sequestration is a nonfunctional pulmonary tissue mass that derives its blood supply from systemic blood supply other than pulmonary circulation. Congenital cystic pulmonary adenomatoid malformation represents a mass consisting of abnormal bronchiolar air spaces and a deficiency of functional alveoli. This is the case report of a 9-year-old girl with intermittent fever, left-sided chest pain, and cough for the past 15 days along with recurrent coughs since childhood suggestive of hybrid pulmonary sequestration, congenital cystic adenomatoid malformation, and dextrocardia.

Minimally invasive fetal therapy for hydropic lung masses: three different approaches and review of the literature.

OBJECTIVE: To report three different antenatal therapeutic approaches for fetal lung masses associated with hydrops. METHODS: Three prospectively followed cases are described, and all 30 previously published minimally invasive cases of fetal therapy for hydropic lung masses are reviewed. RESULTS: Three hydropic fetuses with large intrathoracic lung masses presented at 17, 25 and 21 weeks of gestation, respectively. An aortic feeding vessel was identified in each case and thus a bronchopulmonary sequestration (BPS) was suspected. Under ultrasound guidance, the feeding vessel was successfully occluded with interstitial laser (Case 1), radiofrequency ablation (RFA) (Case 2) and thrombogenic coil embolization (Case 3). Complete (Cases 1 and 2) or partial (Case 3) resolution of the lung mass and hydrops was observed. A healthy infant was born at term after laser therapy (Case 1), and the involved lung lobe was resected on day 2 of postnatal life. In Case 2, hydrops resolved completely following RFA, but an iatrogenic congenital diaphragmatic hernia and abdominal wall defect became apparent 4 weeks later. The neonate died from sepsis following spontaneous preterm labor at 33 weeks. In Case 3, despite technical success in complete vascular occlusion with coils, a stillbirth ensued 2 days after embolization. CONCLUSIONS: The prognosis of large microcystic or echogenic fetal chest masses associated with hydrops is dismal. This has prompted attempts at treatment by open fetal surgery, with mixed results, high risk of premature labor and consequences for future pregnancies. We have demonstrated the possibility of improved outcome following ultrasound-guided laser ablation of the systemic arterial supply. Despite technical success, RFA and coil embolization led to procedure-related complications and need further evaluation.

Sarcoidosis present as endobronchial lung mass: A rare case report with review of literature.

Sarcoidosis is a multisystem granulomatous disorder of unknown etiology, primarily affecting the intrathoracic lymph node and the lung. The endobronchial involvement in sarcoidosis is not uncommon and may appear as nodules, cobblestoning, erythema, or plaque, but presentation as an endobronchial mass has been rarely described. We report here a 50-year-old gentleman who presented with nonproductive cough and dyspnea on exertion. Video bronchoscopy revealed a polypoid mass in the right lower lobe bronchus occluding the posterior basal segment, and bronchial biopsy revealed noncaseating granulomatous inflammation. Bronchoalveolar lavage (BAL) fluid was negative for tuberculosis, fungal infection, and malignancy. Mantoux test was negative, and serum angiotensin-converting enzyme was elevated. The diagnosis of sarcoidosis was made, and the patient was started on an oral corticosteroid. After treatment, the patient showed significant improvement in symptoms. This case report highlights a rare presentation of sarcoidosis as an endobronchial mass lesion. It is important to take a biopsy to differentiate from other common causes of endobronchial mass, such as malignancy and, rarely, tuberculosis. Sarcoidosis should be considered in a differential of the endobronchial mass lesion.

A novel case of left atrial and right lung mass turned out to be unconventional metastasis of uterine leiomyosarcoma with a review of literature.

Uterine leiomyosarcoma (ULMS) is a rare malignancy arising from the myometrial smooth muscle wall, and cardiac metastases are extremely rare. Metastasis to the heart is a very unusual finding, and atrial metastasis is even rarer. Here, we report a case of a 45 year old woman who presented with dyspnea and pleural effusion and had a significant history of hysterectomy done for ULMS. Magnetic resonance imaging revealed a left atrial mass, which was resected and revealed to be a metastasis of leiomyosarcoma on histopathology and immunohistochemistry. Metastatic ULMS may rarely present as a left atrial mass with acute clinical presentation. Detailed clinical history and accurate diagnosis are vital for further management.

Streptococcus intermedius lung infection masquerading as malignancy.

Streptococcus intermedius can cause aggressive infections. One such example as reported in this case is lung abscess which may be mistaken as malignancy on lung imaging.

COVID-19 Pneumonia Presenting As Solitary Pulmonary Lesion.

Common findings of COVID-19 pneumonia on chest CT images include ground-glass opacities and organizing pneumonia. Here, we present a patient with a history of lung cancer who came to our center for re-staging CT studies, which showed a solitary peripheral lung mass suggestive of lung cancer. While being evaluated for the mass, the patient developed respiratory failure due to COVID-19 pneumonia. After treatment for COVID-19 and recovery, CT showed complete resolution of the solitary peripheral lung mass. This case highlights that COVID-19 can, on occasion, present with CT findings that mimic those of lung cancer.