Is the treatment for osteochondrolipomas and lipomas the same? Case report and review of the literature on osteochondrolipoma of chest wall.

Lipomas containing bony and chondroid areas are called osteochondrolipomas. Osteochondrolipomas are extremely rare and their treatment is not known exactly. In this article, we report a 41-year-old male patient who had a 45 mm long subcutaneous mass in the chest wall which was detected 15 years before. When the mass started to grow recently, the patient was admitted to our hospital. Total excision was performed to the mass of the chest wall. According to the histopathological examination of the material, the lesion was an osteochondrolipoma. It might be challenging to diagnose such rare osteochondrolipomas in the tru-cut or small biopsy specimens. Differential diagnosis may be challenging clinically, radiologically, and histopathologically. To our knowledge, this is the fifth case of a totally excised osteochondrolipoma of the chest wall which was reported in the literature.

The importance of FISH signal cut-off values for 9p21 deletion in malignant pleural mesothelioma: Is it underestimated?

Malignant mesothelioma (MM) is an aggressive cancer with a poor prognosis. The most common genetic alteration in MM is the deletion of the INK4a/ARF locus, which encodes the p16 protein and is located on the short arm of chromosome 9 (9p21). Recently, it has been shown that homozygous deletion of 9p21 has both diagnostic and prognostic significance in MM. It is a known fact that, to interpret fluorescence in situ hybridization (FISH) signals, a cut-off value for each probe should be determined for a correct diagnosis. To our knowledge, there is no consensus or confirmed protocol for cut-off values to evaluate FISH signals in MMs. Therefore, the aim of our research was to address 9p21 deletion status and p16 expression profiles of MM by determining our own cut-off values and the effectiveness of using p16 negativity and 9p21 deletion as markers for differentiating MMs from benign mesothelial proliferations in 114 cases. We established a cut-off value for the detection of 9p21 deletion by using 13 benign reactive cases (6 reactive mesothelial hyperplasias and 7 chronic fibrinous pleuritis cases) and found between 0-7%. According to our calculations, homozygous deletion was defined by loss of both p16 gene signals in at least 13.3% of the nuclei that showed at least 1 signal for the CEP 9 probe. Our FISH results showed homozygous 9p21 deletion in 82 of the 114 cases of MM (71.9%), and p16 expression was negative in 75 of the 114 cases (65.8%). The correlation between loss of p16 protein expression and 9p21 deletion was statistically significant. Among the p16-negative cases, 86.7% also had the 9p21 deletion. The combined examination of the 9p21 deletion and loss of p16 expression is helpful for diagnostic purposes, but because the FISH method is an expensive technique and loss of p16 expression is not specific for mesotheliomas, p16 negativity can guide practitioners to eliminate cases that require further investigation by FISH. The variability in the significance of 9p21 homozygous deletion results from inconsistencies among different institutes, suggesting that each institute should establish its own cut-off value using reactive mesothelial proliferations. Alternatively, global studies are needed to assess cut-off values.

The sonographic features of malignant mediastinal lymph nodes and a proposal for an algorithmic approach for sampling during endobronchial ultrasound.

INTRODUCTION: There are several papers on the sonographic features of mediastinal lymph nodes affected by several diseases, but none gives the importance and clinical utility of the features. OBJECTIVE: In order to find out which lymph node should be sampled in a particular nodal station during endobronchial ultrasound, we investigated the diagnostic performances of certain sonographic features and proposed an algorithmic approach. METHODS: We retrospectively analyzed 1051 lymph nodes and randomly assigned them into a preliminary experimental and a secondary study group. The diagnostic performances of the sonographic features (gray scale, echogeneity, shape, size, margin, presence of necrosis, presence of calcification and absence of central hilar structure) were calculated, and an algorithm for lymph node sampling was obtained with decision tree analysis in the experimental group. Later, a modified algorithm was applied to the patients in the study group to give the accuracy. RESULTS: The demographic characteristics of the patients were not statistically significant between the primary and the secondary groups. All of the features were discriminative between malignant and benign diseases. The modified algorithm sensitivity, specificity, and positive and negative predictive values and diagnostic accuracy for detecting metastatic lymph nodes were 100%, 51.2%, 50.6%, 100% and 67.5%, respectively. CONCLUSIONS: In this retrospective analysis, the standardized sonographic classification system and the proposed algorithm performed well in choosing the node that should be sampled in a particular station during endobronchial ultrasound.

18F-FDG PET/CT rarely provides additional information other than primary tumor detection in patients with pulmonary carcinoid tumors.

AIM: The purpose of this study was to assess the contribution of (18)F-fluorodeoxyglucose (FDG) Positron Emission Tomography (PET)/Computed Tomography (CT) in detection and staging of pulmonary carcinoid tumors. METHODS: A total of 22 patients with pulmonary carcinoid tumors (14 typical, 8 atypical) were reviewed in this retrospective study. PET/CT images of all patients were evaluated for primary tumor as well as metastatic regional lymph nodes, bone and other distant metastases. PET/CT positivity of primary tumors was determined by visual interpretation. Tumor size, SUVmax and Hounsfield Unit (HU) values of the tumors were used to test for differences between tumor groups (typical carcinoids and atypical carcinoids). RESULTS: SUVmax of carcinoids ranged from 1.24 to 11.1 (mean, 5.0; median, 2.67). The mean largest diameter of primary tumors was 2.7 ± 1.3 cm, ranging from 1 to 5.5 cm. The overall sensitivity of FDG PET/CT for detection of pulmonary carcinoid tumors was 81.8%. Tumor size, SUVmax and Hounsfield Unit (HU) values of the atypical carcinoids were higher than those for typical carcinoids. However, the results were not statistically meaningful (P > 0.05). The sensitivity and specificity of FDG PET/CT in the detection of mediastinal and hilar lymph nodes metastases were 25% and 83% respectively. One patient had bone metastasis. CONCLUSION: Although FDG PET/CT can be a useful tool for the detection of pulmonary carcinoid tumors and distant metastasis, it cannot discriminate typical carcinoids from atypical ones and absence of an FDG avid lesion cannot exclude pulmonary carcinoid tumors. Moreover, PET/CT is not a reliable tool in the staging of mediastinal and hilar lymph nodes especially for those patients with typical carcinoids.

Integration of 2-deoxy-2-[18F] fluoro-D-glucose PET/CT into clinical management of patients with Wegener's granulomatosis.

OBJECTIVE: Wegener's granulomatosis (WG) is a rare disorder characterized by granulomatous necrotizing vasculitis which mainly affects small- and medium-sized vessels. While the classical triad of involvement is upper and lower respiratory system and glomerulonephritis, WG may involve any organ or system in the body. The aim of our study was to investigate the role of positron emission tomography/computerized tomography (PET/CT) both in the initial evaluation and follow-up of patients with WG. METHODS: We retrospectively evaluated PET/CT data from 13 patients (6 males; 7 females) with a mean age of 45 ± 12.4 years (range 28-63) who underwent either initial evaluation (n = 12) or response evaluation (n = 2) by conventional imaging methods and FDG with PET/CT. PET/CT images were both visually and quantitatively evaluated. The demographic data, clinical and laboratory findings of each patient were also recorded from the hospital files. RESULTS: Lung (n = 13), parapharyngeal space (n = 8), nose (n = 8), and ear (n = 3) were the most common disease sites detected on PET/CT. The entire initial evaluation patients had either solitary or multiple pulmonary nodular/mass lesions with marked increased FDG uptake (mean SUVmax 12 ± 4, range 3.53-19.51) on PET/CT. There was no significant pathological FDG uptake in patients consistent with complete treatment response after appropriate immunosuppressive therapy. PET/CT clearly demonstrated unexpected disease sites besides the respiratory system, with WG involvement except kidneys. Possibly due to physiological urinary excretion of FDG, urine analysis, BUN and creatinine levels were accepted still the best way for diagnosis of renal involvement. CONCLUSION: FDG with PET/CT is a valuable tool in the management of patients with WG for a more accurate clinical evaluation regarding disease extension and treatment response.

Synchronous bilateral multiple typical pulmonary carcinoid tumors: a unique case with 10 typical carcinoids.

Bilateral multiple typical carcinoid tumors of the lung are uncommon malignancies. We discuss the case of a 64 year-old female with a nonproductive cough as the initial symptom. Thoracic computed tomography revealed multiple nodular lesions on both sides, which were initially misdiagnosed as multiple metastases of the lung with an unknown primary. After resection of nodules in the right hemithorax, pathologic examination revealed a typical carcinoid tumor. Bilateral sequential thoracotomy was performed and all ten nodules, (six on the right side and four on the left side), were treated by sublobar resection due to poor respiratory function. Pathological examination revealed all nodules to be typical carcinoid tumors. Following the resections, the patient has remained disease-free for ten months.