Nodular Pleural Thickening Research Articles

Association of PET/CT and VATS findings with histology analysis in the study of pleural effusions

IntroductionHistological analysis of the pleura obtained by video-assisted thoracoscopic surgery (VATS) is the best diagnostic technique in the study of neoplastic pleural effusions. This study evaluates the relationship between Positron Emission Tomography (PET)/Computed Tomography (CT) and VATS findings, the result of the first pleural biopsy, and the final diagnosis of malignancy or non-malignancy. MethodsProspective study of consecutive patients with pleural effusions undergoing PET/CT and VATS from October 2013 to December 2023. The following variables were recorded: PET/CT score (nodular pleural thickening, pleural nodules with standardized uptake value (SUV) > 7.5, lung mass or extra pleural malignancy, mammary lymph node with SUV > 4.5 and cardiomegaly); VATS data (drained volume, visceral and parietal pleural thickening, nodules or masses, septa, plaques, fluid appearance, trapped lung, and suspected diagnosis of the procedure), as well as the histological study of the first pleural biopsy (benign or malignant) and the final diagnosis of benign or malignant pleural effusion. A logistic regression study of the variables was performed. Results95.8% of the patients with PET/CT and pleuroscopy not suggestive of malignancy had non-malignant histological findings, while 93.2% of the patients with PET/CT and pleuroscopy suggestive of malignancy had malignant histological findings. PET/CT, pleuroscopy, and the result of the first pleural biopsy showed a significant association with the final diagnosis of pleural effusion. ConclusionsThere is a strong association between PET/CT findings, VATS and pleural histology.

The great mimicker: Pleural tuberculosis presents as nodular pleural thickening.

The great mimicker: Pleural tuberculosis presents as nodular pleural thickening.

A PET-CT score for discriminating malignant from benign pleural effusions

Background and objectivesThe results of previous PET-CT studies are contradictory for discriminating malignant from benign pleural effusions. We purpose to develop a PET-CT score for differentiating between benign and malignant effusions. Patients and methodsWe conducted a prospective study of consecutive patients with pleural effusions undergoing PET-CT from October 2013 to October 2019 (referral cohort). PET-CT scan features evaluated using the SUV were: linear thickening; nodular thickening; nodules; masses; circumferential thickening; mediastinal and fissural pleural involvement; intrathoracic lymph nodes; pleural loculation; inflammatory consolidation; pleural calcification; cardiomegaly; pericardial effusion; bilateral effusion; lung mass; liver metastasis and other extra-pleural malignancy. The results were validated in an independent prospective cohort from November 2019 to June 2021. ResultsOne hundred and ninety-nine patients were enrolled in the referral cohort (91 with malignant effusions and 108 benign). The most useful parameters for the development of a PET-CT score were: nodular pleural thickening, pleural nodules with SUV>7.5, lung mass or extra pleural malignancy (10 points each), mammary lymph node with SUV>4.5 (5 points) and cardiomegaly (−1 point). With a cut-off value of >9 points in the referral cohort, the score established the diagnosis of malignant pleural effusion with sensitivity 87.9%, specificity 90.7%, positive predictive value 88.9%, negative predictive value 89.9%, positive likelihood ratio 7.81 and negative likelihood ratio 0.106. These results were validated in an independent prospective cohort of 75 patients. ConclusionsPET-CT score was shown to provide relevant information for the identification of malignant pleural effusion.

A PET-CT score for discriminating malignant from benign pleural effusions

Background and objectivesThe results of previous PET-CT studies are contradictory for discriminating malignant from benign pleural effusions. We purpose to develop a PET-CT score for differentiating between benign and malignant effusions. Patients and methodsWe conducted a prospective study of consecutive patients with pleural effusions undergoing PET-CT from October 2013 to October 2019 (referral cohort). PET-CT scan features evaluated using the SUV were: linear thickening; nodular thickening; nodules; masses; circumferential thickening; mediastinal and fissural pleural involvement; intrathoracic lymph nodes; pleural loculation; inflammatory consolidation; pleural calcification; cardiomegaly; pericardial effusion; bilateral effusion; lung mass; liver metastasis and other extra-pleural malignancy. The results were validated in an independent prospective cohort from November 2019 to June 2021. ResultsOne hundred and ninety-nine patients were enrolled in the referral cohort (91 with malignant effusions and 108 benign). The most useful parameters for the development of a PET-CT score were: nodular pleural thickening, pleural nodules with SUV>7.5, lung mass or extra pleural malignancy (10 points each), mammary lymph node with SUV>4.5 (5 points) and cardiomegaly (−1 point). With a cut-off value of >9 points in the referral cohort, the score established the diagnosis of malignant pleural effusion with sensitivity 87.9%, specificity 90.7%, positive predictive value 88.9%, negative predictive value 89.9%, positive likelihood ratio 7.81 and negative likelihood ratio 0.106. These results were validated in an independent prospective cohort of 75 patients. ConclusionsPET-CT score was shown to provide relevant information for the identification of malignant pleural effusion.

Role of percutaneous CT-guided biopsy in the characterisation of pleural diseases.

Computed tomography (CT)-guided biopsy is emerging as a preferred and safe method for obtaining tissue samples in pleural diseases. This study aimed to evaluate the diagnostic yield and safety of percutaneous CT-guided biopsy in pleural diseases and to find CT findings predictive of malignant neoplastic pleural disease. This retrospective study included 77 patients with pleural disease who underwent CT-guided pleural biopsies from July 2013 to May 2020. All procedures were performed with a coaxial semi-automatic biopsy device. Histopathology was performed in all cases, and additional tests such as immunohistochemistry (IHC) or microbiological analysis were carried out depending on clinical suspicion. The correlation of CT findings with final diagnosis was performed by Chi-square, Fisher's exact test and logistic regression analysis. The overall technical success rate of CT-guided pleural biopsy was 100% with a diagnostic yield of 96.1%. No major complication was encountered, with minor complications encountered in the form of minimal pneumothorax and chest pain. Malignant pleural conditions constituted the largest group including metastatic adenocarcinoma as the most common (31.2%), followed by metastatic squamous cell carcinoma and mesothelioma. Tubercular pleural involvement was the second most common category (16.9%). The cartridge-based nucleic acid amplification test (CB-NAAT) assay had 90% sensitivity on pleural tissue in tubercular cases. CT features predictive of malignancy were irregular and nodular pleural thickening, mediastinal and diaphragmatic pleural involvement and mediastinal/chest wall invasion. There was a good correlation between higher pleural thicknesses with malignant outcome. Percutaneous CT-guided biopsy is a safe method for obtaining pleural tissue samples with high diagnostic yield. CT findings provide clues, which favour malignant pleural involvement.

Mesotelioma pleural

Pleural mesothelioma is the main malignant pleural tumor. Most cases are associated with inhalation of asbestos fibers. The most frequent manifestations are dyspnea and chest pain in patients in pleural effusion and/or nodular pleural thickening. The diagnosis is histological, distinguishing between three big subgroups: epithelioid, sarcomatoid, and biphasic. The most used staging is based on the TNM staging system and proposed by the International Association for the Study of Lung Cancer (IASLC). The principal prognostic factors, in addition to TNM stage, are the histological type, age, and the patient's overall condition. In select patients, surgery may be indicated as part of multimodal treatment. In order to determine which patients are candidates for surgery, in addition to the epithelial histological type, an adequate cardiopulmonary reserve, an extension study with a computed tomography scan of the chest and abdomen, magnetic resonance imaging, positron emission tomography, and an examination of the mediastinum with endobronchial ultrasound or mediastinoscopy should be taken into account. In patients who are not candidates for surgery, chemotherapy in a platinum/pemetrexed regimen and/or symptomatic treatment that includes pleurodesis and control of pain and dyspnea should be considered.

Differentiating malignant pleural mesothelioma and metastatic pleural disease based on a machine learning model with primary CT signs: A multicentre study

Rationale and ObjectivesIt is still a challenge to make confirming diagnosis of malignant pleural mesothelioma (MPM), especially differentiating from metastatic pleural disease (MPD). The aim of this study was to develop a model to distinguish MPM with MPD based on primary CT signs. Materials and methodsWe retrospectively recruited 150 MPM patients and 147 MPD patients from two centers and assigned them to training (115 MPM patients and 113 MPD patients) and testing (35 MPM patients and 34 MPD patients) cohorts. The images were analyzed for pleural thickening, hydrothorax, lymphadenopathy, thoracic volume and calcified pleural plaque (CPP). The selected clinical characteristics and primary CT signs comprised the model by multivariate logistic regression in the training cohort. Then the model was tested on the external testing cohort. ROC curve and F1 score were used to validate the capability of the model in both two cohorts. ResultsThere were significant differences between two groups: (1) carcinoembryonic antigen (CEA); (2) nodular and mass pleural thickening; (3) the enhancement of pleura; (4) focal, diffuse and circumferential pleural thickening; (5) the thickest pleura; (6) thickening of diaphragmatic pleura; (7) multiple nodules and effusion of interlobar pleura; (8) hilar LN and ring enhancement of LN; (9) punctate and stipe CPP. The AUC and F1 score of the model were 0.970 and 0.857 in the training cohort, 0.955 and 0.818 in the testing cohort. ConclusionThe model holds promise for use as a diagnostic tool to distinguish MPM from MPD.

S1661 More Than Just a Polyp? The Diagnosis of TB From a Screening Colonoscopy

INTRODUCTION: TB most commonly affects the lung, but it can affect other anatomic sites including the GI tract. On colonoscopy, colonic TB usually presents as ulcerative lesions, nodular lesions or strictures and less likely to present as a polyp. We present a case of a 66 year old female who was found to have small benign appearing colonic polyps on screening colonoscopy, who was eventually diagnosed with pulmonary TB after pathological examination of the polyp. CASE DESCRIPTION/METHODS: A 66-year Filipino female with past medical history significant for HTN and goiter was referred to the GI clinic for initial colon cancer screening. She had no prior colonoscopies. The patient was born in the Philippines and moved to the United States in 1990. She had no family history of GI malignancies. She denied GI symptoms and her only other complaint being malaise. Physical exam including GI exam did not show significant findings. On colonoscopy, three sessile polyps 2–4 mm in size were identified in the ascending colon, in addition to a 5 mm sessile polyp in the cecum. Histopathological evaluation revealed mucosal granulomas with caseating necrosis in the ascending colon polyps. AFB and fungal stains were negative. CXR was done after receiving the pathology results that showed a right upper lobe lung mass concerning for TB vs malignancy so a chest CT with contrast was done which showed a 10 cm mass in the RUL with nodular pleural thickening, hilar and right internal mammary adenopathy. After further questioning, patient mentioned that she had a cough productive of yellowish sputum of one month duration associated with night sweats but denied any other symptoms. Patient was referred to the pulmonary clinic for further evaluation of the lung mass, sputum AFB stain and sputum culture was positive, and she was treated with anti-tuberculosis drug regimen for 9 months. Patient reported significant improvement in symptoms and follow up chest CT scan showed regression in the lung mass. DISCUSSION: GI TB is not uncommon and the disease remains a significant problem in immune suppressed individuals and those born in other countries. Colonic TB presents with non-specific signs and symptoms as well as non-specific colonic findings which contributes to the delay in diagnosis and management of this condition, so we recommend considering TB in the deferential of colonic polyps in immune suppressed patients and patients with risk factors for TB.Figure 1.: Colonic mucosa with caseating granuloma. Histiocytes and multinucleated giant cells rimming the necrosis.Figure 2.: Sessile polyp identified in ascending colon.Figure 3.: Sessile polyp identified in ascending colon.

Correlation between CT findings and thoracoscopic diagnosis in diffuse pleural disease.

Objective:Computed Tomography (CT) is considered part of the routine diagnostic workup for pleural malignancy. The definitive diagnosis of pleural malignancy depends upon histological confirmation by pleural biopsy. The aim of this study is to assess the sensitivity and specificity of CT, in view of the latest imaging technologies, in detecting pleural malignancy compared to definitive histology achieved via thoracoscopy (VATS).Materials and methods:We included in this retrospective study 90 patients (36 F, 54 M) with suspected pleural malignancy evaluated in our Institution with CT scan who received a definitive diagnosis after VATS biopsy. Unaware of histopathologic diagnoses CT scans were evaluated by a junior and two experts thoracic radiologist. Conclusions were reached by consensus.Results:We evaluated all CT signs suggestive for malignant pleural diseases: pleural thickening > 10 mm (Se 0,41 , Sp 0,79); nodular thickening (Se 0,86, Sp 0,75); circumferential thickening (Se 0,79, Sp 0,69); irregular pleural thickening (Se 0,77, Sp 0,91); mediastinal involvement (Se 0,88, Sp 0,64); costal involvement (Se 0,89, Sp 0,60); diaphragmatic involvement (Se 0,88, Sp 0,53). Furthermore, the diagnostic performance of additional CT features was evaluated: concomitant costal, mediastinal and diaphragmatic pleura lesions (Se 0,84, Sp 0,69); nodular/irregular thickening with mediastinal pleural involvement (Se 0,83, Sp 0,90); nodular/irregular thickening with diaphragmatic pleural involvement (Se 0,81, Sp 0,90).Conclusions:CT confirms its central role in the pleura malignancy. The high sensibility, respect to previous studies, especially in the presence of nodular pleural thickening, may lead to reconsider at least partly the diagnostic pathway of diffuse pleural disease, avoiding the use of VATS in patients not eligible for surgery, in favor of US or CT guided core biopsy. (www.actabiomedica.com)

A Rare Case of Desmoplastic Mesothelioma With Good Survival Despite Lymph Node Metastasis

Abstract Introduction Desmoplastic mesothelioma (DMM), a rare histological subtype of malignant pleural mesothelioma (MPM), is lethal and has very poor prognosis. Metastasis is commonly reported in DMM compared to other histological subtypes. Here we report a case of DMM with good survival (>1 year) despite lymph node metastasis. Case Report A 62-year-old female with a history of smoking and possible asbestos exposure presented with cough and wheeze in 2012. Computed tomography (CT) revealed left-sided pleural plaques and multiple ground-glass pulmonary nodules. In 2017, repeat CT showed increased diffuse left nodular pleural thickening. Positron emission tomography revealed hypermetabolic, nodular pleural thickening in the hemithorax, compatible with neoplasia. Needle biopsy in January 2018 showed pleural tissue with haphazard, nodular growth of spindled mesothelial cells, suspicious for desmoplastic mesothelioma. Definitive diagnosis was not possible due to lack of fat invasion and absence of supportive evidence by immunohistochemical stains. The patient underwent pleurectomy in February 2018. On histopathology, the majority of the tumor showed a desmoplastic pattern, composed of malignant spindled cells arranged haphazardly in a dense hyalinized stroma with chronic inflammatory infiltrate. AE1/AE3, calretinin, and D2-40 immunohistochemical stains highlighted the infiltrating neoplastic cells, which were negative for WT-1. BAP-1 was retained. The pattern of immunoreactivity supported the diagnosis of DMM. The tumor also involved visceral pleura, pulmonary parenchyma, and pericardium. It invaded into fat and displayed lymphovascular invasion. A metastatic focus of DMM was present in a lymph node. The tumor was staged as pT3N1. On recent examination, the patient only had complaints of mild breathlessness and stable hydro-pneumothorax, without any other comorbidities. Conclusion Our finding is unusual, since among the mesothelioma subtypes, DMM has the shortest survival, usually not more than 6 months. We report an extremely rare case of DMM with survival of >1 year despite invasion of lung parenchyma and lymph node metastasis.

Computed tomography features of local pleural recurrence in patients with malignant pleural mesothelioma treated with intensity-modulated pleural radiation therapy.

This study was conducted in order to describe the computed tomography (CT) features of local pleural recurrence in patients with malignant pleural mesothelioma undergoing intensity-modulated pleural radiation therapy (IMPRINT) as part of multimodality treatment. In this observational study, 58 patients treated with IMPRINT between September 21, 2004, and December 1, 2014 were included. Baseline and follow-up CT scans were qualitatively assessed. On follow-up scans, pleural thickening was categorized as unchanged, decreased, or new/increased. New/increased pleural abnormality was subcategorized as diffuse smooth pleural thickening, diffuse nodular pleural thickening, focal pleural nodule, or multiple pleural nodules. To identify features more frequently present at the time of local recurrence, follow-up scans with local recurrence were matched to four control scans; exact conditional logistic regression was performed. Twenty-one (36%) patients had local pleural recurrence and 20 (34%) patients had nonpleural recurrence; 3 patients had both types of recurrence. The 1-year cumulative incidence rate of local recurrence was 27% (95% confidence interval 15, 39). On follow-up scans, three patterns of pleural abnormality were significantly associated with local recurrence: new/increased multiple pleural nodules (10 (48%) positive scans vs 0 control scans), new/increased diffuse nodular pleural thickening (7 (33%) positive scans vs 1 (1%) control scans), and new/increased focal pleural nodule (3 (14%) positive scans vs 1 (1%) control scan) (p < 0.001 for all). Multiple new/increased pleural nodules are the feature most commonly present at local recurrence following IMPRINT; however, any pattern of increased nodular pleural thickening is suspicious. • In patients with mesothelioma receiving intensity-modulated pleural radiation as part of multimodality therapy, increasing multiple pleural nodules is the computed tomography feature most commonly present at local recurrence. • In these patients, any CT pattern of increased nodular pleural thickening should be considered suspicious for local recurrence. • The most common sites of nonpleural recurrence were lung parenchyma, thoracic lymph nodes, and peritoneum.

Role of Multislice CT in Diagnosis, Staging and Evaluation of Malignant Pleural Mesothelioma

Background: Malignant mesothelioma is a rare but fatal disease that arises from the epithelial lining of the pleura, peritoneum, pericardium and tunica vaginalis. Malignant pleural mesothelioma (MPM) is the most common form, accounting for 80-90% of malignant mesotheliomas Aim of the work: was to identify the value of CT in diagnosing malignant pleural mesothelioma and applying the AJCC and the IMIG staging system for MPM. At the time to identify the limitations of CT if any. Patient and methods: This prospective study included a total of 20 patients with CT findings suggestive of malignant pleural mesothelioma, diagnosed at Radiology Department, Damanhur Oncology Center. All patients had undergone multislice CT chest with intravenous contrast for detection and staging of the tumor. This study was conducted between March 2018 and December 2018. The data collected were tabulated and analyzed statistically. Results: CT study of the chest for cases of MPM was able to evaluate and diagnose the disease, with most of the important staging items being easily seen on CT yet this study also showed the limitations of CT in the staging MPM since CT alone was not able to prove the involvement of the chest wall, diaphragmatic muscle and trans diaphragmatic extension. Conclusions: Chest CT alone is often sufficient for disease staging and treatment planning. Typical CT findings that suggest MPM include unilateral pleural effusion with nodular irregular pleural thickening which can be discrete or diffuse with or without inter lobar fissure thickening and nodal metastasis.

Role of Multislice CT in Diagnosis, Staging and Evaluation of Malignant Pleural Mesothelioma

Background: Malignant mesothelioma is a rare but fatal disease that arises from the epithelial lining of the pleura, peritoneum, pericardium and tunica vaginalis. Malignant pleural mesothelioma (MPM) is the most common form, accounting for 80-90% of malignant mesotheliomas Aim of the work: was to identify the value of CT in diagnosing malignant pleural mesothelioma and applying the AJCC and the IMIG staging system for MPM. At the time to identify the limitations of CT if any. Patient and methods: This prospective study included a total of 20 patients with CT findings suggestive of malignant pleural mesothelioma, diagnosed at Radiology Department, Damanhur Oncology Center. All patients had undergone multislice CT chest with intravenous contrast for detection and staging of the tumor. This study was conducted between March 2018 and December 2018. The data collected were tabulated and analyzed statistically. Results: CT study of the chest for cases of MPM was able to evaluate and diagnose the disease, with most of the important staging items being easily seen on CT yet this study also showed the limitations of CT in the staging MPM since CT alone was not able to prove the involvement of the chest wall, diaphragmatic muscle and trans diaphragmatic extension. Conclusions: Chest CT alone is often sufficient for disease staging and treatment planning. Typical CT findings that suggest MPM include unilateral pleural effusion with nodular irregular pleural thickening which can be discrete or diffuse with or without inter lobar fissure thickening and nodal metastasis.

Nodules and masses are associated with malignant pleural effusion in dogs and cats but many other intrathoracic CT features are poor predictors of the effusion type.

Thoracic CT may be used in the workup of patients with pleural effusion. In humans, certain pleural features on CT aid in diagnosing an underlying cause for pleural effusion, whereas this is not well studied in veterinary medicine. This retrospective cross-sectional analytical study assessed pleural and other intrathoracic abnormalities on CT in dogs and cats with pleural effusion and explored potential discriminatory features between effusion types. Eighty-nine dogs and 32 cats with pleural cytology and/or histopathology were categorized into malignant pleural disease (15 dogs and 11 cats), pyothorax (34 dogs and 7 cats), chylothorax (20 dogs and 11 cats), transudative (11 dogs and 2 cats), and hemorrhagic effusion (9 dogs and 1 cat). Multivariable logistic regression analysis comparing malignancy to other effusions found that older patient age (dogs: odds ratio 1.28, P=0.015; cats: odds ratio 1.53, P=0.005), nodular diaphragmatic pleural thickening (dogs: odds ratio 7.64, P=0.021; cats: odds ratio 13.67, P=0.031), costal pleural masses (dogs: odds ratio 21.50, P=0.018; cats: odds ratio 32.74, P=0.019), and pulmonary masses (dogs: odds ratio 44.67, P=0.002; cats: odds ratio 18.26, P=0.077) were associated with malignancy. In dogs, any costal pleural abnormality (odds ratio 47.55, P=0.002) and pulmonary masses (odds ratio 10.05, P=0.004) were associated with malignancy/pyothorax, whereas any costal pleural abnormality (odds ratio 0.14, P=0.006) and sternal lymphadenopathy (odds ratio 0.22, P=0.040) were inversely associated with transudates. There were, however, many overlapping abnormalities between effusion types, so further diagnostic testing remains important for diagnosis.

Multidetector CT Findings and Differential Diagnoses of Malignant Pleural Mesothelioma and Metastatic Pleural Diseases in Korea.

ObjectiveTo compare the multidetector CT (MDCT) features of malignant pleural mesothelioma (MPM) and metastatic pleural disease (MPD).Materials and MethodsThe authors reviewed the MDCT images of 167 patients, 103 patients with MPM and 64 patients with MPD. All 167 cases were pathologically confirmed by sonography-guided needle biopsy of pleura, thoracoscopic pleural biopsy, or open thoracotomy. CT features were evaluated with respect to pleural effusion, pleural thickening, invasion of other organs, lung abnormality, lymphadenopathy, mediastinal shifting, thoracic volume decrease, asbestosis, and the presence of pleural plaque.ResultsPleural thickening was the most common CT finding in MPM (96.1%) and MPD (93.8%). Circumferential pleural thickening (31.1% vs. 10.9%, odds ratio [OR] 3.670), thickening of fissural pleura (83.5% vs. 67.2%, OR 2.471), thickening of diaphragmatic pleura (90.3% vs. 73.4%, OR 3.364), pleural mass (38.8% vs. 23.4%, OR 2.074), pericardial involvement (56.3% vs. 20.3%, OR 5.056), and pleural plaque (66.0% vs. 21.9%, OR 6.939) were more frequently seen in MPM than in MPD. On the other hand, nodular pleural thickening (59.2% vs. 76.6%, OR 0.445), hilar lymph node metastasis (5.8% vs. 20.3%, OR 0.243), mediastinal lymph node metastasis (10.7% vs. 37.5%, OR 0.199), and hematogenous lung metastasis (9.7% vs. 29.2%, OR 0.261) were less frequent in MPM than in MPD. When we analyzed MPD from extrathoracic malignancy (EMPD) separately and compared them to MPM, circumferential pleural thickening, thickening of interlobar fissure, pericardial involvement and presence of pleural plaque were significant findings indicating MPM than EMPD. MPM had significantly lower occurrence of hematogenous lung metastasis, as compared with EMPD.ConclusionAwareness of frequent and infrequent CT findings could aid in distinguishing MPM from MPD.

Chest CT findings of pleural tuberculosis: differential diagnosis of pleural tuberculosis and malignant pleural dissemination

The imaging features of pleural tuberculosis (PTB) can be similar to those of malignant pleural dissemination (MPD) with several case reports of CT findings in atypical presentations of PTB. To describe the computed tomography (CT) features of PTB by comparing these imaging findings with those of MPD and to use the results to differentiate between the two diseases. The study included 135 patients with PTB and 69 with MPD. The CT images were assessed in terms of the presence, extent, and contour of pleural thickening. Pleural nodules were analyzed in terms of number, size, and location. The CT findings of PTB and MPD were compared. The CT findings of PTB included circumferential pleural thickening (32.6%), mediastinal pleural involvement (31.9%), nodular thickening (8.9%), and pleural thickening >1 cm (2.2%). The CT features of MPD included nodular pleural thickening (56.5%), mediastinal pleural involvement (40.6%), circumferential thickening (23.2%), and pleural thickening >1 cm (7.2%). Comparing PTB and MPD, nodular pleural thickening was observed more frequently with MPD than PTB (P <0.001). Nodular pleural thickening is observed in 8.9% of the patients with PTB on chest CT. Comparing PTB and MPD, nodular pleural thickening was the only finding significantly associated with MPD, particularly with nodules >10 mm.

English

Non Resolving pneumonias always present a difficult problem. Sometimes despite every effort, the diagnosis is not obvious. We report a case of ductal carcinoma of breast presenting as nonresolving pneumonia in a female patient with dry cough and bilateral crackles on physical examination. An initial CT Thorax showed pneumonic patches in the lingula and middle lobe. There was also mediastinal lymphadenopathy. She was evaluated by bronchoscopic procedures which were inconclusive except for chronic inflammation seen on trans-bronchial lung biopsy. A subsequent PETCT of the chest revealed patchy FDG avid sub-segmental collapse, consolidation with air bronchogram in lingular segment. There were also bilateralpulmonary few sub-centimeter nodular lesions andleft pleural thickening. However the primary breast lesion was not FDG avid. The diagnosis was made by lymph node biopsy of recently appearing supra-clavicular lymph node. The primary lesion was detected by clinical breast examination and confirmed by USG guided FNAC.

Asymmetrically increased rib cage uptake on bone scintigraphy: Incidental detection of pleural mesothelioma on single photon emission computed tomography/computed tomography

Follow-up bone scintigraphy (BS) in a patient of carcinoma left breast, who was treated with surgery followed by radiotherapy 12 years back, revealed asymmetrically increased radiotracer uptake in left-sided ribs. Since, this pattern was atypical for metastatic rib involvement, single photon emission computed tomography/computed tomography (SPECT/CT) of thorax was done in the same setting which revealed circumferential nodular left-sided pleural thickening. Biopsy confirmed it to be pleural mesothelioma. Left-sided ribs showed no abnormality on CT, thus suggesting the rib uptake as reactive in nature. This pattern of asymmetric rib uptake on BS should be kept in mind and warrants further investigation for determining underlying pathology.

A Case Report of IgG4-Related Disease Clinically Mimicking Pleural Mesothelioma

An immunoglobulin G4 (IgG4)-related disease is a recently emerging entity, and a few cases of IgG4-related disease in lung and pleura have been reported. Herein, we report the case of a 74-year-old man with IgG4-related disease of lung and pleura, clinically suspicious of malignant mesothelioma. Chest computed tomography showed diffuse nodular pleural thickening, and microscopic finding disclosed diffuse thickening of visceral pleura with infiltrations of many lymphoplasma cells with increased number of IgG4-positive plasma cells and a few multinucleated giant cells. It is important for pathologists and clinicians to recognize this rare entity and its histologic finding, because it can be confused with malignant tumors on the radiologic examination although it can be treated with steroid therapy.

Fungating Mass as First Presentation of Advanced Breast Cancer

A 52-year-old woman visiting from the nation of Tonga presented to the Emergency Department with shortness of breath and an enlarging right breast mass that she first noticed one year prior to evaluation. Physical examination revealed a pulse of 120 beats/min, a respiratory rate of 40 breaths/min and a necrotic right breast mass, measuring 15 cm × 7.5 cm (Fig. 1). Diminished breath sounds and dullness to percussion were noted at the right posterior chest. Computed tomography of the chest showed one dominant (Fig. 2, X) and multiple smaller lesions in the right breast; a right-sided pleural effusion (Fig. 2, asterisk); nodular pleural thickening (Fig. 2, arrowhead); lung parenchymal nodules (Fig. 2, arrow); and diffuse lymphadenopathy. Biopsy demonstrated infiltrating poorly differentiated ductal adenocarcinoma. While fungating breast masses are considered locally advanced disease (stage III), she was diagnosed with stage IV breast cancer due to the presence of distant metastases.1–3 Globally, breast cancer incidence is increasing.4,5 In developing countries >60 % of women present with later stage cancers (III/IV).4 In one case series, 39 % of 212 patients presented with fungating breast masses.6 This patient was subsequently discharged with palliative care follow-up. Figure 1 Necrotic right breast mass. Figure 2 Computed tomography of the chest showing one dominant (X) and multiple smaller lesions in the right breast; a right-sided pleural effusion (asterisk); nodular pleural thickening (arrowhead); lung parenchymal nodules (arrow); and diffuse lymphadenopathy. ...