Pleural Nodularity Research Articles

DUETS for Light's in separating exudate from transudate.

Fifty years since its inception, Light's criteria have aided in classifying pleural effusions (PEs) as exudates if 1 or more criteria are met. Thoracic ultrasound (US) emerges as a non-invasive technique for point of care use especially if pleural procedures are contemplated. We aimed to develop a score based on radiological and US features that could separate exudates from transudates without serum and pleural fluid biochemical tests necessary for Light's criteria. A prospective review of consecutive patients with PE who underwent thoracocentesis was performed. CXRs were evaluated for laterality followed by US for echogenicity, pleural nodularity, thickening and septations. PE was classified as exudate or transudate according to Light's criteria and corroborated with albumin gradient. A score combining radiological and US features was developed. We recruited 201 patients with PE requiring thoracocentesis. Mean age was 64 years, 51% were females, 164 (81.6%) were exudates, and 37 (18.4%) were transudates. Assigning 1-point for Diaphragmatic nodularity, Unilateral, Echogenicity, Pleural Thickening and Septations, DUETS ranged from 1 to 5. DUETS ≥2 indicated high likelihood for exudate (PPV 98.8%, NPV 100%) with 1% misclassification versus 6.9% using Light's criteria (p < 0.001). DUETS separated exudates from transudates with good accuracy, and could obviate paired serum and pleural fluid tests necessary for Light's criteria computation. Our study reflected real world practice where DUETS performed better than Light's criteria for PE that arose from more than one disease processes, and in the evaluation of patients with PE who have received diuretics.

Evaluation of the Diagnostic Accuracy of a Computed Tomography-Based Scoring System in the Differentiation between Malignant and Benign Pleural Effusion

Abstract Background Pleural effusion in particular is considered a sign of an underlying pathology, so ti is necessary ot search for the cause and determine whether it is a benign cause or a malignant one as they differ in treatment and prognosis. Aim of the Work To assess the accuracy of contrast-enhanced CT chest to predict the nature of pleural effusion whether benign or malignant using the CT-based scoring system developed by Porcel et al.'(1) Patients and Methods This study was a retrospective study that involved reviewing the contrast-enhanced CT chest done at the radiodiagnosis department in Ain Shams University Hospitals of 30 adult patients (age &amp;gt;18 years old) withunilateral or bilateral pleural effusion, and scoring ti according to hte Porcel et al (" CT scoring system while being blinded to the final diagnosis. The total score was then compared to the biopsy or cytology of the patient to determine its accuracy. Results Analyzing the data showed that the highly significant item of the scoring system denoting malignancy was pleural lesion followed by lung masses, liver metastasis, abdominal masses, and absence of pericardial effusion. The cutoff value in our study was found to be total score &amp;gt;7 denoting malignancy with a sensitivity of 94.12%, a specificity of 100%, a PPV (positive predictive value) of 100, a NPV (negative predictive value) of 92.2 and AUC (area under curve) = 0.986. On the other hand, the cutoff value of the study done by Porcel et al ( (27 denotes malignancy) gave a sensitivity of 94.1%, a specificity of 92.3%,a PPV of 94.12, a NPV of 92.31, and an accuracy of 93.33% in our study while in their study gave a sensitivity of 88%, aspecificity of 94%, and AUC = 0.919. Conclusion This is a simple chest CT scan scoring system, which includes the evaluation of pleural nodularity or thickening, liver metastases, abdominal masses, lung nodules or masses, pleural loculations, pericardial effusions, and cardiomegaly. It can be used as a reliable tool that helps determine the differential diagnosis ofpleural effusion yet does not replace cytology/biopsy. Further studies assessing this C T scan score are recommended.

Added value of 40 keV virtual monoenergetic images for diagnosing malignant pleural effusion on chest CT.

This study aimed to evaluate the added value of 40 keV virtual mono-energetic images (VMIs) obtained from dual-layer detector CT (DLCT) for diagnosing malignant pleural effusion (MPE) in patients presenting with unilateral pleural effusion on chest CT. This retrospective study included 75 patients with unilateral pleural effusion who underwent contrast-enhanced chest CT scans using DLCT. Quantitative and qualitative assessments of the visibility of pleural thickening were conducted on both conventional 120 kVp images and 40 keV VMIs. Two independent radiologists reviewed chest CT scans with or without 40 keV VMIs to detect pleural nodules or nodular thickening for the diagnosis of MPE. Diagnostic performances were compared and independent predictors of MPE were identified through multivariate logistic regression analysis using CT and clinicopathologic findings. Pleural thickening associated with MPE demonstrated a higher contrast-to-noise ratio value and greater visual conspicuity in 40 keV VMIs compared to benign effusions (p < 0.05). For both readers, the use of 40 keV VMIs significantly improved (p < 0.05) the diagnostic performance in terms of sensitivity and area under the curve (AUC) for diagnosing MPE through the detection of pleural nodularity. Inter-observer agreements between the two readers were substantial for both 120 kVp images alone and the combined use of 40 keV VMIs. Initial cytology results and pleural nodularity at 40keV were identified as independent predictors of MPE. The use of 40 keV VMIs from DLCT can improve diagnostic performance of readers in detecting MPE among patients with unilateral pleural effusion.

Predictions of PD-L1 Expression Based on CT Imaging Features in Lung Squamous Cell Carcinoma.

To develop models to predict programmed death ligand 1 (PD-L1) expression in pulmonary squamous cell carcinoma (SCC) using CT. A total of 97 patients diagnosed with SCC who underwent PD-L1 expression assay were included in this study. We performed a CT analysis of the tumors using pretreatment CT images. Multiple logistic regression models were constructed to predict PD-L1 positivity in the total patient group and in the 40 advanced-stage (≥ stage IIIB) patients. The area under the receiver operating characteristic curve (AUC) was calculated for each model. For the total patient group, the AUC of the 'total significant features model' (tumor stage, tumor size, pleural nodularity, and lung metastasis) was 0.652, and that of the 'selected feature model' (pleural nodularity) was 0.556. For advanced-stage patients, the AUC of the 'selected feature model' (tumor size, pleural nodularity, pulmonary oligometastases, and absence of interstitial lung disease) was 0.897. Among these factors, pleural nodularity and pulmonary oligometastases had the highest odds ratios (8.78 and 16.35, respectively). Our model could predict PD-L1 expression in patients with lung SCC, and pleural nodularity and pulmonary oligometastases were notable predictive CT features of PD-L1.

A Combination of Ultrasound Characteristics with Macroscopic and Biochemical Features to Diagnose the Etiology of Lymphocytic Pleural Effusions

Objectives: The primary aim of this study was to improve the diagnosis of lymphocytic pleural effusions (LPEs) by combining their ultrasound characteristics with their macroscopic and biochemical features. Methods: This prospective, single-center, clinical observational study was conducted over a period of three years. The possible malignant etiology of LPEs was assessed using several diagnostic criteria: 1. ultrasound characteristics of the LPEs; 2. typical combinations of macroscopic and ultrasound features; and 3. the logistic regression method with three parameters—pleural nodularity, absence of fibrin, and serum protein concentration. Results: Eighty-four patients with LPEs were included in this study. Pleural nodularity (first criterion) was an ultrasound characteristic that yielded the best individual results (p &lt; 0.001) in the differentiation of malignant and nonmalignant etiologies of LPEs (accuracy 73.81%). The combination of the second and third criteria yielded the best results in the prediction of a malignant etiology of LPEs (sensitivity 90.48%, specificity 83.33%, PPV 84.44%, NPV 89.74%, accuracy 86.90%). Based on the results of this prospective study, a protocol for the diagnostic procedure of lymphocytic pleural effusions without a definitive fluid diagnosis has been proposed. Conclusions: A combination of the ultrasound characteristics of LPEs and their macroscopic and biochemical features has improved the predictive accuracy for the malignant etiology of LPEs.

Abstract 3065: Increased longevity and quality of life with treatment with a progesterone receptor modulator in a patient with treatment resistant stage IV small cell lung cancer

Abstract The progesterone receptor modulator, mifepristone, has been found to provide extension of life by years and marked palliative benefits in several cases of non-small cell lung cancer (NSCLC) despite progression with platinum-based chemotherapy, check-point inhibitors, and third-generation tyrosine inhibitors. Presented here is a case of small cell lung cancer (SCLC) treated with mifepristone. This patient was diagnosed at age 58 with stage IV NSCLC with EGFR deletion 19 mutation. He was treated with single agent osimertinib 80mg once/day. Two months later his serial CT scan showed improvement. He was treated with stereotactic ablative radiotherapy for one persisting lesion. He was able to conduct a very active life. However, clinical symptoms started to return after 8 months, and CT of the chest showed slightly increased size of a the previously treated right upper lobe mass with increased small right effusion, increased pleural nodularity, and new interlobular septal thickening. Biopsy of the pleural mass showed transformation to SCLC. He failed a clinical trial. He began mifepristone orally 200mg/day. Within 1 month he was able to resume normal activity including strenuous sports. CT scans 2 months later showed no longer any pleural effusions, pleural nodularity, or growth of the persisting nodule that had been previously radiated. His absence of clinical symptoms continued for 10 more months but CT now showed slight growth of the persisting lesion. He assumed that with the growth that mifepristone was losing its effectiveness, and after consultation with another oncologist, elected to be treated in another clinical study for a new promising drug for SCLC that precluded him from continuing mifepristone. He died 5 months later. The main benefit of mifepristone is believed to be by blocking membrane rather than nuclear progesterone receptors (PRs) that are responsible for producing an immunosuppressive protein called the progesterone induced blocking factor which allows various cancers to spread. A previous case of stage IV NSCLC without any tumor markers treated with mifepristone had no growth and good health x 2 ½ years when 1 lesion begins to grow slowly. His oncologist suggested stopping mifepristone and try a check-point inhibitor. Instead, he continued mifepristone. He died 3 years later from pneumonia still feeling quite well while the one lesion continued to grow slowly. Another case of rapidly progressing lung cancer diagnosed by CT scan corrected her severe hypoxia (PO2 70 mmHg) and hyponatremia (serum Na+ of 118 mmol/L) after 1 month of taking mifepristone. Her lesions mostly disappeared and 5 years later she died of a myocardial infarction. Though clinically suspicious of SCLC, it was not biopsy proven. Hopefully this case will inspire a clinical trial of PR antagonists for SCLC. Citation Format: Jerome H. Check, Carrie Wilson, Diane Check, Trina Poretta, Maya Srivastava. Increased longevity and quality of life with treatment with a progesterone receptor modulator in a patient with treatment resistant stage IV small cell lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3065.

ES07.01 Radiological Evaluation of Pleural Effusion in a Cancer Patient

Pleural effusion (PE) is not infrequently seen in cancer patients. Malignant pleural effusion (MPE) is an exudative effusion with malignant cells. MPE is a common symptom and accompanying manifestation of metastatic disease. It affects up to 15% of all patients with cancer and is the most common in lung, breast cancer, and gastrointestinal tract adenocarcinoma or ovarian, gynecological malignancies and malignant mesothelioma. Once PE is identified in a cancer patient, the most important issue is to clarify the nature of pleural effusion which is benign or malignant. The most common radiographic evaluation of cancer patients is chest radiograph. Radiographical detection of small PE is difficult on chest PA view unless significant amount to obscured the lateral costophrenic angles. Computed tomography (CT) is commonly used for clinical staging which may reveal the presence of pleural effusion, thickening, nodularity or mass(es). The presence of pleural nodularity or masses in a cancer patient is frequently due to pleural metastasis or tumor seeding. Pleural effusion in patients with lung cancer may raise high suspicion of malignant pleural effusion (M1a) unless there is associated pneumonia or heart failure which may be the etiology of pleural effusion. Clinical workup of the persistent PE in a cancer patient should be carried out even nonvisualization of pleural nodularity or tumor seeding. Microscopic evidence or analysis of the cell block from PE is important to diagnose the etiology of pleural effusion. In this refreshed lecture, we are going to show typical MPE and suggested algorithm if PE is found in a cancer patient. pleural effusion, Radiology

Laboratory and radiological discrimination between tuberculous and malignant pleural effusions with high adenosine deaminase levels.

Background/AimsPleural fluid adenosine deaminase (ADA) levels are useful in discriminating tuberculous pleural effusions (TPEs) from malignant pleural effusions (MPEs). However, some patients with MPE exhibit high-ADA levels, which may mimic TPEs. There is limited data regarding the differential diagnosis between high-ADA MPE and high-ADA TPE. This study aimed to identify the predictors for distinguishing high-ADA MPEs from high-ADA TPEs.MethodsPatients with TPE and MPE with pleural fluid ADA levels ≥ 40 IU/L were included in this study. Clinical, laboratory, and radiological data were compared between the two groups. Independent predictors and their diagnostic performance for high-ADA MPEs were evaluated using multivariate logistic regression analysis and receiver operating characteristic curve.ResultsA total of 200 patients (high-ADA MPE, n = 30, and high-ADA TPE, n = 170) were retrospectively included. In the multivariate analysis, pleural fluid ADA, pleural fluid carcinoembryonic antigen (CEA), and pleural nodularity were independent discriminators between high-ADA MPE and high-ADA TPE groups. Using pleural ADA level of 40 to 56 IU/L (3 points), pleural CEA level ≥ 6 ng/mL (6 points), and presence of pleural nodularity (3 points) for predicting high-ADA MPEs, a sum score ≥ 6 points yielded a sensitivity of 90%, specificity of 96%, positive predictive value of 82%, negative predictive value of 98%, and area under the receiver operating characteristic curve of 0.965.ConclusionsA scoring system using three parameters may be helpful in guiding the differential diagnosis between high-ADA MPEs and high-ADA TPEs.

Thoracic ultrasound for malignant pleural effusion: a systematic review and meta-analysis.

This systematic review aimed to evaluate the diagnostic accuracy of thoracic ultrasound in malignant pleural effusion.Articles published until December 2019 in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and the International Clinical Trials Registry Platform were screened by two authors independently to extract data and evaluate the risks of bias and applicability using the modified Quality Assessment of Diagnostic Accuracy Studies-2 tool. We described the forest plots of each thoracic ultrasound finding. We estimated the pooled sensitivity and specificity of pleural nodularity using the bivariate random-effects model.We included seven articles and found that each thoracic ultrasound finding had low sensitivity. The pooled specificity of pleural nodularity was 96.9% (95% CI 93.2%–98.6%).In conclusion, thoracic ultrasound is not useful in ruling out malignant pleural effusion. Physicians can proceed rigorously to repeat thoracentesis or other invasive procedures when pleural nodularity is detected.

Idiopathic Pleural Effusions: Characteristics and Discrimination From Cytology-Negative Malignant Pleural Effusions

BackgroundThe etiology of pleural effusions often remained unknown notwithstanding surgical pleural biopsy and further clinical observation. A better understanding of clinical characteristics of patients with idiopathic pleural effusion (IPE) may improve the ability to differentiate between IPEs and cytology-negative malignant pleural effusions (MPEs) and facilitate the identification of patients requiring invasive investigation. However, little is known about the clinical factors that can help distinguish patients with IPE from those with cytology-negative MPE. Materials and MethodsPatients who were diagnosed with IPE or cytology-negative MPE between 2010 and 2017 were enrolled in this retrospective study. Clinical, laboratory and radiologic characteristics were compared between patients with IPE and cytology-negative MPE. Diagnostic performances of predictors for IPE were assessed using receiver operating characteristic curves. ResultsOf 146 patients undergoing pleural biopsy owing to cytology-negative pleural effusion of uncertain cause, MPE was confirmed in 54 patients. IPE was ultimately diagnosed in 22 patients. Multivariate analysis demonstrated that a minimal amount of pleural effusion (odds ratio [OR] = 12.41, P = 0.039), presence of pleural nodularity (OR = 0.01, P < 0.001) and pleural fluid carcinoembryonic antigen levels less than 14 ng/mL (OR = 87.59, P = 0.002) were independent factors for distinguishing IPEs from cytology-negative MPEs. A combination of the absence of pleural nodularity with pleural fluid carcinoembryonic antigen levels less than 14 ng/mL yielded an area under the curve of 0.94 (sensitivity = 91% and specificity = 96%). ConclusionsUsing these readily available parameters to identify IPE in patients with cytology-negative exudative effusion of unknown cause can help guide decision-making when choosing to perform an invasive pleural biopsy or to take a conservative approach.

TB or not TB: an uncanny radiology

A 52-year-old male smoker presented with a 2-month history of progressive breathlessness and weight loss. He denied having cough, wheeze, hemoptysis or fever. Although tachypneic (rate 26/min), he was maintaining...

A CURIOUS CASE OF CYCLICAL PNEUMOTHORAX

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Spontaneous pneumothorax is classified as primary or secondary based on whether underlying lung disease is present. Secondary spontaneous pneumothorax usually occurs due to underlying obstructive lung disease or infections, however less common causes should also be considered and a thorough history should be obtained. CASE PRESENTATION: A 48-year- old otherwise healthy woman with a history of endometriosis presented with right shoulder pain that started after doing push-ups at the gym. She denied chest pain and shortness of breath and was hemodynamically stable. Right pneumothorax was incidentally found on chest x-ray, which was thought to be spontaneous in origin. She was managed conservatively without chest tube placement. However, she returned to the hospital four weeks later with dyspnea and chest pain. On further questioning, she reported a long-standing history of dysmenorrhea accompanied by shortness of breath and mid-sternal, non-exertional chest pain. She noted that all symptoms occurred usually 2-3 days after onset of menstruation. Computed Tomography (CT) of the chest revealed pleural nodularity suggestive of endometrial implants. Empiric treatment with leuprolide, a gonadotropin receptor agonist, was initiated for presumed thoracic endometriosis, after which she did not have recurrence of symptoms. DISCUSSION: Catamenial pneumothorax is a syndrome of recurrent pneumothoraxes occurring in association within 48 to 72 hours of menses. It is encountered in 3-6% of spontaneous pneumothorax cases among women of reproductive age. Its pathogenesis remains poorly understood; some of the proposed mechanisms include acquired diaphragmatic fenestration caused by endometriosis, micro embolization and peritoneal pleural migration of endometrial tissue, and prostaglandin F2 causing bronchiolar constriction and alveolar rupture of the lungs leading to pneumothorax. Diagnosis requires establishing a temporal relationship between pneumothoraxes and menstruation. High resolution CT (HRCT) of the chest is one of the main imaging modalities to support the diagnosis. Management of a catamenial pneumothorax is identical to that of pneumothorax of any etiology. Small asymptomatic or mildly symptomatic pneumothoraxes may be managed conservatively while large ones require tube thoracostomy. Long-term treatment of recurrent catamenial pneumothoraxes involves either suppression of ovulation or ablation of the pleural space to interrupt the pattern of recurrence. Surgical management is performed when medical treatment fails and consists of endometrial tissue removal through video-assisted thoracoscopic surgery (VATS) or open surgery. CONCLUSIONS: Neglect of the menstrual history may prevent and/or delay diagnosis, leading both to an underestimation of the true incidence of this disorder and to a delay in initiation of appropriate therapy. Reference #1: Catamenial pneumothorax caused by thoracic endometriosis. Paolo Maniglio MD, Enzo Ricciardi MD, Federica Meli MD, Salvatore Giovanni Vitale MD, Marco Noventa MD, Amerigo Vitagliano MD, Gaetano Valenti MD, Valentina Lucia La Rosa, MD, Antonio SimoneLaganà MD, Donatella Caserta MD. Reference #2: Catamenial pneumothorax: retrospective study of surgical treatment. Patrick Bagan MD, Françoise Le Pimpec MD, Barthes MD, aJalal Assouad MD, Redha Souilamas MD, Marc Riquet MD, PhD. DISCLOSURES: No relevant relationships by Nikita Fernandes, source=Web Response No relevant relationships by Lakshmi Priyanka Mahali, source=Web Response No relevant relationships by Jonathan Ross, source=Web Response

Is transthoracic ultrasound (TUS) a reliable predictor of the nature of pleural and peripheral pulmonary lesions? Correlation with cyto-histological findings

BackgroundWe focused on determining the most reliable transthoracic ultrasound (TUS) criteria that can predict malignancy of the pleural and peripheral pulmonary lesions and correlating our data with CT and cyto-histological findings. Sixty-nine patients (38 males and 31 females) were enrolled in our prospective study. They were divided into group I (48 patients), which included patients with pleural effusion, and group II (21 patients), which included patients with peripheral pulmonary lesions. All patients underwent chest X-ray (postero-anterior and lateral views), transthoracic ultrasound (TUS), CT chest, guided Tru-cut or surgical biopsies and histopathology, and/or needle aspiration and cytology.ResultsIn group I, the presence of pleural nodularity was a predictor of malignancy with significant statistical difference (b value < 0.001) and receiver operating curve (ROC) curve analysis showed pleural thickening cutoff value of 7 mm at a maximum combined sensitivity and specificity of 75% and 80% respectively and area under the curve 0.825. In group II, distorted intralesional vascular pattern, pleural, and chest wall invasion were statistically significant ultrasonographic malignant predictors (b values are <0.001, 0.016, and 0.004 respectively).ConclusionTUS is a valuable and safe complementary method in differentiation between benign and malignant pleural effusion and peripheral pulmonary lesions but is not a substitute for CT.

Malignant pleural mesothelioma: diagnostic value of medical thoracoscopy and long-term prognostic analysis

BackgroundMalignant pleural mesothelioma (MPM) is marked by its difficult diagnosis and poor prognosis. Medical thoracoscopy (MT) is an effective and safe procedure for the diagnosis of exudative pleural effusions and many factors associated with poor prognosis of MPM. We conducted this study to investigate the value of MT for diagnosing of MPM and to identify prognostic factors for MPM patients.MethodsFrom July 2005 through June 2014, a total of 833 patients with undiagnosed pleural effusions underwent MT and pleural biopsies were taken. Clinical data of all patients with MPM were retrospectively analyzed, and those with complete follow-up data were analyzed for prognostic factors.ResultsEventually, MPM was the final diagnosis in 40 patients. Diagnostic efficiency of MT for MPM was 87.5%, since diagnosis of MPM failed to be established in 5 patients during the initial MT. Median survival was 17.1 mo (95% confidence interval: 13.6–20.7 mo). MT findings of pleural adhesion and plaques were adverse prognostic factors for MPM. In addition, old age, male gender, smoking history, histological type, poor staging, no treatment, low total protein level in pleural fluid, and computed tomographic findings such as pulmonary consolidation or infiltration, mediastinal lymphopathy, pulmonary mass or nodules, and pleural nodularity were also poor prognostic factors for MPM.ConclusionsMT is safe with a high positive rate in the diagnosis of MPM, and pleural adhesion and plaques seen under MT may be the adverse prognostic factors for MPM. Multiple clinical characteristics can affect the survival of MPM patients.

A Case of Adenocarcinoma in a Patient With Sarcoidosis Presenting as a Mandibular Lesion

SESSION TITLE: Metastatic and Other Primary Lung Tumors SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Sarcoidosis is a disease characterized by the presence of noncaseating granulomas in affected organs, most commonly lung and lymph nodes with symptoms commonly manifesting in the skin, joints, and eyes.1 The variability of symptoms mimic a long list of other disorders, making the disease challenging to diagnose and manage, even confounding the diagnosis of other disease processes in a patient with Sarcoidosis. We present a case of a patient with Sarcoidosis diagnosed with primary lung adenocarcinoma that was discovered secondary to complaints of a rapidly growing mandibular mass. CASE PRESENTATION: A 64 year old male, former smoker, with a PMHx of Sarcoidosis with uveitis, skin, and joint involvement on chronic prednisone therapy presented to his pulmonologist for cough with phlegm production, fatigue, and a chronic toothache for three months. He was recently seen by his dentist for complaints of toothache in a right lower molar. No improvement was noted even after tooth extraction. His chest x-ray showed a small right pleural effusion with no other acute findings so the patient was treated for bronchitis. He returned one week later with worsening fatigue and hemoptysis. His steroid dose was increased and he was given antibiotics. He presented to his PCP four days later for sudden worsening of his tooth pain and new lesion on his right mandible. The lesion was biopsied and pathology demonstrated adenocarcinoma, poorly differentiated, CK7+ suggesting lungs as a primary source. Secondary to concerns of a pulmonary primary, investigation was initiated with a CT chest that was significant for right pleural effusion and a pleural nodularity possibly representing Sarcoidosis vs malignant neoplasia. Thoracentesis, bronchoscopy with washings, and EBUS studies were then obtained. Cells with similar histology and staining pattern were found in his pleural fluid and right hilar lymph node. PET scan revealed primary malignancy in the right lower lung with further metastatic disease in lung, mediastinum, liver, bone and retroperitoneal space. While treatment was initially aggressive, the patient’s condition continued to deteriorate and he eventually transitioned to hospice care. DISCUSSION: Our patient, who had relatively well-controlled Sarcoidosis, presented with new onset tooth pain, cough, phlegm production progressing to hemoptysis and joint pain. All were easily attributable to Sarcoidosis but in fact represented fairly advanced metastatic adenocarcinoma. CONCLUSIONS: We highlight this case first as an example of a rare presentation of adenocarcinoma presenting as dental pain in a patient with Sarcoidosis. Secondly, as an illustration that the varied presentation of Sarcoidosis can act as an imposter distracting the clinician from the diagnosis of an important underlying pathology. Reference #1: N/A. (2013, June 14). National Heart, Lung, and Blood Institute. Retrieved 2017, from What Is Sarcoidosis?: https://www.nhlbi.nih.gov/health/health-topics/topics/sarc DISCLOSURE: The following authors have nothing to disclose: Jason Taylor, Nooreen Hussain, Subramanyam Chittivelu No Product/Research Disclosure Information

Safety and Performance Characteristics of Outpatient Medical Thoracoscopy and Indwelling Pleural Catheter Insertion for Evaluation and Diagnosis of Pleural Disease at a Tertiary Center in Canada.

Background Many centers performing medical thoracoscopy (MT) to diagnose pleural disease will insert a chest tube and admit patients to hospital after the procedure, which is inconvenient for patients and contributes to healthcare costs. We report the data on the safety, outcomes, and performance characteristics of outpatient MT with indwelling pleural catheter (IPC) insertion in a large Canadian cohort. Methods This retrospective cohort study reviewed patients who underwent outpatient MT and IPC insertion under conscious sedation. Patients without complications were discharged the same day. We report the data on safety, outcomes, and performance characteristics of our program. Results Outpatient MT and IPC insertion was performed on 218 patients. 99.1% of patients were safely discharged the same day. There was no procedure associated mortality. Pleural malignancy (59.6%) and nonspecific pleuritis (29.4%) were the most common pathologies. Pleural nodularity detected endoscopically was excellent at predicting malignancy with a positive predictive value of 92.5% and is more frequently detected endoscopically when compared to CT scan (p < 0.001). Conclusions In the setting of a comprehensive pleural disease program, outpatient MT can be safely performed and is an alternative to an inpatient surgical approach for undiagnosed pleural effusions.

Pulmonary sarcomatoid carcinoma: An uncommon entity in a 40 years female

A middle-aged female presented with nonpleuritic chest pain with progressive dyspnea and unmeasured weight loss and anorexia for last 4 months. The patient had pallor, clubbing, but no peripheral lymphadenopathy. Clinically, vesicular breath sound was diminished over anterior, posterior, and lateral aspect of the right hemithorax with a dull note on percussion. Chest radiography showed homogenous opacity involving the right hemithorax with blunting of right costophrenic angle without contralateral shifting of the lower mediastinum. Contrast-enhanced computed tomography (CT) thorax revealed a large mixed density mass lesion occupying the entire right hemithorax with peripheral contrast enhancement. The lesion narrowed the right pulmonary artery and insinuated the adjacent mediastinum, but no evidence of pleural nodularity. CT guided fine-needle aspiration cytology from the mass was inconclusive. Tru-cut biopsy from the mass showed spindle-shaped cells, with nuclear pleomorphism and mitotic figures, arranged in interlacing fascicles. The histopathology was suggestive of spindle cell neoplasm. Immunohistochemistry (IHC) showed pancytokeratin (AE1/3), cytokeratin 7, vimentin, and epithelial membrane antigen positivity, whereas immunonegativity to thyroid transcription factor-1, WT-1, and calretinin. The radiological picture with IHC pattern favored the diagnosis of pulmonary sarcomatoid carcinoma.

Catamenial pneumothorax: a unique radiologic and intraoperative finding

Catamenial pneumothorax is a relatively uncommon disease process, hallmarked by the presence of thoracic endometriosis causing cyclic spontaneous pneumothoraces. Identification of stigmata of catamenial pneumothorax on imaging is rare and is primarily limited to magnetic resonance imaging (MRI) or diaphragmatic components of the disease process. Evidence of the pleural component found on computed tomography (CT) has yet to be described in the literature. A 26-year-old female with past medical history of endometriosis presents with shortness of breath and pleuritic chest pain. Chest X-ray (CXR) denoted a significant right-sided hydropneumothorax for which a tube thoracostomy was placed. Subsequent chest CT scan noted the pneumothorax, absence of bullous disease, and the presence of apical pleural nodularity and associated pleural thickening. Persistent air leak mandated surgical exploration, and she underwent a right video-assisted thoracic surgery (VATS) which had unique findings. There were extensive web-like fibrotic bands throughout the parietal pleura, beginning at the apex and extending inferior laterally. Small darkened regions with nodular extensions, presumed thoracic endometriosis, were present on the lung parenchyma and parietal pleura. Pleurectomy with mechanical pleurodesis was performed along with apical wedge resections. Pathology denoted endometriosis within the pleural specimen. No symptoms have recurred in 5 months, and repeat CT scan denoted the absence of pneumothorax and good parietal-visceral pleural approximation. CT findings suggestive of catamenial pneumothorax are rare and are usually demonstrative of the diaphragmatic component of disease. Fibrous adhesive disease is rare as well and likely resultant of repeated inflammation, albeit the lack of previous symptoms or pneumothoraces. This case demonstrates not only a unique intraoperative finding but also a rare radiologic finding which may aid in the future diagnosis of pneumothorax from thoracic endometriosis.

Application of medical thoracoscopy in diagnosis of sarcoidosis‐related pleural effusion

Pleural effusion caused by sarcoidosis is unusual. Medical thoracoscopy could help clinicians detect associated pleural disease, yet studies on thoracoscopic observations in sarcoidosis pleural involvement are rare. In this article, we report the utility of medical thoracoscopy in diagnosing sarcoid-related pleural disease for three patients. Pleural nodularity was common with solitary and multiple nodules evident; biopsies confirmed the presence of diagnostic noncaseating granulomas.

Preoperative Computed Tomography Findings Predict Surgical Resectability of Thymoma

The aim of the study was to identify preoperative computed tomography (CT) imaging characteristics that correlated with surgical resectability. We retrospectively reviewed the CT scans of 133 patients who underwent surgical resection for thymoma at our institution between July 21, 1997, and September 22, 2010. Imaging characteristics recorded included tumor size, attenuation, contact of mediastinal vessels, tumor morphology, infiltration of surrounding fat, changes in the adjacent lung parenchyma, lymphadenopathy, and pleural involvement. The study group included 66 men and 67 women, aged 23-88 years (mean 58.8 years). Eighty patients (60.2%) were Masaoka stage I or II and 53 (39.8%) were Masaoka stage III or IV. Twenty-three patients (17.3%) had an incomplete surgical resection. Of these, 15 patients had microscopic residual disease (11.2%) and eight had gross residual disease (6.0%). The preoperative CT characteristics that correlated with an incomplete surgical resection included a lobulated tumor contour (p = 0.016), greater than or equal 50% abutment of the circumference of an adjacent vessel (p < 0.001), thoracic lymphadenopathy (p = 0.029), adjacent lung changes (p = 0.005) and pleural nodularity (p = 0.001). Tumor size was larger in the incompletely versus completely resected groups, with mean values of 9.7 and 6.9 cm (p value 0.013). On multivariate analysis, only degree of abutment of adjacent vessels and pleural nodularity were independent predictors of incomplete resection. Preoperative CT findings can predict the likelihood of successful surgical resection and could help to identify patients who might benefit from neoadjuvant chemotherapy.