Solid Pulmonary Lesions Research Articles

A Case of Cartagenet's Syndrome Presenting as a Solid Pulmonary Lesion

Background: Cartagena syndrome is a very rare disease with typical clinical manifestations of chronic sinusitis, bronchiectasis, and visceral inversion. Although it is not difficult to diagnose, many physicians do not pay enough attention to it, and it is often misdiagnosed or underdiagnosed. Here, we describe a patient with Cartagena syndrome who presented with solid pulmonary lesions on admission to the hospital. Case Details: A 15-year-old young woman with clinical symptoms such as cough, expectoration, nasal congestion, and runny nose came to the hospital this time due to the aggravation of cough and expectoration symptoms and chest pain. At admission, chest CT showed consolidation of the middle lobe of the left lung and inversion of the whole internal organs. After anti infection and expectorant treatment, the symptoms improved. Reexamination of chest CT showed that inflammation was obviously absorbed, the middle lobe bronchiectasis was obvious, and improved sinus CT showed extensive sinusitis, The final clinical diagnosis was Katane syndrome. Conclusion: It is not difficult to diagnose Cartagene syndrome with typical triad, but it is easy to miss or misdiagnose those with atypical imaging manifestations. For patients with lung consolidation and visceral inversion, we should think of the possibility of Cartagene syndrome, and timely review chest CT and improve relevant examinations to avoid missed diagnosis and misdiagnosis.

BILATERAL PNEUMOTHORACES SECONDARY TO ANGIOSARCOMA OF THE SCALP

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Angiosarcoma is a rare and aggressive tumor that develops from the endothelium of lymphatic or blood vessels and typically originates in the head and neck. It is a disease of older adults and, despite aggressive therapy, has a notoriously poor prognosis. Metastatic disease is common to the liver, breast, bone, and skin with 20% of patients developing solid, cavitary and cystic pulmonary lesions. Secondary spontaneous pneumothorax (SSP) due to malignancy is rare and develops from spontaneous rupture of cystic lung lesions in angiosarcoma. CASE PRESENTATION: The patient is an 87-year-old woman with a past medical history of angiosarcoma of the scalp status-post surgical resection and radiation treatment with new metastases to the carotid lymph nodes and spleen. She presented to the emergency department (ED) in acute hypoxic respiratory failure (AHRF) with an arterial oxygen saturation of 82% despite oxygen supplementation and was hypotensive. Chest x-ray and CT chest both demonstrated large bilateral pneumothoraces. Placement of bilateral chest tube thoracostomy resulted in lung expansion and improvement in oxygen saturation and hemodynamic status. The patient underwent bilateral pleurodesis with doxycycline and removal of chest tubes 3 days later with no further complications and was subsequently discharged home. One month later the patient presented to the ED with AHRF secondary to reoccurrence of bilateral spontaneous pneumothoraces. After chest tube thoracostomy the patient was transferred to inpatient hospice. DISCUSSION: SSP is an uncommon complication of pulmonary metastasis accounting for <1% of all spontaneous pneumothoraces. Simultaneous bilateral SSP is an even rarer occurrence accounting for <1% of all cases of spontaneous pneumothoraces. Other reported causes of bilateral pneumothorax include sarcoidosis, radiation, trauma, iatrogenesis, and cystic lung disease. Based on literature review there have been <20 reports worldwide of bilateral pneumothorax caused by pulmonary metastatic angiosarcoma. Prognosis after pneumothorax is poor with mortality reported within several months. Once the disease has progressed to this point, it is important to involve palliative care and hospice to discuss prognosis and goals of care. CONCLUSIONS: No established systemic treatment exists for angiosarcoma despite sporadic reports of moderately effective chemotherapy. With the high metastatic potential of angiosarcoma and its predilection towards the lungs, along with the rarity of SSP (especially bilaterally), a high degree of suspicion and close monitoring is required when pulmonary lesions are noted on imaging in this group of patients. REFERENCE #1: Upadya A, Amoateng-Adjepong Y, Haddad RG. Recurrent bilateral spontaneous pneumothorax complicating chemotherapy for metastatic sarcoma. South Med J. 2003;96(8):821-823. REFERENCE #2: Jimenez, D., Antaki, J., & Kamangar, N. (2016). Metastatic Pulmonary Angiosarcoma Presenting With Bilateral Secondary Spontaneous Pneumothoraces. Journal of Intensive Care Medicine, 32(4), 292–296. doi:10.1177/0885066616683323. REFERENCE #3: Marie Christine Aubry. Chapter 29 - Pulmonary Involvement by Extrapulmonary Neoplasms. Editor(s): Dani S. Zander, Carol F. Farver. In The Foundations in Diagnostic Pathology Series, Pulmonary Pathology, Churchill Livingstone, 2008. Pages 622-635. ISBN 9780443067419. DISCLOSURES: No relevant relationships by Anas Ahmed, source=Web Response No relevant relationships by Thomas Donnelly, source=Web Response No relevant relationships by Joy Wang, source=Web Response No relevant relationships by Steven Young, source=Web Response No relevant relationships by Nicholas Zingas, source=Web Response

Computed Tomography findings of atypical intralobar pulmonary sequestration: Research Article

Backgrounds: Bronchopulmonary sequestration (BPS) is a rare congenital anomaly of the lung that has two different types as intralobar and extralobar. In this study, we aimed to present six cases of intralobar sequestration with atypical findings in terms of feeding, drainage and, localization. Methods: Patients diagnosed with intralobar pulmonary sequestration in our clinic between 2015-2019 were evaluated retrospectively. Demographical features and atypical Computed Tomography (CT) findings of the patients were presented by literature. Results: Among 45 patients with intralobar sequestration, six ones (13.3%) (5 males and 1 female) with a mean age of 43.5±25.4 (0-78) years old) had atypical pulmonary findings on CT images. Atypical features regarding arterial supply was detected in 8.9%, venous drainage in 2.2%, location in 4.4%, radiological appearance ın 4.4% and co-existing lesion in 2.2% of the patient with intralobar sequestration. Conclusion: Typical and atypical features of pulmonary sequestration must be well-known for differential diagnosis of solid or cystic pulmonary lesions.

Diagnostic value of radial endobronchial ultrasonographic features in predominant solid peripheral pulmonary lesions.

BackgroundTransbronchial lung biopsy (TBLB) of peripheral pulmonary lesions (PPLs) is usually performed for a definite diagnosis. Radial probe endobronchial ultrasonography is often acknowledged as a good guidance method for TBLB as it can help physicians confirm the lesions’ position. It is also a non-invasive imaging diagnostic method. This clinical study was designed to evaluate the ability of radial endobronchial ultrasonography (R-EBUS) to differentiate benign from malignant predominant solid PPLs based on imaging features.MethodsPatients with predominant solid PPLs were enrolled in this study retrospectively. TBLB was performed using R-EBUS with or without other guidance techniques. One typical sonographic image and one video of each lesion were recorded for analysis. Six radial probe endobronchial ultrasonographic image features (size, shape, echogenicity, margin, blood vessel, and linear-discrete air bronchogram) were studied by ultrasonography specialists and physicians who were blinded to the final diagnosis. The sum score model of the combined predictive factors indicated the best diagnostic accuracies for predicting malignant PPLs. The model group results were used to establish the diagnostic standard for a verification group.ResultsA total of 303 patients were enrolled in the model group from July 2018 to July 2019 at the Shanghai Chest Hospital (214 with malignant and 89 with benign lesions). The mean lesion long axis on computed tomographic images was 34.39±13.79 mm. There were significant statistical differences between benign and malignant lesions in the long axis, short axis, shape, margin, blood vessel, and linear-discrete air bronchogram assessed by radial endobronchial ultrasound. Long axis, lobulation, distinct but not sharp margin, absence of blood vessel, and absence of linear-discrete air bronchogram were good predictive factors of malignant lesions. A sum score model value of 79.54% of these combined factors indicated the best diagnostic accuracy for predicting malignant lesions. Eighty-seven patients were enrolled in the verification group from August to October 2019. The sum score model showed a diagnostic accuracy of 82.76%.ConclusionsRadial endobronchial ultrasonographic features can differentiate malignant from benign lesions and thus have potential diagnosis value in predominant solid PPLs.

SYMPTOMATIC PULMONARY AND INTRACRANIAL NODULES IN A PATIENT WITH LONGSTANDING, UNCONTROLLED RHEUMATOID ARTHRITIS

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary manifestations of rheumatoid arthritis (RA) are found in 60-80% of all RA patients and are responsible for 10-20% of RA-related mortality. RA nodules are observed in approximately 20% of RA patients with 20- 32% prevalence pulmonary RA nodules. Rarer intracranial RA nodules have been described in two case studies.1 Here we present a patient who demonstrates significant symptomatic pulmonary nodulosis along with intracranial nodules leading to intractable seizures and ventilator support. CASE PRESENTATION: Our patient was a 67-year-old woman with a 9-year history of RA, recurrent bilateral knee septic arthritis, and three months of focal seizures who presented to the emergency department for breakthrough focal seizures. Prior magnetic resonance imaging (MRI) showed contrast enhancing right temporal and right thalamic nodules up to 4mm consistent with electroencephalogram (EEG) localization of the seizures. Rheumatologically, the patient had RA flares multiple times per month despite maximal doses of hydroxychloroquine, leflunomide, and methrotrexate (MTX). 6 months prior, an outpatient Chest CT ordered for evaluation of dyspnea showed multiple solid and cavitary pulmonary lesions. Endobronchial ultrasound with biopsy of nodules showed necrotizing granulomatous inflammation consistent with RA nodules. During hospitalization, the patient presented with mildly elevated CRP, RF, and anti-CCP, and mildly decreased complement C3 but otherwise normal exam and negative serologic and cerebrospinal fluid tuberculosis, fungal, bacterial, viral, cancer and autoimmune workup. Repeat imaging showed multiple new bilateral pulmonary nodules up to 2.3 cm with stable intracranial nodules despite empiric acyclovir. The patient continued to have seizures in the unit despite maximal doses of intravenous seizure medication, six days later developing, ultimately fatal severe metabolic acidosis, bradycardia, and hypotension. DISCUSSION: This unique case of symptomatic intracranial and pulmonary nodules in the setting of RA does not have much literature accompaniment, but we hope to add our experience to a potential disease etiology. Several case reports, however, do show reduction in pulmonary nodule size with oral steroid courses. There is currently no strong consensus on treatment of RA nodules. While RA nodules are often considered relatively benign, in this patient the EEG and imaging finding suggest that the nodules may have significantly contributed to this patient’s breakthrough seizures. Unfortunately due to this patient’s comorbidities and tenuous medical status, pathologic review of the brain lesions was not obtained. CONCLUSIONS: This report highlights the need to consider RA as a potentially reversible cause when considering unexplained systemic findings, as well as the need for more research into treatment of extraarticular manifestations of RA. Reference #1: Esposito AJ, Chu SG, Madan R, Doyle TJ, Dellaripa PF. Thoracic Manifestations of Rheumatoid Arthritis. Clin Chest Med 2019;40(3):545–560. DISCLOSURES: No relevant relationships by Oleh Hnatiuk, source=Web Response No relevant relationships by adarsh vangala, source=Web Response No relevant relationships by Nicholas Villalobos, source=Web Response

Role of Various DW MRI and DCE MRI Parameters as Predictors of Malignancy in Solid Pulmonary Lesions.

We aimed to evaluate various diffusion and dynamic contrast-enhanced magnetic resonance imaging (DCE MRI) parameters in differentiating malignant from benign pulmonary lesions. We enrolled 31 (22 males) patients who had solid pulmonary lesion(s) >2 cm in our cross sectional study. Of these, 23 (74.2%) were found to be malignant on histopathology. Dynamic contrast-enhanced MRI was performed using 36 dynamic measurements (volumetric interpolated breath-hold examination). Diffusion-weighted MRI (DW MRI) performed at b value of 800 s/mm2. We measured different diffusion and perfusion parameters, for example, diffusion-weighted imaging (DWI) SI, mean apparent diffusion coefficient (ADC), minimum ADC, lesion-to-spinal cord ratio, DWI score, T2 score, Ktrans, Kep, and Ve. We stratified values of each parameter as high if it was >median of values observed in our data set and low if it was ≤median. Normally distributed data were compared by unpaired t test, whereas non-normal continuous data were compared by Kruskal Wallis-H test. We applied Wilson score method to calculate sensitivity, specificity, and predictive values of parameters that were statistically significant by type of lesion with reference to histopathological examination as gold standard. Diffusion-weighted imaging SI, mean ADC, minimum ADC, DWI score and Ktrans values were found to be significantly different (P value < .05) by type of lesion. Ktrans was found to have the highest diagnostic accuracy (74.2%) among these parameters. Ktrans and mean ADC had similar sensitivity of 65.2%. However, Ktrans had highest diagnostic accuracy among various DWI and DCE MRI parameters in predicting malignancy in solid pulmonary lesions. In our study, we found a cutoff value 0.251 min-1 for Ktrans as 100% specific.

Efficacy of rapid on-site evaluation for diagnosing pulmonary lesions and mediastinal lymph nodes: a systematic review and meta-analysis

Although rapid on-site evaluation (ROSE) is gradually becoming an integral part of the modern Interventional Pulmonology, the clinical benefit of ROSE is still a matter of controversy. The objective of this meta-analysis was to clarify whether ROSE is effective in diagnosing pulmonary lesions and mediastinal lymph nodes, synchronously, to assess circumstances under which ROSE makes more sense. MEDLINE and EMBASE were searched for studies comparing any outcome between ROSE and no-ROSE group in diagnosing pulmonary lesions and mediastinal lymph nodes. Statistical calculations were conducted using Review Manager, version 5.3, and Stata Release 12.0. Meta-analysis was completed using a random-effects model when I2≥50% or a fixed-effect otherwise. Heterogeneity was assessed by the I2-statistic test. Publication bias was assessed by the Begg's test. This Literature search yielded 27 studies altogether. The pooled risk difference of adequate rate was 0.12 [95% confidence intervals (CI): 0.07-0.16, I2=0%], the combined risk difference (RD) of diagnostic yield was 0.14 (95% CI: 0.09-0.18, I2=57%) while the pooled RD of sensitivity for malignancy was 0.10 (95% CI: 0.06-0.14, I2 =20%). Significant heterogeneity only existed in diagnostic yield (I2=57%, P=0.001). Further subgroup analysis documented a higher increase in diagnostic yield when sampling solid pulmonary lesions than sampling hilar/mediastinal lymph nodes 0.16 (95% CI: 0.12-0.20, I2=0%) versus 0.08 (95% CI: 0.04-0.13, I2=10%) and when applied to patients with suspected/diagnosed lung cancer than unselected patients 0.12 (95% CI: 0.06 to 0.18) versus 0.11 (95% CI: -0.07 to 0.28). ROSE is a useful technology in diagnosing pulmonary lesions and mediastinal lymph nodes, especially when sampling solid pulmonary lesions or applied to patients with suspected lung cancer.

Differentiating between malignant and benign solid solitary pulmonary lesions: are intravoxel incoherent motion and diffusion kurtosis imaging superior to conventional diffusion-weighted imaging?

To quantitatively compare the diagnostic values of various diffusion parameters obtained from mono- and biexponential diffusion-weighted imaging (DWI) models and diffusion kurtosis imaging (DKI) in differentiating between benign and malignant solitary pulmonary lesions (SPLs). Multiple b-value DWIs and DKIs were performed in 89 patients with SPL by using a 3-T magnetic resonance (MR) imaging unit. The apparent diffusion coefficient (ADC) of various b-value sets, true diffusivity (D), pseudo-diffusion coefficient (D*), perfusion fraction (f), apparent diffusional kurtosis (Kapp), and kurtosis-corrected diffusion coefficient (Dapp) were calculated and compared between the malignant and benign groups using a Mann-Whitney U test. Receiver-operating characteristic analysis was performed for all parameters. The ADC(0, 150) values of malignant tumors were lower than those of the benign group (p = 0.01). The ADC(0, 300), ADC(0, 500), ADC(0, 600), ADC(0, 800), ADC(0, 1000), ADCtotal, D, and Dapp of malignant tumors were significantly lower than those of benign lesions (all p < 0.001). D*, f, and Kapp showed no statistically significant differences between the two groups. ADCtotal showed the highest area under the curve (AUC = 0.862), followed by ADC(0, 800)(AUC = 0.844), ADC(0, 600)(AUC = 0.843), D(AUC = 0.834), ADC(0, 1000)(AUC = 0.834) and ADC(0, 500)(AUC = 0.824), Dapp(AUC = 0.796), and ADC(0, 300) (AUC = 0.773). However, the difference in diagnostic efficacy among these parameters was not statistically significant (p > 0.05). Intravoxel incoherent motion (IVIM) and DKI-derived parameters have similar performance compared with conventional ADC in differentiating SPLs. • Mono- and biexponential DWI and DKI are feasible for differentiating SPLs. • ADC (0, ≥500) has better performance than ADC (0, <500) in assessing SPLs. • IVIM and DKI have similar performance compared with conventional DWI in differentiating SPLs.

ES 07.02 Guided Bronchoscopy for Peripheral Lung Nodules

In the past several years, X-ray fluoroscopy had been commonly employed to determine the lung field during transbronchial biopsy (TBB); however, precise localization of a PPL has not always been possible leading to low diagnostic yield. For ground glass opacities (GGOs), the value of X-ray fluoroscopy even becomes less. The value of virtual X-ray fluoroscopy and CT fluoroscopy has potential but remains to be known. The advent of endobronchial ultrasound (EBUS) has dramatically increased precise bronchoscopic confirmation of the location of a PPL before sampling. In particular, the radial probe EBUS is used to indicate that a lesion has been reached. For solid peripheral pulmonary lesions (PPLs), Kurimoto et al have described three major types of echogenicities that might differentiate between benignity and malignancy. For GGOs, we have observed constant radial-EBUS patterns that we called blizzard and mixed blizzard signs. Currently, several acquired resistance mechanisms and rare driver oncogenes are identified in non-small cell lung cancer (NSCLC) relapses. Re-biopsy increases valuable information to guide treatment strategies, but the utility and feasibility of bronchoscopic re-biopsy especially endobronchial ultrasound (EBUS) guided re-biopsy has not been investigated. We recently reported the utility of bronchoscopic (EBUS-guided) re-biopsy for detecting the mutation in NSCLC. Re-biopsy by both EBUS-TBNA and EBUS-GS were useful and safe sampling procedures for mutation analysis of EGFR-TKI resistant NSCLC. Another alternative approach, specifically liquid biopsy, now present as a crucial point in the field. Liquid biopsy has grown in importance because the genetic profile of tumors can affect how well they respond to a certain treatment. A recent paper showed that the concordance between re-biopsy and liquid biopsy, including plasma DNA and circulating tumor cell, was 57–60%. The usefulness of monitoring T790M status in liquid biopsy was already reported. Although liquid biopsy has the potential to detect new mutations after chemotherapy, several reports have demonstrated some difficulties in detecting tumor-derived mutations in plasma. Therefore, liquid biopsy and re-biopsy may be considered to be complementary methods of mutation analysis. I would like to share our data and actual cases in this talk. re-biopsy, transbronchial needle aspiration through a guide sheath (GS-TBNA), virtual bronchoscopic navigation (VBN)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Pulmonary MRI at 3T: Non-enhanced pulmonary magnetic resonance Imaging Characterization Quotients for differentiation of infectious and malignant lesions

ObjectiveTo investigate 3T pulmonary magnetic resonance imaging (MRI) for characterization of solid pulmonary lesions in immunocompromised patients and to differentiate infectious from malignant lesions. Materials and methodsThirty-eight pulmonary lesions in 29 patients were evaluated. Seventeen patients were immunocompromised (11 infections and 6 lymphomas) and 12 served as controls (4 bacterial pneumonias, 8 solid tumors). Ten of the 15 infections were acute. Signal intensities (SI) were measured in the lesion, chest wall muscle, and subcutaneous fat. Scaled SIs as Non-enhanced Imaging Characterization Quotients ((SILesion−SIMuscle)/(SIFat−SIMuscle)*100) were calculated from the T2-weighted images using the mean SI (T2-NICQmean) or the 90th percentile of SI (T2-NICQ90th) of the lesion. Simple quotients were calculated by dividing the SI of the lesion by the SI of chest wall muscle (e.g. T1-Qmean: SILesion/SIMuscle). ResultsInfectious pulmonary lesions showed a higher T2-NICQmean (40.1 [14.6–56.0] vs. 20.9 [2.4–30.1], p<0.05) and T2-NICQ90th (74.3 [43.8–91.6] vs. 38.5 [15.8–48.1], p<0.01) than malignant lesions. T1-Qmean was higher in malignant lesions (0.85 [0.68–0.94] vs. 0.93 [0.87–1.09], p<0.05). Considering infections only, T2-NICQ90th was lower when anti-infectious treatment was administered >24h prior to MRI (81.8 [71.8–97.6] vs. 41.4 [26.6–51.1], p<0.01). Using Youden’s index (YI), the optimal cutoff to differentiate infectious from malignant lesions was 43.1 for T2-NICQmean (YI=0.42, 0.47 sensitivity, 0.95 specificity) and 55.5 for T2-NICQ90th (YI=0.61, 0.71 sensitivity, 0.91 specificity). Combining T2-NICQ90th and T1-Qmean increased diagnostic performance (YI=0.72, 0.77 sensitivity, 0.95 specificity). ConclusionConsidering each quotient alone, T2-NICQ90th showed the best diagnostic performance and could allow differentiation of acute infectious from malignant pulmonary lesions with high specificity. Combining T2-NICQ90th with T1-Qmean increased overall performance, especially regarding sensitivity.

EBUS for Solid and Ground Glass Opacity Pulmonary Lesions

In the past several years, X-ray fluoroscopy had been commonly employed to determine the lung field during transbronchial biopsy (TBB); however, precise localization of a PPL has not always been possible leading to low diagnostic yield. For ground glass opacities (GGOs), the value of X-ray fluoroscopy even becomes less. We have previously reported the use of tomosynthesis instead for GGOs. The value of virtual X-ray fluoroscopy and CT fluoroscopy has potential but remains to be known. The advent of endobronchial ultrasound (EBUS) has dramatically increased precise bronchoscopic confirmation of the location of a PPL before sampling. In particular, the radial probe EBUS is used to indicate that a lesion has been reached. For solid peripheral pulmonary lesions (PPLs), Kurimoto et al have described three major types of echogenicities that might differentiate between benignity and malignancy. For GGOs, we have observed constant radial-EBUS patterns that we called blizzard and mixed blizzard signs.

Predicting Factors for Conversion from Fluoroscopy Guided Percutaneous Transthoracic Needle Biopsy to Cone-Beam CT Guided Percutaneous Transthoracic Needle Biopsy

서는 유용하면서 간편한 시술이다(1). 일반적으로는 투시 조영 Purpose: To evaluate the predicting factors for conversion from fluoroscopy guided percutaneous transthoracic needle biopsy (PTNB) to cone-beam CT guided PTNB. Materials and Methods: From January 2011 to December 2012, we retrospectively identified 38 patients who underwent cone-beam CT guided PTNB with solid pulmonary lesions, and 76 patients who underwent fluoroscopy guided PTNB were matched to the patients who underwent cone-beam CT guided PTNB for age, sex, and lesion location. We evaluated predicting factors such as, long-axis diameter, short-axis diameter, anterior-posterior diameter, and CT attenuation value of the solid pulmonary lesion affecting conversion from fluoroscopy guided PTNB to conebeam CT guided PTNB. Pearson χ test, Fisher exact test, and independent t test were used in statistical analyses; in addition, we also used receiver operating characteristics curve to find the proper cut-off values affecting the conversion to cone-beam CT guided PTNB. Results: Short-axis, long-axis, anterior-posterior diameter and CT attenuation value of the solid pulmonary lesion in patients who underwent fluoroscopy guided PTNB were 2.70 ± 1.57 cm, 3.40 ± 1.92 cm, 3.06 ± 1.81 cm, and 35.67 ± 15.70 Hounsfield unit (HU), respectively. Short-axis, long-axis, anterior-posterior diameter and CT attenuation value of the solid pulmonary lesion in patients who underwent cone-beam CT guided PTNB were 1.60 ± 1.30 cm, 2.20 ± 1.45 cm, 1.91 ± 1.99 cm, and 18.32 ± 23.11 HU, respectively. Short-axis, long-axis, anterior-posterior diameter, and CT attenuation value showed a significantly different mean value between the 2 groups (p = 0.001, p < 0.001, p = 0.003, p < 0.001, respectively). Odd ratios of CT attenuation value and short-axis diameter of the solid pulmonary lesion were 0.952 and 0.618, respectively. Proper cut-off values affecting the conversion to cone-beam CT guided PTNB were 1.65 cm (sensitivity 68.4%, specificity 71.1%) in short-axis diameter and 29.50 HU (sensitivity 65.8%, specificity 65.8%) in CT attenuation value. Conclusion: Low CT attenuation value and small short-axis diameter of the solid pulmonary lesion affect conversion from fluoroscopy guided PTNB to cone-beam CT guided PTNB. Index terms Percutaneous Transthoracic Needle Biopsy Cone-Beam CT Solid Pulmonary Lesion Fluoroscopy Predicting Factors

Synchronous bilateral bronchial carcinoid diagnosed with combined dual tracer (18F-FDG and 68Ga-DOTATOC) PET/CT scans

A 38-year-old non-smoker female with unremarkable history presented with an insidious onset of dry cough. Computed tomography revealed two solid round pulmonary lesions, curiously symmetrically located in the middle lobe and in the lingular segment, respectively (Fig. 1). Trans-bronchial needle biopsy was limited by a profuse bleeding and the diagnosis was inconclusive. The radiological differential diagnosis consisted of non-neoplastic disease, synchronous/multifocal bronchial carcinoids and pulmonary metastases from unknown neoplasm.

Influence of rigid coregistration of PET and CT data on metabolic volumetry: a user’s perspective

BackgroundWhile non-rigid fusion is by definition expected to alter the information of positron emission tomography (PET) data, we assessed whether rigid transformation also influences metabolic tumor volume (MTV) determination.MethodsThe PET/computed tomography (CT) data of 28 solid pulmonary lesions of 20 tumor patients examined with 18 F-Fluordeoxyglucose (FDG) was retrospectively analyzed. The original (OR) hardware-coregistered PET images were fused with contrast-enhanced diagnostic CT (CT1, 1 mm slices) and low dose CT (CT5, 5 mm slices). After automatic rigid transformation (Mirada Fusion7D) using two algorithms (rigid fast (RF), rigid slow (RS)), MTV and maximal standardized uptake value (SUVmax) were determined applying four different segmentation methods with either fixed or background-adapted thresholding and compared to OR-PET data.ResultsRelative differences in SUVmax compared to OR data revealed no significant differences for RF (median, −0.1%; interquartile range (IQR), −1.1% to 0.9%; p = 0.75) and RS (median, 0.5%; IQR, −0.6% to 1.3%; p = 0.19) in CT1, whereas in CT5 significant deviations were observed for RF (median, −9.0%; IQR, −10.9 to −6.1; p < 0.001) and RS (median, −8.4%; IQR, −11.1 to −5.6; p < 0.001). Relative MTV differences were 0.7% (IQR, −3.0% to 2.7%; p = 0.76) for RF and −1.3% (IQR, −3.6% to 0.9%; p = 0.12) for RS in CT1. Coregistration led to significant MTV differences in RF (median, 10.4%; IQR, 7.4% to 16.7%; p < 0.001) and RS (median, 10.6%; IQR, 5.4% to 17.7%; p < 0.001) in CT5.ConclusionsRigid coregistration of PET data allows a quantitative evaluation with reasonable accuracy in most cases. However, in some cases, it can result in substantial deviations of MTV and SUVmax. Therefore, it is recommended to perform quantitative evaluation in the original PET data rather than in coregistered PET data.

Evaluation of lung tumor perfusion by dynamic contrast-enhanced MRI

The characterization of solid pulmonary lesions with imaging methods remains a diagnostic challenge. The aim of this study was to correlate kinetic parameters of dynamic perfusion magnetic resonance imaging (MRI) with histological tumor classification. Dynamic contrast-enhanced MRI of 31 patients with pulmonary masses (five benign lesions, 26 malignant tumors) was acquired in the tumor areas every 20 s for a mean duration of 124 s. Contrast uptake (CU) was measured by signal analysis in regions of interest (ROIs). The beginning and duration of CU, maximum CU (MCU, % of baseline), maximum contrast upslope (%/s) and the delay to the maximum contrast upslope (s) were calculated. All lesions were classified histologically. The beginning of CU correlated significantly with the MCU delay in all lesions (P=.033). The frequency of a plateau phase was higher in malignant tumors compared to benign lesions (P=.031). Masses with a high MCU showed more frequently a washout of contrast medium after a plateau phase (P=.006) and a higher maximum contrast upslope (P<.001). The MCU delay time was shorter in adenocarcinoma than in squamous cell carcinoma (P=.004). These results indicate that dynamic contrast enhanced MRI might become instrumental in differentiating benign from malignant intrapulmonary tumors and distinguishing adenocarcinoma from squamous cell carcinoma.

The Advantage of PET and CT Integration in Examination of Lung Tumors

Purpose. To evaluate the diagnosis value of integrated positron emission tomography and computed tomography (PET/CT) with lung masses, this study emphasized the correlation between tumor size and maximum standardized uptake value (SUVmax) in selected regions of interest (ROI) of lung masses. Material and Methods. A retrospective analysis was performed on 85 patients with solid pulmonary lesions, all verified by pathology. The morphology, edge (speculated margins and lobule), size, density of pulmonary masses, and on-chest CT images were reviewed. The SUVmax in ROI of pulmonary masses was calculated. Results. Among the 85 patients with lung masses, 59 patients presented with pulmonary malignant neoplasm and 26 patients with benign lesions. The sensitivity, specificity, and accuracy were 89.8%, 61.5%, 81.2%, respectively, for PET measurement only, 88.1%, 65.4%, 81.2% for CT only, and 96.6%, 80.8%, 91.8% for PET/CT. The size of pulmonary malignant neoplasm in the 59 patients was apparently correlated with the ROI's SUVmax (, ). However, the size of pulmonary benign mass in the 26 patients was not correlated with the SUVmax. Conclusion. PET/CT is of greater value in characterization of lung masses than PET and CT performed separately. The examination of lung tumor can be further specified by the correlation between the size of pulmonary malignant neoplasm and the ROI's SUVmax.

Massive cavitation of solid pulmonary metastatic lesions in a breast cancer patient: a case report

A 40-year-old female with metastatic breast cancer developed multiple lung nodules some of them with cavitations. Following treatment with Taxol/Herceptin most of the lesions disappeared and in many cavity lesions appeared. There was no further change in the appearance of lung lesions.

Magnetic resonance imaging of pulmonary parenchymal disease using a modified breath-hold 3D gradient-echo technique: initial observations.

To determine the potential of a modified breath-hold 3D gradient-echo technique for visualizing pulmonary parenchymal diseases. Twenty-one magnetic resonance imaging (MRI) studies of the lungs were performed in 20 patients (15 male and 5 female; age range, 7.7-86.1 years) with pulmonary diseases comprising non-small-cell, small-cell, and bronchioalveolar carcinomas, endobronchial mucoepidermoid carcinoma, metastases, pneumonia, Wegener's granulomatosis, chronic obstructive pulmonary disease, arterio-venous malformation, and bronchogenic cyst. Confirmation of diagnoses was obtained via histopathology (14 patients) and follow-up (6 patients). MRI studies were performed at 1.5 T before and after administration of gadolinium using a modified volumetric interpolated breath-hold examination (VIBE) sequence. All images were evaluated prospectively regarding lesion detection and characterization. MR findings were correlated with final diagnoses. Retrospective grading (scores, 1-4) was performed for general image quality (rated "poor" to "excellent"); presence of artifacts ("negligible" to "severe"); and imaging quality of pulmonary lesions (conspicuity and contrast on pre- and postgadolinium images). Twenty-three solid pulmonary lesions, 25 infiltrates and segmental atelectases, and 1 cyst were detected and prospectively correctly diagnosed. Sizes ranged from 0.3-10 cm. The mean scores for image quality and presence of artifacts were 3.3 (SD, 0.7) and 1.8 (SD, 0.7), respectively. Conspicuity and contrast of pulmonary lesions received mean scores between 3.0 and 3.8 (SD, 0.4-0.7). This MRI technique allows imaging of a wide spectrum of solid and nonsolid pulmonary parenchymal diseases with reproducible high image quality, effective suppression of artifacts, high resolution, and visualization of gadolinium enhancement.

Pitfalls in the diagnosis of complicated pulmonary hydatid disease

The aim of this study was to present the pitfalls in the diagnosis of complicated pulmonary hydatid disease and to discuss the unusual radiological presentations of this endemic disorder in Turkey.We retrospectively evaluated 34 patients (12 females) aged between 8 and 64 years, who were operated on at our centre between 1991 and 1998 and diagnosed with complicated pulmonary hydatid cyst histopathologically. Computerized tomography (CT) scans of these patients were reviewed double-blind by two radiologists. The patients were then divided into two groups: group 1: initial radiological impression is pulmonary hydatid cyst and group 2: initial radiological impression is not pulmonary hydatid disease. These two groups were evaluated in terms of symptoms, radiographical presentation and laboratory tests.The presence of cystic appearance, water-lily sign, ring enhancement concomitant with intact cysts unanimously led the radiologists to the diagnosis of complicated pulmonary hydatid cyst, whereas solid appearance and presence of bronchial obliteration made the diagnosis unlikely. In such circumstances patient history, laboratory findings and bronchoscopic evaluation helped the diagnosis.In conclusion, in endemic regions like Turkey, atypical radiological presentation of complicated pulmonary hydatid disease should be considered in the differential diagnosis of solid pulmonary lesions.