A. Cataldi

The anterior mediastinum: diseases.

Mediastinal tumours are frequently asymptomatic and first noted on routine chest radiograph. In most cases, evaluation should proceed to spiral computed tomography (sCT) of the chest with iodinated contrast material. The specific location and appearance of tumours on sCT is instrumental in planning further diagnostic and treatment strategies. Primary tumours in the anterior mediastinum account for half of all mediastinal masses. They comprise various benign and malignant neoplasms, but a wide variety of nonneoplastic lesions (developmental, inflammatory) can present as a localised mass in this compartment. The most common primary anterior mediastinal tumours are thymoma, teratoma and lymphoma; all other lesions are rare. Nonneoplastic conditions include thymic cysts, lymphangioma and intrathoracic goitre. Understanding the pathology, clinical presentation, imaging and diagnosis of the major tumour types is instrumental in the safe and efficient work–up of a mediastinal mass. Patients with primary mediastinal masses and cysts will usually undergo surgical resection; radiological and clinical features should prompt limited biopsy specimens followed by oncologic consultation, and chemotherapy or radiotherapy when appropriate. The objective of this review was to examine the role of diagnostic imaging in the management of masses of the anterior mediastinum.

CT-guided percutaneous transthoracic biopsy in the diagnosis of mediastinal masses: evaluation of 73 procedures

PurposeThis study was performed to evaluate the factors affecting the diagnostic accuracy and rate of complications of CT-guided percutaneous transthoracic needle biopsy of mediastinal masses.Materials and methodsWe reviewed 73 consecutive mediastinal biopsies in 70 patients. Final diagnoses were based on a retrospective analysis of surgical outcomes, results of repeat biopsies or findings of imaging and clinical follow-up lasting at least 4 months. Benign and malignant biopsy findings were compared with the final outcomes to determine the diagnostic accuracy of the method. Finally, we analysed the complications.ResultsCT-guided percutaneous transthoracic needle biopsy provided adequate samples in 61/73 cases, with a total sample rate of 83.6%. Of these 61 biopsies, 51 yielded a correct diagnosis with specific histological typing, mainly in the case of thymoma and metastasis. Lymphomas were less reliably diagnosed. The overall sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy values were 83.6%, 100%, 100%, 35.3% and 83.6%, respectively. Pneumothorax was the most common complication (5.5%).ConclusionsCT-guided percutaneous transthoracic needle biopsy is an easy, reliable and safe procedure that obviates the need for exploratory surgery in medically treatable or unresectable cases. It should be the first invasive procedure in the diagnostic workup of mediastinal masses.RiassuntoObiettivoValutare i fattori che influenzano l’accuratezza diagnostica ed il tasso di complicanze dell’agobiopsia transtoracica percutanea TC-guidata di lesioni espansive mediastiniche.Materiali e metodiSono state considerate 73 procedure bioptiche mediastiniche consecutive su 70 pazienti. La diagnosi finale deriva dall’analisi dei risultati della chirurgia, di un’eventuale successiva agobiopsia transtoracica o dall’esito del follow-up clinico/radiologico pari ad un periodo non inferiore a 4 mesi. I riscontri bioptici con esito benigno e maligno sono stati confrontati con la diagnosi finale, ricavando l’accuratezza diagnostica della metodica. È stata quindi condotta un’analisi delle complicanze.RisultatiL’agobiopsia percutanea trastoracica sotto guida TC ha fornito materiale adeguato in 61/73 casi, offrendo un tasso di campionamento complessivo del 83,6%. Di queste 61 procedure, 51 hanno stabilito la diagnosi corretta con specificità di istotipo, principalmente nei casi di timoma e di lesioni metastatiche. Il gruppo dei linfomi ha riscontro diagnostico meno affidabile. I valori globali di sensibilità, specificità, valore predittivo positivo, valore predittivo negativo e accuratezza diagnostica sono risultati pari a 83,6%, 100%, 100%, 35,3%, e 83,6% rispettivamente. Lo pneumotorace ha rappresentato la complicanza più comune (5,5%).ConclusioniL’agobiopsia percutanea trastoracica sotto guida TC rappresenta procedura semplice, affidabile e sicura, evitando il ricorso ad un accertamento esplorativo chirurgico nei casi passibili di trattamento medico o non resecabili. Dovrebbe costituire il primo accertamento invasivo nella gestione diagnostica di una formazione espansiva mediastinica.

Accuracy of CT-guided transthoracic needle biopsy of lung lesions: Factors affecting diagnostic yield

PurposeThis study was performed to analyse the variables affecting the diagnostic accuracy of computed tomography (CT)-guided transthoracic needle biopsy of pulmonary lesions.Materials and methodsA retrospective study of 612 consecutive procedures with confirmed final diagnoses was undertaken. Benign and malignant needle biopsy results were compared with final outcomes to determine diagnostic accuracy. A statistical analysis of factors related to patient characteristics, lung lesions and biopsy technique was performed to determine possible influences on diagnostic yield. A p value less than 0.05 was interpreted as statistically significant.ResultsThere were 508 (83%) malignant and 104 (17%) benign lesions. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy for a diagnosis of malignancy were 90.2%, 99.0%, 99.8%, 67.3% and 91.7%, respectively. Overall diagnostic accuracy was 83.3%. Variables affecting diagnostic accuracy were the final diagnosis (benign 67%, malignant 92%; p<0.001) and lesion size (lesions<1.5 cm 68%, lesions 1.5–5.0 cm 87%, lesions>5 cm 78%; p<0.05).ConclusionsIn CT-guided transthoracic needle biopsy, the final diagnosis and lesion size affect diagnostic accuracy: benign lung lesions and lesions smaller than 1.5 cm or larger than 5.0 cm in diameter provide lower diagnostic yield.RiassuntoObiettivoValutare i fattori che influenzano l’accuratezza diagnostica dell’agobiopsia transtoracica percutanea TC-guidata di lesioni polmonari.Materiali e metodiSono state considerate retrospettivamente 612 procedure bioptiche consecutive per le quali è risultata disponibile la diagnosi definitiva. I reperti bioptici benigni e maligni sono stati confrontati con la diagnosi finale, ricavando l’accuratezza diagnostica della metodica. È stata quindi condotta un’analisi statistica relativamente a variabili proprie del paziente, della lesione e della tecnica bioptica per determinare possibili influenze sui valori di accuratezza. I dati ottenuti sono stati considerati statisticamente significativi per valori di p<0,05.RisultatiCinquecentootto lesioni (83%) sono risultate, alla diagnosi finale, maligne, mentre 104 (17%) benigne. I valori di sensibilità, specificità, valore predittivo positivo, valore predittivo negativo ed accuratezza, riferiti ad una diagnosi di malignità, sono risultati rispettivamente del 90,2%, 99,0%, 99,8%, 67,3% e 91,7%. L’accuratezza diagnostica globale della procedura è stata dell’83,3%. Le variabili che hanno influenzato significativamente i livelli di accuratezza sono risultate la diagnosi finale (espansi benigni 67%, maligni 92%; p<0,001) ed il diametro medio della lesione (lesioni<1,5 cm 68%, tra 1,5 e 5,0 cm 87%, >5 cm 78%; p<0,005).ConclusioniLa diagnosi finale (benignità versus malignità) e le dimensioni della lesione influenzano l’accuratezza diagnostica della metodica: addensamenti polmonari di natura benigna e lesioni con diametro <1,5 cm o >5 cm sono caratterizzati da livelli minori di accuratezza diagnostica.

Bronchogenic cysts in the adult: diagnostic criteria derived from the correct use of standard radiography and computed tomography

Purpose . This study was undertaken to identify the radiographic and computed tomography patterns allowing a diagnosis of bronchogenic cystMaterials and methods . We retrospectively reviewed chest radiographs and CT scans of 21 adults (ten men and 11 women, age range 18–74 years) with a histologically confirmed diagnosis of bronchogenic cystResults . Sixteen cysts were located in the mediastinum and five in the lungs. On chest radiography, mediastinal cysts appeared as sharply marginated rounded areas of increased opacity; intrapulmonary cysts also exhibited an air-fluid interface. CT confirmed these morphological features in all cases. In addition, analysis of attenuation values allowed the subdivision of mediastinal cysts into three groups: fluid density (four cases), air density (two cases) and soft-tissue density (ten cases)Conclusions . All bronchogenic cysts were visualised on chest radiography, but the findings were nonspecific and required further characterisation by CT. The CT findings proved to be diagnostic when cystic attenuation values were evident. When soft-tissue attenuation values were demonstrated, a confident diagnosis was not possible, and other solid lesions had to be considered. In such cases, magnetic resonance imaging may be helpful to ascertain the cystic nature of the lesionsRiassuntoObiettivo . Identificare i segni radiografici e TC che permettano di porre diagnosi di cisti broncogeneMateriali e metodi . Sono stati esaminati retrospettivamente i radiogrammi e le TC del torace di 21 pazienti adulti (11 donne e 10 uomini), di età compresa tra 18 e 74 anni, con diagnosi di cisti broncogena confermata istologicamenteRisultati . Le cisti broncogene erano localizzate a livello del mediastino in 16 casi e nel polmone in 5. Nelle radiografie standard del torace le cisti mediastiniche apparivano come opacità tondeggianti a margini netti, mentre quelle intraparenchimali differivano soltanto per la presenza del livello idro-aereo. La TC ha confermato tutti gli aspetti morfologici rilevati nei radiogrammi standard. Basandosi sui valori di attenuazione, le cisti mediastiniche sono state classificate nei seguenti gruppi: lesioni a densità liquida (4 casi), a densità aerea (2 casi) ed a densità dei tessuti molli (10 casi)Conclusioni . Le radiografie del torace dimostrano la presenza della lesione in tutti i pazienti, ma gli aspetti radiografici risultano aspecifici e devono essere ulteriormente valutati mediante esame TC. I reperti tomodensitometrici sono caratteristici quando le lesioni hanno densità liquida. Quando invece hanno attenuazione pari a quella dei tessuti molli, devono essere prese in considerazione nella diagnosi differenziale altre lesioni solide; in questi casi la RM può essere utile per determinarne la natura cistica

Solitary fibrous tumor of the lung: Three rare cases of intraparenchymal nodules

Solitary fibrous tumor (SFT) of the pleura usually presents as a peripheral mass, in contact with the surface of the pleura. However, on occasion, it can occur separately from the pleura, in the lung parenchyma. We describe the radiological and imaging features of three SFTs of the lung, diagnosed in our department, with relevant clinical data. The diagnosis of SFT of the lung, although rare, should be considered in a slow-growing solitary lung parenchymal nodule.

Computed tomography and thymoma: distinctive findings in invasive and noninvasive thymoma and predictive features of recurrence

Purpose Our goal was to assess the computed tomo graphy (CT) imaging findings of thymoma and to correlate these features with Masaoka staging system and prognosis.