Aldo Cataldi

Diagnostic accuracy and complication rate of CT-guided fine needle aspiration biopsy of lung lesions: A study based on the experience of the cytopathologist

Background: CT-guided transthoracic needle biopsy is a well-established technique for the diagnosis of focal lung lesions. Fine needle aspiration biopsy (FNAB) requires the presence of a cytopathologist on-site to assess the adequacy of samples. For this reason FNAB is less and less used, and core biopsy is the first-line procedure when an experienced cytopathologist is not immediately available. Purpose: To evaluate the accuracy and complication rate of CT-guided FNAB of lung lesions according to the experience of the cytopathologist on-site. Material and Methods: A total of 321 consecutive biopsies were considered. Immediate cytological assessment was performed by an experienced cytopathologist for the first 165 procedures (group A) and by two training pathologists for the remaining 156 biopsies (group B). At the time of FNAB the pathologist assigned a semiquantitative score (0–3) to each specimen to assess its diagnostic quality. All variables between the two groups were analyzed by chi-square and Students t test. A P value <0.05 was considered statistically significant. Results: For all procedures, overall diagnostic accuracy was 80% for cytology alone, with no statistical difference between the two groups for diagnostic accuracy and sample score assigned. In all, 75% of the cytological samples (75% group A, 74% group B) obtained a higher score with a specific diagnosis of histotype. A post biopsy pneumothorax was detected in 27% of biopsies (25% group A, 28% group B). Thirteen patients (4.0%) required chest tube insertion for treatment. For all cases, the pneumothorax rate was significantly affected by the number of samples obtained (P=0.02), but not by the pleural punctures (P=0.15). There was no statistically significant difference between the two groups concerning the number of needle passes and complication rate (P>0.05). Conclusion: The efficacy and safety of CT-guided FNAB is not significantly affected by the training level of the cytopathologist on-site. Moreover, the number of specimens obtained for each procedure is a risk factor for pneumothorax.

Differentiation of Rebound and Lymphoid Thymic Hyperplasia from Anterior Mediastinal Tumors with Dual-Echo Chemical-Shift MR Imaging in Adulthood: Reliability of the Chemical-Shift Ratio and Signal Intensity Index

PURPOSE To prospectively evaluate (a) effectiveness and limits of dual-echo chemical-shift magnetic resonance (MR) imaging for distinguishing hyperplastic thymus from anterior mediastinal tumors in adulthood by using chemical-shift ratio ( CSR chemical-shift ratio ) and signal intensity index ( SII signal intensity index ), with proposal of optimal threshold value for each, and (b) whether age affects these indexes. MATERIALS AND METHODS Study was institutional review board approved, with informed consent obtained. Ninety-two subjects (53 men, 39 women; age range, 18-84 years) were divided into a rebound and lymphoid hyperplasia group (group A, 30 patients) and a tumor group (group B, 62 patients). MR images were assessed; interrater reliability was evaluated. Differences in CSR chemical-shift ratio and SII signal intensity index were tested with the Mann-Whitney U test and the Kruskal-Wallis test. Discrimination abilities of CSR chemical-shift ratio and SII signal intensity index were evaluated with logistic regression models, and optimal cutoff points were proposed. Quantitative parameters were correlated with age by using Pearson correlation coefficients. RESULTS Interreader agreement was excellent (intraclass correlation coefficient: CSR chemical-shift ratio , 0.893; SII signal intensity index , 0.898). Mean CSR chemical-shift ratio and SII signal intensity index ± standard deviation were 0.545 ± 0.162 and 46.29% ± 18.41 for group A and 1.045 ± 0.094 and -0.06% ± 4.89 for group B, respectively, with significant differences for both indexes between groups (P < .0001). No overlap was found for SII signal intensity index between groups; CSR chemical-shift ratio values overlapped in a few younger adults. Distinguishing hyperplastic thymus from tumors was better with SII signal intensity index than CSR chemical-shift ratio . Respective sensitivity, specificity, and cutoff points were 100%, 100%, and 8.92% for SII signal intensity index and 100%, 96.7%, and 0.849 for CSR chemical-shift ratio . Significant correlation was found for CSR chemical-shift ratio (r = -0.761) and SII signal intensity index (r = 0.821) with age in group A (P < .001). For group B, significant correlation with age was seen for CSR chemical-shift ratio (r = 0.702, P < .001) but not SII signal intensity index (r = -0.196, P = .127). All subjects but one in group A and none in group B had signal intensity decrease at chemical-shift MR imaging. CONCLUSION With dual-echo chemical-shift MR imaging, SII signal intensity index and CSR chemical-shift ratio have high accuracy to distinguish thymic hyperplasia from tumors, although overlapped CSR chemical-shift ratio values can occur in early adulthood.

Acute abdomen as an unusual presentation of hepatic PEComa. A case report

Perivascular epithelioid cell (PEC) tumors (or PEComas) are myomelanocytic lesions defined by coexpression of melanocytic and muscle markers, suggesting dual differentiation. They are rare mesenchymal tumors and include subtypes with distinct clinical features: angiomyolipoma, lymphangioleiomyomatosis, and clear cell “sugar” tumors of the lung, pancreas and uterus. Consequent upon the World Health Organizations recognition of PEC-derived tumors as a distinct entity, an increasing number of reports has documented PEComas arising at various anatomical locations. Clear cell myomelanocytic tumors of the falciform ligament/ligamentum teres (CCMTs) represent a rare variant of the PEComas. These hepatic PEComas, different from angiomyolipoma of the liver, pose a clinical, radiological and morphological diagnostic challenge. Because of their rarity, the clinical features and biological behavior of these tumors have yet to be established. We experienced our first case of CCMT in a 36-year-old woman who presented to our emergency department with a 3-day history of abdominal discomfort and progressive growth of an epigastric bulk. Intralesional hemorrhage was causing abdominal distension, which progressed to acute abdomen soon after. The hemoglobin concentration was 9.9 g/dL. Liver laboratory tests showed slight elevation of AST, ALT and gamma-GT. The alpha-fetoprotein level was not elevated. The radiological images showed a hemorrhagic mass with some bizarre features in left hepatic lobe, immediately adjacent to the ligamentum teres and falciform ligament. The patient underwent a left hepatic lobectomy. The diagnosis of CCMT was based on histological and immunohistochemical staining. The postoperative course was uneventful. The patient received no adjuvant treatment and is currently, 34 months after surgery, alive and disease free. In this report we describe a peculiar and hitherto undescribed clinical presentation of this tumor and its further course. Moreover, we discuss previously undescribed diagnostic imaging. We recommend that all unusual carcinomas and mesenchymal tumors of the liver should be tested for HMB-45: when positive, there is a high likelihood of PEComa.

C2-02: Factors effecting risk of pneumothorax (PNX) in CT-guided transthoracic needle biopsy of lung lesions: results of 708 consecutive procedures

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Nodular sclerosing Hodgkin disease presenting as a sternal mass.

A 20-year-old man complained of slight chest pain of 6 months’ duration. There was tenderness on palpation of the manubrium sterni where there was a noticeable mass that had increased in size during the previous month. Chest radiography showed a solitary, predominantly osteolytic sternal lesion (white arrows) with an associated soft-tissue mass (black arrow). Computed tomography (CT) confirmed a manubrial lesion invading the anterior mediastinum without any other apparent site of disease. Cytological examination of a fine-needle-aspiration smear was not diagnostic. Surgical biopsy of the sternal mass gave equivocal results: the morphology and location suggested eosinophilic granuloma of bone (histiocytosis X), whereas immunohistochemistry suggested Hodgkin disease. Subsequent removal of a single small (1Æ5 cm diameter) left supraclavicular lymph node demonstrated nodular sclerosing Hodgkin disease. The patient was treated with combined-modality therapy (ABVD protocol, six cycles of doxorubicin, bleomycin, vinblastine, dacarbazine; radiotherapy, 36 Gy). At present he remains in complete remission, with a follow-up of 32 months. Osseous involvement occurs during the course of Hodgkin disease (dorsolumbar spine, pelvis, ribs and femora in decreasing order of frequency) in 5–20% of patients and in only 1–4% of patients at presentation. Location in the sternum is rarely encountered, but it may occur at any stage of disease. Presentation with isolated sternal disease is exceptional. Diagnosis may be difficult as clinical and radiological signs are not specific and histological findings are not always easy to interpret.

A case of epigastric pain in the ED: late mechanical complication after vertical banded gastroplasty

A 50-year-old woman presented to our emergency department complaining of recurrent epigastric stabbing pain on eating of 1 month duration. She had a history of morbid obesity treated 13 years before with laparoscopic vertical banded gastroplasty (VBG). Diagnosis was made by radiology, after upper gastrointestinal series and abdominal unenhanced computed tomography. These demonstrated intragastric band migration, with outlet stenosis of narrowed stomach. Vertical banded gastroplasty is a miniinvasive approach that gives the benefits of shorter hospital stay, less postoperative pain, and quicker functional recovery. However, many complications are known and require recognition to be appropriately treated. In our case, the history and clinical presentation led to a high suspicion of intraabdominal pathology due to postoperative complication. Radiologic upper gastrointestinal investigation and computed tomography findings were then decisive to detect the intragastric band migration.

Delayed Presentation of a Huge Mediastinal Hematoma After Blunt Chest Trauma With Extrapericardial Cardiac Tamponade: A Multiphase–multidetector Spiral Computed Tomography Study

A 42-year-old man, a professional construction worker, was admitted to the emergency department after being hit by an 80-kg bar of steel. He complained of light anterior chest pain, with no signs or symptoms of respiratory distress and denied any drug intake. Peripheral oximetry was 99%, blood pressure 140/92 mm Hg, cardiac frequency 92 beats/min, and blood tests measured red blood cells 5,010,000, white blood cells 7,130, and platelets 268,000. Standard radiologic examinations of the chest, ribs, and sternum showed neither fractures nor mediastinal abnormalities. Ketorolac 30 mg was administered while keeping the patient under observation. After an interval of 3 hours, suddenly, he complained of deep pain in the sternal/parasternal region and in the back, not relieved by the administration of paracetamol and tramadol. Measured blood pressure was 100/70 mm Hg, cardiac frequency 115 beats/min, and peripheral oximetry 97%. A follow-up chest film revealed mediastinum widening, and multiphase 64-slice computed tomography (CT), executed immediately thereafter, demonstrated huge anterior mediastinal hematoma with hyperdense foci of active bleeding because of contrast media extravasation during arterial phase, causing cardiac compression and extra pericardial cardiac tamponade (Figs. 1 and 2). The patient was then transferred to the operating room, and after the preparation of femoral vessels, sternotomy was performed; massive effusion of the mediastinum and extensive diaphragmatic contusion were noticed. After opening of the pericardium, pericardial effusion and cardiac harm could be ruled out. Bilateral hemothorax was also observed with extensive pleural damage. Internal mammary arteries were undamaged while numerous intercostal arteries were bleeding; a careful and prolonged work was necessary for hemostasis. The postsurgical course was uneventful. Mediastinal hematoma in the settings of blunt chest trauma can produce potentially serious problems. Nonaortic sources include disruption of arch vessels, rupture of small mediastinal veins, dissection of blood from the retropharyngeal space, fractures of ribs/sternum, and injury to the intercostal and internal thoracic vessels.1,2 Mediastinal hematoma presents a dual threat to hemodynamic stability both as a source of blood loss and because of the compression of vascular structures, such as the heart and pulmonary arteries. Although our patient was initially in good conditions and hemodynamically stable with no radiologic abnormalities, some hours later, he developed chest pain with hypotension because of sudden growth of a large mediastinal hematoma. Multiphase multidetector CT in our case allowed prompt detection of active bleeding in the arterial phase, a specific sign of arterial injury that may require immediate surgical or interventional therapy. Furthermore, cardiac disorders can often complicate extracardiac thoracic disease; improvements in CT scanner technology have markedly shortened the scanning times and now provide cardiac images of excellent quality during routine chest CT examinations.

Invecchiamento del torace

Il torace dell’anziano senza patologia evidente e caratterizzato da reperti che occupano una sorta di “terra di nessuno” tra il normale e il patologico. L’invecchiamento comporta fisiologicamente delle modificazioni che devono essere riconosciute per non essere interpretate erroneamente come patologiche. D’altra parte, l’anziano tende ad ammalarsi di piu e sono piu frequenti le pluripatologie, per cui la diagnostica per immagini e un elemento chiave di chiarimento di quadri clinici spesso sfumati e non di rado puo consentire anticipazione della diagnosi, a tutto vantaggio della tempestivita dell’intervento terapeutico.

Renal Hodgkin's disease

A 44-year-old woman was admitted to hospital because of malaise, fever and night sweats of 3 months duration; menorrhagia occurred a week before admission. Physical examination showed only moderate splenomegaly. Blood examination showed pancytopenia, disseminated intravascular coagulation and increased lactate dehydrogenase. Liver and renal function tests were normal. A computerized tomography (CT) scan of the thorax, abdomen and pelvis showed multiple soft tissue attenuation masses in both kidneys (left; arrows). Renal lesions were initially thought to be of infectious origin: the patient was treated with broad-spectrum antibiotics but the symptoms persisted. Bone marrow biopsy and uterine curettage were diagnostic of Hodgkin’s disease of the mixed cellularity type. The patient was then treated with the ABVD (adriamycin, bleomycin, vinblastine, dacarbazine) protocol with prompt symptomatic recovery. An abdominal CT scan after three cycles of chemotherapy showed complete resolution of renal lesions (right). Renal involvement in Hodgkin’s disease is a very uncommon event, documented in < 1% of patients at diagnosis; however, such a possibility should be taken into account in the differential diagnosis of a patient with fever of unknown origin and multiple renal lesions.