Alok Nath

CT-Guided Percutaneous Biopsy of Intrathoracic Lesions

Percutaneous CT-guided needle biopsy of mediastinal and pulmonary lesions is a minimally invasive approach for obtaining tissue for histopathological examination. Although it is a widely accepted procedure with relatively few complications, precise planning and detailed knowledge of various aspects of the biopsy procedure is mandatory to avert complications. In this pictorial review, we reviewed important anatomical approaches, technical aspects of the procedure, and its associated complications.

Tracheobronchopathia osteochondroplastica--a rare or an overlooked entity?

Tracheobronchopathia osteochondroplastica is an idiopathic non-malignant disease of large airways featured by submucosal cartilaginous to osseous nodules overlying the cartilaginous rings, which may be focal or diffuse. Clinical presentation varies from asymptomatic to symptoms like breathlessness, recurrent chest infections, cough and hemoptysis. Due to the lack of awareness of this disease, it remains an under recognized entity. We are describing the computed tomography and bronchoscopic findings of two recently diagnosed cases at our institute. The purpose of this report is to familiarize radiologists with imaging appearance of this condition, with the goal of increasing clinical suspicion of this uncommon condition.

Bronchial Artery Aneurysm due to Pulmonary Tuberculosis: Detection with Multidetector Computed Tomographic Angiography

A case of bronchial artery aneurysm due to pulmonary tuberculosis is reported. The patient presented with massive hemoptysis and the diagnosis was made using multidetector computed tomographic (MDCT) angiography. Selective bronchial arteriogram confirmed the MDCT findings and bronchial artery embolization was successfully performed with cessation of hemoptysis. Our article emphasizes the value of MDCT angiography in the diagnosis and management of such cases.

Lemierre's Syndrome presenting with neurological and pulmonary symptoms: Case report and review of the literature.

Lemierre’s Syndrome (LS) is a potentially life-threatening condition, characterized by clinical or radiologic evidence of internal jugular vein thrombosis following an oropharyngeal infection, most commonly by Fusobacterium necrophorum. A high index of suspicion and early recognition is important for successful management and to prevent systemic complications like multiorgan failure with extremely high morbidity, prolonged hospitalization and, not uncommonly, death. We are reporting a rare case of LS that was complicated with internal jugular vein and cavernous sinus thrombosis along with lung metastatic lesions, which was diagnosed and treated at our institute.

Primary papillary adenocarcinoma of the lung: Report of two cases

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An Unusual Complication During Bronchoscopy: Hypotension, Global ST Segment Elevation, and Acute Severe Left Ventricular Systolic Dysfunction

Bronchoscopy is widely performed and generally considered safe. Cardiac complications during bronchoscopy are uncommon, and usually occur in elderly patients with coexistent coronary artery disease, hypertension, or severely impaired pulmonary function and resting hypoxemia. We report a patient who developed sudden onset restlessness, chest discomfort, hypotension, global ST elevation in multiple electrocardiogram leads, and acute severe left ventricular systolic dysfunction during a bronchoscopic transbronchial lymph node biopsy. Differential diagnosis included a massive myocardial infarction, apical ballooning (Tako-tsubo syndrome), or coronary vasospasm. The electrocardiogram changes resolved spontaneously, and a coronary angiogram 48 hours later revealed normal coronary artery anatomy and normal LV function. The patient made an uneventful recovery. It is important for physicians to be aware of such unusual complications to be able to appropriately manage these patients in clinical practice.

Male Breast Cancer Presenting with Bilateral Pleural Effusion

Dear Editor, Bilateral pleural effusion is a common clinical entity, but has never been reported as presentation of male breast cancer. The article reports about a 72-year-old Asian Indian male, who presented with breathlessness and anasarca since 1 year, progressively increasing since 1 month. The patient was breathless at rest and had a room air saturation of 86%. Personal history comprised of weekly intake of 5-6 pegs of whisky (approximately 100-120 g equivalent ethanol) since the past 30 years. The patient never smoked and had no history of illicit drug abuse, but had Type II diabetes mellitus and hypertension for past 5 years. General physical examination revealed icterus, bilateral pitting pedal edema, and a single left axillary lymph node, which was 2 cm in size, hard, mobile, and nontender on palpation. Respiratory system examination revealed enlarged breasts bilaterally on inspection and diminished air entry in the infra-scapular and infra-axillary regions on both sides. Palpation revealed a 3 × 2 cm nontender lump deep to the left nipple, not fixed to the chest wall. Abdominal examination revealed firm, irregular, nontender hepatomegaly (liver span 16 cm) and ascites. Hemogram and clinical chemistry were normal, except Hb (9 g/dl), s. bilirubin (3.1 g/dl), and albumin (2.2 g/dl) levels. Chest X-ray showed bilateral pleural effusion [Figure 1]. Ultrasonography (USG) whole abdomen revealed ascites and hepatomegaly with coarse echotexture. We did a therapeutic pleural fluid aspiration (800 ml from left and 1 lit from the right). Pleural effusion was exudative lymphocyte predominant with normal sugar and adenosine deaminase (ADA) levels on both sides. Left sided pleural fluid cytology was positive for adenocarcinoma cells. CECT thorax showed bilateral pleural effusion and fracture of rib. [Figure 2]. USG-guided fine needle aspiration cytology (FNAC) of left axillary lymph node was positive for metastatic ductal carcinoma. Core biopsy from the left breast lump revealed invasive ductal carcinoma [Figure 3]. A nodule of soft tissue density was seen in left breast [Figure 4]. Bone scan did not show any abnormal uptake. The patient was diagnosed as a case of metastatic invasive ductal carcinoma of left breast (cT2N1M1), and referred to Oncology department for further management. In view of poor general condition (ECOG 3), he was given palliative chemotherapy with fluorouracil, adriamycin (doxorubicin) and cyclophosphamide (FAC) regimen with 20% dose reduction (5-fluorouracil 500 mg/m2 i.v. on day 1, doxorubicin 50 mg/m2 i.v. on day 1, and cyclophosphamide 500 mg/m2 i.v. on day 1; repeated every 4 weekly). The patient died due to disease progression after receiving two cycles of chemotherapy. Figure 1 Scanogram showing bilateral pleural effusion Figure 2 Contrast-enhanced computed tomography thorax showing fracture of left rib Figure 3 High power view of breast nodule biopsy showing invasive ductal carcinoma Figure 4 Contrast-enhanced computed tomography thorax showing left breast nodule Breast cancer is the most common malignancy in females, but it is rare in males. Males comprise 0.7% of all breast cancer patients.[1] The etiology of male breast cancer comprises of hormonal, familial, genetic, and racial factors. Hormonal causes are increased estrogen-testosterone ratio (Klinefelter syndrome); increased estrogen levels (cirrhosis, exogenous administration in transsexuals, and prostate cancer therapy) and decreased androgen levels (testicular diseases like mumps and undescended testis or injury due to trauma or heat and electromagnetic radiation).[2] Familial predisposition occurs by presence of BRCA-2 gene mutations or a first degree female relative with breast cancer.[3] Genetic disorders like Cowden syndrome and hereditary nonpolyposis colonic cancer predispose males to breast cancer.[4] Racial predisposition for male breast cancer is seen in Jews and North American Black males.[5] Other predisposing factors are gynecomastia, alcohol intake of more than 60 g/day and obesity.[5] Bilateral gynecomastia may hide a malignant breast lump and unilateral gynecomastia may mimic one on clinical examination. Male breast cancer manifests as a hard, painless subareolar lump eccentric to the nipple. Pain occurs in 5% cases. Nipple retraction occurs in 9%, discharge in 6%, and ulceration in 6% cases. Pagets disease is the presenting feature in 1% cases.[6] Secondary features of malignancy are nipple retraction, skin ulceration or thickening, increased breast trabeculation, and axillary lymphadenopathy.[7] Invasive ductal carcinoma is the most common type of male breast carcinoma (90%). Other types include ductal carcinoma in situ (10%), invasive papillary (2%), medulllary (2%), and mucinous carcinomas (1%).[8] Ducts lie close to dermal lymphatics, pectoral fascia, and subareolar lymphatic channels in male breast. Due to lack of sufficient connective tissue, the ducts lie in close proximity to lymphatic system and metastasis occurs earlier in male breast. Estimates suggest 42% of breast cancer cases in men are diagnosed in advanced stages (stage III or IV).[9] Tumor size and lymph node involvement are the most important prognostic factors for male breast cancer. Other factors are histological grade and hormone receptor status. Expression of Her2-neu correlates with probability of increased relapse rates and higher stage and grade of the carcinoma.[2] Local disease is treated by modified radical mastectomy with axillary lymph node dissection or sentinel node biopsy.[9] Adjuvant chemotherapy is given for node positive disease. Tamoxifen is the therapy of choice for estrogen receptor positive cancer and metastatic disease.[10] An elderly male with co-morbidities (hypertension and diabetes mellitus), history of chronic alcohol intake, and presenting with anasarca and bilateral pleural effusion is usually suspected to have decompensated chronic liver disease or congestive heart failure, as they are most common differential diagnosis. Investigations revealed it to be a male breast cancer presenting with bilateral pleural effusion and pathological rib fracture. Malignancy should be considered among the differential diagnosis of bilateral pleural effusions in elderly.

Imaging of Tuberculosis of the Abdominal Viscera: Beyond the Intestines

There is an increasing incidence of both intraand extra-thoracic manifestations of tuberculosis, in part due to the AIDS epidemic. Isolated tubercular involvement of the solid abdominal viscera is relatively unusual. Cross-sectional imaging with ultrasound, multidetector computed tomography (CT), and magnetic resonance imaging (MRI) plays an important role in the diagnosis and post treatment follow-up of tuberculosis. Specific imaging features of tuberculosis are frequently related to caseous necrosis, which is the hallmark of this disease. However, depending on the type of solid organ involvement, tubercular lesions can mimic a variety of neoplastic and nonneoplastic conditions. Often, cross-sectional imaging alone is insufficient in reaching a conclusive diagnosis, and image-guided tissue sampling is needed. In this article, we review the pathology and cross-sectional imaging features of tubercular involvement of solid abdominopelvic organs with a special emphasis on appropriate differential diagnoses.

Dilated cardiomyopathy following trastuzumab chemotherapy

The war against cancer has seen a proliferation in armamentarium over the last decades. A new antineoplastic agent, trastuzumab, was synthesized in 1991 and gained United States Food and Drug Administration approval in 1998 for treatment of metastatic breast cancer. Cardiotoxicity manifesting as dilated cardiomyopathy is a rarely reported adverse effect of trastuzumab. We hereby report a case of dilated cardiomyopathy, which occurred following trastuzumab chemotherapy in a 32–year-old female. The patient responded to discontinuation of trastuzumab and standard medical treatment. Extensive search of Indian literature revealed no reported case of dilated cardiomyopathy occurring due to trastuzumab.

Use of dedicated optical tracheal dilator for postintubation tracheal stenosis: First report from India

Postintubation tracheal stenosis is preventable yet commonly occurring clinical condition. Early in the disease, nonspecific symptoms may predominate but once the stenosis reaches a critical stage life-threatening respiratory compromise may ensue. Bronchoscopic interventions are an invaluable tool in the management both as a primary treatment and as an interim procedure before the surgery. Optical dilatational tracheoscopy is a safe and minimally invasive procedure in the treatment of benign tracheal stenosis. Involvement of multidisciplinary team early in the treatment planning gives the best possible results.