Diana Palacio

Thoracic Manifestations of Inflammatory Bowel Disease

OBJECTIVE The purpose of this article is to present the spectrum of inflammatory bowel disease manifestations in the chest, including the airways, lung parenchyma, pulmonary vasculature, and serosal surfaces. CONCLUSION The spectrum of inflammatory bowel disease manifestations in the chest is broad, and the manifestations may mimic other diseases. Knowledge of these manifestations in conjunction with pertinent clinical data is essential for establishing the correct diagnosis and treatment.

Pre–Radiation Therapy Fluorine 18 Fluorodeoxyglucose PET Helps Identify Patients with Esophageal Cancer at High Risk for Radiation Pneumonitis

PURPOSE To examine the association between pre-radiation therapy (RT) fluorine 18 fluorodeoxyglucose (FDG) uptake and post-RT symptomatic radiation pneumonitis (RP). MATERIALS AND METHODS In accordance with the retrospective study protocol approved by the institutional review board, 228 esophageal cancer patients who underwent FDG PET/CT before chemotherapy and RT were examined. RP symptoms were evaluated by using the Common Terminology Criteria for Adverse Events, version 4.0, from the consensus of five clinicians. By using the cumulative distribution of standardized uptake values (SUVs) within the lungs, those values greater than 80%-95% of the total lung voxels were determined for each patient. The effect of pre-chemotherapy and RT FDG uptake, dose, and patient or treatment characteristics on RP toxicity was studied by using logistic regression. RESULTS The study subjects were treated with three-dimensional conformal RT (n = 36), intensity-modulated RT (n = 135), or proton therapy (n = 57). Logistic regression analysis demonstrated elevated FDG uptake at pre-chemotherapy and RT was related to expression of RP symptoms. Study subjects with elevated 95% percentile of the SUV (SUV95) were more likely to develop symptomatic RP (P < .000012); each 0.1 unit increase in SUV95 was associated with a 1.36-fold increase in the odds of symptomatic RP. Receiver operating characteristic (ROC) curve analysis resulted in area under the ROC curve of 0.676 (95% confidence interval: 0.58, 0.77), sensitivity of 60%, and specificity of 71% at the 1.17 SUV95 threshold. CT imaging and dosimetric parameters were found to be poor predictors of RP symptoms. CONCLUSION The SUV95, a biomarker of pretreatment pulmonary metabolic activity, was shown to be prognostic of symptomatic RP. Elevation in this pretreatment biomarker identifies patients at high risk for posttreatment symptomatic RP.

Multidetector Computed Tomography Pulmonary Angiography Pitfalls in the Evaluation of Pulmonary Embolism With Emphasis in Technique

Pulmonary embolism (PE) is considered the third most common acute cardiovascular disease after myocardial infarction and stroke.Most preventable deaths associatedwith PE can be attributed to missed diagnosis, rather than therapy failure; thus, accurate and fast diagnosis of PE is important and greatly influences patient outcome. Computed tomography pulmonary angiography (CTPA) was first introduced as a diagnostic test for PEwith the arrival of helical CT scanners in the early 1990s. Less than a decade later, with improvements in resolution, acquisition speed, and image quality, multidetector CTPA (MDCTPA) became the most used diagnostic modality in the evaluation of PE. In 2007, the Fleischner Society declared that MDCTPA had fulfilled the conditions to replace conventional pulmonary angiography as the standard of reference for diagnosing acute PE. The recent introduction of dual-source MDCT technology adds functional assessment to the established anatomical evaluation, potentially further enhancing the capability of CTPA to determine the presence and clinical significance of pulmonary thromboembolism. The sensitivity and specificity for the diagnosis of PE since the era of single-slice helical CTPA has improved from 53%91% and 78%-97%, respectively, to 83%-100% and 89%97%, respectively, with MDCTPA. Several studies on single-slice and early-generation MDCTPA have reported “indeterminate” results ranging from 0.5%-10%, with a mean at approximately 6%. In a more recent study with 40-slice MDCT, 3.2% of 220 consecutive reports were deemed

The ‘wandering appendicolith’

Acute appendicitis is a common pediatric surgical emergency. Successful surgical appendectomy requires removal of the appendix and its contents. A retained appendicolith is a complication that occurs when the appendicolith is expulsed from the appendix as a result of perforation or failure of removal during surgery. An ectopic appendicolith can migrate to a variety of ectopic locations, acting as a nidus for abscess. Clinical presentation may be delayed by days, weeks or even months after surgery. We present and discuss an unusual case of empyema caused by migration of an appendicolith into the chest cavity. Management of these retained appendicoliths requires drainage of the abscess and extraction of the appendicolith.

Posttraumatic ventricular pseudoaneurysm in a 7-year-old child diagnosed with multidetector CT of the chest: a case report.

We report the CT findings on a 7-year-old male who developed a left ventricular pseudoaneurysm involving the anterior septal left ventricular wall after blunt chest trauma.

Radiologists remember mountains better than radiographs, or do they?

Abstract. Expertise with encoding material has been shown to aid long-term memory for that material. It is not clear how relevant this expertise is for image memorability (e.g., radiologists’ memory for radiographs), and how robust over time. In two studies, we tested scene memory using a standard long-term memory paradigm. One compared the performance of radiologists to naïve observers on two image sets, chest radiographs and everyday scenes, and the other radiologists’ memory with immediate as opposed to delayed recognition tests using musculoskeletal radiographs and forest scenes. Radiologists’ memory was better than novices for images of expertise but no different for everyday scenes. With the heterogeneity of image sets equated, radiologists’ expertise with radiographs afforded them better memory for the musculoskeletal radiographs than forest scenes. Enhanced memory for images of expertise disappeared over time, resulting in chance level performance for both image sets after weeks of delay. Expertise with the material is important for visual memorability but not to the same extent as idiosyncratic detail and variability of the image set. Similar memory decline with time for images of expertise as for everyday scenes further suggests that extended familiarity with an image is not a robust factor for visual memorability.

Idiopathic bronchiolitis with features of diffuse panbronchiolitis in an African-American patient with hepatitis C virus infection

Diffuse panbronchiolitis (DPB) is an idiopathic inflammatory process involving respiratory bronchioles, largely restricted to Japanese people and associated with HLA Bw54. We report a case of idiopathic bronchiolitis with DPB features in an African American with hepatitis C virus infection, correlated with postmortem anatomic findings. The 53-year-old patient presented with shortness of breath and productive cough. Examination revealed hypercapnic respiratory failure. Lung computed tomography showed diffuse centrilobular nodules and branching linear opacities, whereas lung biopsy demonstrated diffuse peribronchiolar fibrosis and chronic inflammation with bronchiolectasis. He died 37 days postadmission. Autopsy revealed numerous bronchiolocentric nodules with bronchiolectasis and sheets of foamy macrophages in alveolar septa and spaces. This is a rare example of idiopathic bronchiolitis with features of DPB in an hepatitis C virus-infected African-American patient. Hepatitis C virus infection is known to be associated with extrahepatic pulmonary manifestations, and DPB may be one of these. Early diagnosis will allow appropriate treatment and may slow the disease progression.

Low-grade (often multifocal) osteomyelitis (a diagnostic problem and/or a mimicker of tumor).

Low-grade osteomyelitis often is difficult to diagnose with certainty [1–3]. Furthermore it has a propensity to mimic malignant bone tumors, especially Ewing’s sarcoma. Often there is very little associated soft tissue swelling and the history and clinical presentation are those of an indolent problem. In other cases the problem is multifocal, but not always synchronous. The lesions may occur months or even years apart [1–3]. In many cases it is difficult to isolate a pathogen, but often the offending organism is Staphylococcus aureus [1–3]. However, other, more or less, opportunistic organisms also can be the cause [4], and some cases are associated with chronic inflammatory intestinal problems such as Crohn’s disease and ulcerative colitis [5–7]. Because the disease process is very indolent the pattern of bony destruction is not one of permeative, rampant bone destruction. In addition multilayered (acute) periosteal new bone deposition usually is absent and substituted by thicker solid periosteal new bone deposition [8, 9]. Diaphyseal [10], metaphyseal–epiphyseal [11], flat bone [12], mandible [13–16], and spinal [4, 17] involvement are common. Nuclear scintigraphy, although non-specific is excellent in confirming the presence of these lesions and detecting those at multiple sites. CT and MR are useful in further delineating any given lesion, but in the end it is the plain film detection of the lesion, which steers the work-up of the patient in the right direction. Sites of involvement

Diagnosing conduit leak after esophagectomy for esophageal cancer by computed tomography leak protocol and standard esophagram: Is old school still the best?

The imaging modalities available to evaluate anastomotic leak complicating esophagectomy include CT-Esophageal Protocol (CTEP) and esophagram. The purpose of this study was to compare the performance of these two modalities, alone or in combination, with the final diagnosis of leak established by endoscopy, surgery and/or the clinical course and evaluate management implications.

Pitfalls and Limitations in Non-Small Cell Lung Cancer Staging

Computed tomography (CT), 18 F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (FDG-PET/CT), magnetic resonance (MR) imaging, and minimally invasive procedures such as endobronchial ultrasound–guided fine-needle aspiration and mediastinoscopy have increased the accuracy of clinical staging of non–small cell lung cancer (NSCLC). Typically, CT is used to assess the anatomical extent of the disease and optimally evaluate the primary tumor, FDG-PET improves the detection of nodaland extrathoracic metastatic disease, and MR imaging can be used to evaluate tumor extension into the chest wall and brachial plexus. 1 However, although the accuracy of staging is important in determining the appropriate management of patients, the performance of different imaging studies varies. For example, CT has low sensitivity and specificity to detect nodal metastatic disease, whereas FDG-PET offers limited anatomical information. These limitations can potentially affect the accuracy of the seventh American Joint Committee on Cancer tumor-node-metastasis staging system for NSCLC. In this article, we review potential pitfalls and limitations of imaging that can affect the accuracy of initial staging in patients with NSCLC and their implications in oncologic management.