Eric A. Jensen

Comparison of positron emission tomography, computed tomography, and endoscopic ultrasound in the initial staging of patients with esophageal cancer

IntroductionImprovement in esophageal cancer staging is needed. Positron emission tomography (PET), computed tomography (CT), and endoscopic ultrasound (EUS) in the staging of esophageal carcinoma were compared.MethodsPET, CT, and EUS were performed and interpreted prospectively in 75 patients with newly diagnosed esophageal cancer. Either tissue confirmation or fine needle aspiration (FNA) was used as the gold standard of disease. Sensitivity and specificity for tumor, nodal, and metastatic (TNM) disease for each test were determined. TNM categorizations from each test were used to assign patients to subgroups corresponding to the three treatment plans that patients could theoretically receive, and these were then compared.ResultsLocal tumor staging (T) was done correctly by CT and PET in 42% and by EUS in 71% of patients (P value > 0.14). The sensitivity and specificity for nodal involvement (N) by modality were 84% and 67% for CT, 86% and 67% for EUS, and 82% and 60% for PET (P value > 0.38). The sensitivity and specificity for distant metastasis were 81% and 82% for CT, 73% and 86% for EUS, and 81% and 91% for PET (P value > 0.25). Treatment assignment was done correctly by CT in 65%, by EUS in 75%, and by PET in 70% of patients (P value > 0.34).ConclusionsEUS had superior T staging ability over PET and CT in our study group. The tests showed similar performance in nodal staging and there was a trend toward improved distant disease staging with CT or PET over EUS. Assignment to treatment groups in relation to TNM staging tended to be better by EUS. Each test contributed unique patient staging information on an individual basis.

Diagnosis of Usual Interstitial Pneumonitis in the Absence of Honeycombing: Evaluation of Specific CT Criteria With Clinical Follow-Up in 38 Patients

OBJECTIVE We sought to evaluate specific CT criteria for the diagnosis of usual interstitial pneumonitis (UIP) in the absence of honeycombing. These criteria included peripheral reticulation and lobular distortion; some upper lobe involvement, but a lower zone predominance; a heterogeneous appearance with areas of normal lung, minimal reticulation, and substantial distortion alternating throughout the study and often on an individual image; a nonsegmental distribution; and traction bronchiectasis. MATERIALS AND METHODS We searched reports of CT studies performed between January 1, 2009, and January 1, 2012, to identify patients for whom UIP was a likely or probable diagnosis and reviewed the CT study for each case (n = 106). There were 38 patients who met all CT criteria and who also had a clinical diagnosis of idiopathic UIP (also known as idiopathic pulmonary fibrosis [IPF]) and follow-up of at least 6 months, as determined from the electronic medical record. We reviewed prior and subsequent CT examinations in this cohort. RESULTS The median age of our patients was 80 years, and the duration of clinical follow-up was 6-104 months (mean, 38 months; median, 37 months). For all patients, a pulmonary medicine physician made a working diagnosis of IPF. Fifteen patients died from pulmonary complications, and 16 of the surviving patients had clinical or functional progression of disease. There were no instances in which the initial diagnosis was revised or reversed. CONCLUSION Strict application of specific CT criteria may allow a specific diagnosis of UIP in the proper clinical setting in the absence of honeycombing.

Meal-induced dysphagia and otalgia secondary to a pyriform sinus fistula

A 30-year-old woman presented with otalgia, dysphagia, nausea, and vomiting. Dysphagia and otalgia occurred with solids and would progressively worsen during the course of a meal. She had no symptoms when fasting. An esophagogastroduodenoscopy (EGD) was obtained to investigate her dysphagia. The EGD was unremarkable, with normal-appearing esophageal mucosa. No strictures were seen. In view of her symptoms and negative EGD, a barium esophagram was obtained. The esophagram revealed a fistulous tract and cavity apparently arising from the lower cervical esophagus and displacing the esophagus to the right and posteriorly (Figure 1). The patient was given effervescent tablets, and upon distension of the cavity with air, left-sided otalgia was elicited and the filled cavity compressed the esophagus. A CT scan of the head and neck showed the fistulous tract directly connecting to the left pyriform sinus and extending adjacent to the esophagus at the level of C6–7 (Figure 2). No other abnormalities were identified. A careful review of the patient’s history was negative for acute suppurative thyroiditis or recurrent deep neck abscesses, as well as for ingestion of injurious substances. To exclude Crohn’s disease, a small bowel followthrough was obtained and was normal. A previous colonoscopy was normal. Cervical exploration revealed the fistulous tract and associated cavity, which were excised. No other abnormalities

Multiple nodules and masses: An unusual etiology

Pulmonary nodules are a common abnormality detected at chest radiography, and even more so with thoracic computed tomography. Multiple pulmonary nodules are most commonly the result of previous granulomatous infection or metastatic disease. Less commonly, multiple pulmonary nodules may be the result of lymphoproliferative disorders and other rare conditions, such as rheumatoid lung nodules and amyloidosis. Pulmonary hyalinizing granuloma (PHG) is a very rare lesion that may be associated with an immunologic or postinfectious trigger. This disorder shows dense networks of hyalinized collagen bundles concentrically arranged around small blood vessels at histopathologic examination. These sclerotic nodules are often hypocellular but are often surrounded by an inflammatory infiltrate, commonly a lymphoplasmacytic infiltrate accompanied by histiocytes, fibroblasts, and occasionally eosinophils. PHG may be detected asymptomatically but is often associated with nonspecific symptoms. The age range of patients affected by PHG is wide, but averages around 43 years. PHG may present as a solitary pulmonary nodule, but more commonly manifests as multiple, bilateral nodules, or masses, occasionally very large, that rarely cavitate or calcify, but may grow slowly over time. The imaging features are nonspecific, with hypermetabolism, or lack thereof, noted with positron emission tomography. Bronchoscopy with transbronchial biopsy or transthoracic core biopsy may occasionally establish the diagnosis of PHG, but, often, these procedures are nondiagnostic, and surgical lung biopsy is needed to establish the correct diagnosis. PHG is typically indolent in nature and generally has a good prognosis.

A rare cause of right ventricular failure

Metastatic disease may affect the thorax in a number of different ways, most commonly in the form of lung nodules, lymph node enlargement, pleural effusion, and osseous lesions. Much less commonly, extrathoracic malignancies may embolize to the lungs. Large vessel tumor emboli may be detected in thoracic imaging studies as pulmonary arterial filling defects or as “beaded”-appearing pulmonary vessels. Occasionally, tumor embolization may affect only the small pulmonary arteries and may induce fibrocellular intimal hyperplasia and produce thrombotic vascular occlusion, resulting in increased pulmonary vascular resistance and elevated pulmonary arterial pressure, potentially precipitating right ventricular failure: this condition is referred to as pulmonary tumor thrombotic microangiopathy. Patients with tumor thrombotic microangiopathy may present with worsening shortness of breath and progressive exercise intolerance, eventually manifesting features of right ventricular failure. The imaging features of tumor thrombotic microangiopathy are generally nonspecific, but thoracic computed tomography may show small nodular opacities with branching configurations resembling infectious bronchiolitis, or mosaic perfusion due to small vessel obstruction producing pulmonary perfusion derangements. Ventilation-perfusion scintigraphy will commonly show small, often nonsegmental, mismatched perfusion defects, and positron emission tomography may show hypermetabolism. The diagnosis of tumor thrombotic microangiopathy may be suspected in patients with known extrathoracic malignancy with persistent, progressive imaging abnormalities and unexplained dyspnea or hypoxemia, particularly when features of pulmonary hypertension are evident, although the diagnosis is rarely established before death.

An Unusual Disorder Involving the Central Nervous System and the Thorax

The fact that the thorax is occasionally involved in disorders primarily presenting in extrathoracic locations often prompts screening chest imaging studies for asymptomatic patients. A number of disorders primarily presenting outside the thorax may have subclinical thoracic involvement, including v

Multifocal recurrent lung opacities in a renal failure patient

Pulmonary vasculitides include a broad variety of disorders having in common inflammation and destruction of the blood vessels within the lung. Granulomatosis with polyangiitis (GPA), formerly known as Wegener granulomatosis, is an antineutrophil cytoplasmic antibody (ANCA)-associated small-vessel vasculitis that affects a number of organ systems, and is the most common of the ANCA-associated vasculitides. GPA affects a broad age range, most commonly presenting in middle-aged adults. The classic triad of GPA, the combination of upper-airway disease (sinusitis, otitis media, ulcerations, tracheobronchial stenoses), lower-respiratory tract disease, and glomerulonephritis, is not always evident at presentation. Imaging manifestations of GPA commonly include multiple, bilateral nodules or masses that often show cavitation or necrosis. Less commonly, diffuse lung opacity resulting from alveolar hemorrhage, or tracheobronchial stenoses, may be seen. The diagnosis of systemic GPA can often be suggested when c-ANCA/anti-PR-3 antibodies are detected in the proper clinical context, but not infrequently, the diagnosis rests on recognition of a combination of characteristic clinical, laboratory, and imaging findings in combination with histopathologic material from a biopsy. The mainstay of treatment of GPA is corticosteroid therapy in combination with other immunosuppressive agents.

Cavitary lung disease in a heart transplant patient

Invasive fungal infections are highly aggressive and occur almost exclusively in severely immunocompromised patients, such as solid organ and hematopoietic stem cell transplant recipients, patients with profound and prolonged neutropenia, patients with diabetes mellitus (particularly with ketoacidosis), and those with other conditions. The most common invasive fungal infection in these patients is invasive aspergillosis. However, use of antifungal prophylaxis, among other considerations, leads to a relative increase in non-Aspergillus invasive fungal infections, such as mucormycosis. Mucormycosis may present in a manner that clinically and radiographically resembles invasive aspergillosis, but distinguishing these 2 infections is important because the common treatment for invasive aspergillosis—voriconazole—is not active against mucormycosis. Although the diagnosis of mucormycosis often requires microbiological identification of the organism, several computed tomographic features, including the reverse halo sign, multiple (>10) nodules, micronodules, and pleural effusion, may favor the diagnosis of mucormycosis over invasive aspergillosis. Such a distinction may prove very useful when a confirmatory tissue diagnosis is not possible. The mainstay of treatment for mucormycosis includes reversal of identifiable risk factors, surgical debridement of necrotic tissue, and appropriate antifungal therapy. In selected patients, iron chelation therapy may be of benefit.

A calcified mass within the thorax: An unusual diagnosis

Inflammatory myofibroblastic tumor (IMT) is a rare proliferative lesion also referred to as an inflammatory pseudotumor, among a number of other pseudonyms. IMTs are comprised of variable amounts of spindle cells, collagen, and inflammatory cells, including plasma cells, foamy histiocytes, and lymphocytes. IMTs may affect different organ systems, but the thorax is the most commonly affected, particularly the lung or the airways, and less commonly the mediastinum. IMTs exhibit a variable biological behavior, ranging from spontaneous involution to locally aggressive behavior, including recurrence after resection, regional extension, and even distant metastatic deposits. Genetic assessment has revealed neoplastic features in some IMTs, but not others, rendering the IMT classification ambiguous. Pulmonary IMTs affect patients over a wide age range, but are most frequently encountered in children, adolescents, or young adults. IMTs are occasionally discovered asymptomatically, but may present fever, dyspnea, chest pain, or hemoptysis. Thoracic IMTs primarily present on imaging as a solitary pulmonary nodule or mass, which may show calcification: an appearance suggestive of IMT when a nodule or a mass is encountered in a young patient. The margins of thoracic IMTs range from circumscribed to lobulated or poorly defined. Intense contrast enhancement is common with IMTs, and the lesions may even be associated with aberrant systemic arterial supply, simulating pulmonary sequestration. Thoracic IMTs are usually treated with limited surgical resection, with corticosteroid therapy or radiation utilized for unresectable patients or patients with inadequate surgical margins.

A thoracic mass discovered at abdominal imaging

Solitary fibrous tumor of the pleura (SFTP) is a rare primary pleural neoplasm arising from the submesothelial mesenchymal cell layer just beneath the mesothelial lining of the pleura. SFTPs consist of spindle cells embedded within variable amounts of connective tissue, typically staining positive for vimentin and antibodies to CD34. SFTPs are often attached to pleural surfaces through a pedicle. Histopathologic criteria for malignancy include high mitotic counts (>4 mitoses per 10 high-power fields), pleomorphism, hypercellularity, tumor giant cells, necrosis, and hemorrhage. Chest radiography in patients with SFTP shows a peripheral mass displaying characteristics suggesting an extraparenchymal location: obtuse angles with the chest wall associated with a circumscribed border on one side of the lesion with an indistinct, “fading” margin on the opposite side of the lesion. Cross-sectional imaging findings of SFTP include a variably sized mass contacting the chest wall or the diaphragm, showing enhancement after intravenous contrast administration. Calcification and effusion are uncommon. Magnetic resonance imaging may show decreased T1 and T2 signal, suggesting the fibrous nature of SFTPs, and also typically shows intense, heterogeneous, intravenous contrast enhancement. The treatment of choice for SFTP is wide surgical resection.