G. Ferretti

Early detection of lung cancer: role of biomarkers

Early detection of lung cancer requires none or few invasive techniques. Distal lung cancer (40% of the cases in most European countries) can be sensitively detected by spiral computed tomography. Theoretically, in 60% of cases, the proximal lesions (main to segmental bronchi, accessible by bronchoscopy) should be able to be detected by sputum cytology. Unfortunately, this very specific technique has a low sensitivity and is time consuming. Fluorescent bronchoscopy increases the detection rate of early or micro-invasive lesions and may be proposed in highly selected populations, but not as a screening test. Biomarkers in blood and sputum have not yet been clinically validated. However, the amount of data generated from studies first on resected tumours, then on early bronchial lesions and more recently on blood and sputum offer a wide field for investigation. Lung carcinogenesis is a multistep process characterised by the accumulation of successive molecular genetic and epigenetic abnormalities, resulting in selection of clonal cells with uncontrolled growth capacities throughout the whole respiratory tract (field cancerisation). Molecular lesions far precede morphological transformation of preneoplastic bronchial lesions (dysplasia) or alveolar lesions (atypical alveolar hyperplasia). Genetic and epigenetic abnormalities in the genes involved in cell cycle, senescence, apoptosis, repair, differentiation and cell migration control may be detected on bronchial biopsies, on respiratory cells from the sputum and even in the circulating deoxyribonucleic acid (DNA). The key genes involved include those in the P53- retinoblastoma (Rb) pathways. The balance between cyclin-dependent kinases and their inhibitors regulates the level of Rb phosphorylation and its function at G1-S transition; P53 plays at least two functions (cell cycle and apoptosis control). The balance of bax-bcl2 is important in the control of apoptosis as well as loss of fragile histidine triad expression. O(6)-methylguanine-DNA methyltransferase seems to be important in DNA repair control, the RARβ receptor in differentiation, and cadherin H and E and different metalloproteases genes in cell migration. The demonstration of hyperexpression or silencing of these genes needs different validated techniques: immunohistochemistry on biopsies or cytological preparations, molecular biology techniques for mutations, loss of heterozygosity and aberrant methylation abnormalities. Automation and miniaturisation of these techniques will allow early detection and may be widely applied once clinically validated.

Central airway stenoses: preliminary results of spiral-CT-generated virtual bronchoscopy simulations in 29 patients

Abstract. The purpose of this study was to determine the feasibility of using virtual bronchoscopy simulations to depict stenoses of the tracheobronchial tree. Virtual bronchoscopy simulations, based on ray casting, were applied to spiral-CT data sets of 29 patients presenting 41 stenoses of the central airways, proved with fiberoptic bronchoscopy. Simulations of the inner walls of the airways were of good quality in 27 of 29 patients. Airway stenoses were depicted in 39 of 41 cases. Evaluation of the length of stenoses and surrounding tissues required simultaneous display of multiplanar reformations. Virtual bronchoscopy provides a valuable road map for bronchoscopy, in an image format familiar to bronchoscopists.

Endovascular treatment of superior vena cava obstruction in patients with malignancies

Abstract. The aim of this study was to report our experience on the management of superior vena cava obstruction (SVCO) secondary to malignant disease, using endovascular procedures. Twenty-six patients with SVCO due to primary or secondary tumors of the lung or the mediastinum, or catheter inserted for treatment of an extra-thoracic neoplasm, had an endovascular therapy which consisted of stenting, angioplasty, thrombo-aspiration or local fibrinolysis. Immediately after the procedure, rapid relief of symptoms occurred in 24 (90 %) of the patients. The mean Kishis score decreased from 5.5 to 0.96. Immediate complications included one death related to pericarditis bleeding following fibrinolysis. Three patients relapsed after 20 days, 4 months and 6 months, and needed a second stenting. At 6 months the primary patency rate was 83 % and the secondary patency rate was 89 %. Endovascular treatment of SVCOs is a simple and safe procedure to restore the patency of the superior vena cava in malignant SVCO. It should be indicated in most cases as first-line treatment and performed as early as possible.

Virtual tools for imaging of the thorax

Helical computed tomography (HCT) allows for volume acquisition of the entire thorax during a single apnoea. Combination of HCT acquisition with synchronous vascular enhancement gives rise to HCT angiography (HCTA). In the last decade, HCT and HCTA have revolutionized the diagnosis of thoracic diseases, modifying many diagnostic algorithms. Because HCT provides for a true volume acquisition free of respiratory misregistration, three-dimensional (3D) rendering techniques can be applied to HCT acquisitions. As these 3D rendering techniques present the HCT information in a different format to the conventional transaxial CT slices, they can be summarized as virtual tools. The purpose of this review is to give the readers the most important technical aspects of virtual tools, to report their application to the thorax, to answer clinical and scientific questions, and to stress their importance for patient management, clinical decision making, and research.

CT characteristics of resolving ground-glass opacities in a lung cancer screening programme

PURPOSE This study aimed at evaluating the computed tomography (CT) characteristics of resolving localized ground-glass opacities (GGOs) in a screening programme for lung cancer. MATERIAL AND METHODS 280 patients at high-risk for lung cancer (221 men, 59 women; mean age, 58.6 years), divided into four groups (lung cancer history (n = 83), head and neck cancer history (n = 63), symptomatic (n = 88) and asymptomatic (n = 46) cigarette smokers), were included in a prospective trial with annual low-dose CT for lung cancer screening. We retrospectively reviewed all localized GGOs, analyzed the CT characteristics on initial CT scans and changes during follow-up (median 29.1 months). Variables associated with resolution of GGOs were tested using chi-square or Mann-Whitney tests. RESULTS A total of 75 GGOs were detected in 37 patients; 54.7% were present at baseline and 45.3% appeared on annual CT. During follow-up, 56.2% persisted and 43.8% disappeared. The resolving localized GGOs were significantly more often lobular GGOs (p = 0.006), polygonal in shape (p = 0.02), mixed (p = 0.003) and larger (p < 0.0001) than non-resolving localized GGOs. CONCLUSION Localized GGOs are frequent and many disappeared on follow-up. CT characteristics of resolving GGOs show significant differences compared to persistent ones. This study emphasizes the importance of short-term CT follow-up in subjects with localized GGOs.

Adequacy of CT-guided biopsies with histomolecular subtyping of pulmonary adenocarcinomas: influence of ATS/ERS/IASLC guidelines.

INTRODUCTION As metastatic pulmonary adenocarcinomas are routinely investigated for EGFR, KRAS, and ALK mutations/rearrangement, adequacy of CT-guided trans-thoracic needle biopsies (TTNB) needs to be evaluated in respect with the 2011 ATS/ERS/IASLC guidelines. METHODS Two series of consecutive TTNB with 18-gauge needles performed before and after the publication of the ATS/ERS/IASLC guidelines, were retrospectively compared regarding their adequacy for histological sub-typing and EGFR/KRAS mutations and ALK rearrangement testing; the first series included 43 TTNB collected from January 2010 to February 2011, and the second one 48 TTNB collected from March 2011 to December 2012. RESULTS 28 women and 63 men were included; the 2 groups were comparable in age, in mean size of lesions (32.5 mm), and distance of the lesion from the pleura. By comparing the first to the second series, the number of biopsies increased from 1.6 to 1.85, their mean length increased from 10.9 to 12.5mm, and the mean number of stainings (TTF1, P63, CK5-6, mucins) per biopsy decreased from 2.6 to 1. Mean tumor cell percentage was 42%, mean total DNA extracted increased from 2.7 to 3.8 μg. In the first series, 85% of TTNB allowed EGFR exons 19 and 21 and KRAS mutations pyrosequencing and 72% additional EGFR exons 18 and 20 mutation analyses, versus 98% and 92% in the second. CONCLUSIONS With respect to ATS/ERS/IASLC guidelines, radiologists, biologists and pathologists have improved their practice; accordingly, CT-guided TTNB enable a precise histological sub-typing and provide sufficient DNA amount for genetic analyses.

Unusual cystic presentation of pulmonary nodular amyloidosis associated with MALT-type lymphoma

The case reported herein consists of nodular pulmonary amyloidosis presenting with unusual cystic radiological features which reveal a pulmonary localisation of an extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma). The present case is the first to report a radiological presentation of nodular pulmonary amyloidosis in the absence of Sjögrens syndrome. Although transthoracic fine-needle biopsy was helpful for the diagnostic of amyloidosis, final diagnosis of associated MALT-type lymphoma required an open lung biopsy. This emphasises the importance of performing surgical investigations in pulmonary nodular amyloidosis in order to depict the presence of underlying lung tumours or lymphoproliferative disorders.

Haemoptysis associated with pulmonary varices: demonstration using computed tomographic angiography

A 67 yr old female with mitral stenosis presented with an acute haemoptysis caused by the rupture of pulmonary varices. Chest radiography and bronchoscopy showed nonspecific abnormalities. The diagnosis of this rare but potentially lethal complication was made using computed tomographic angiography with three-dimensional volume rendering.

Imaging of Tumors of the Trachea and Central Bronchi

Tumors of the trachea and central bronchi can be benign or malignant. Clinical presentation may be confusing, particularly in benign tumors that can be misdiagnosed as asthma or chronic bronchitis. Chest radiography has many limitations and is often considered unremarkable in patients with tumors of the central airways; therefore, multidetector CT (MDCT) has become the most useful noninvasive method for diagnosing and assessing the central airways. The purpose of this article is to provide a review of imaging of the tumors of the trachea and central bronchi. We emphasize the crucial role of MDCT and postprocessing techniques in assessing neoplasms of the central airways.

Syndrome de lemierre : apport de l'imagerie

Resume Le syndrome de Lemierre est defini par une thrombophlebite septique de la veine jugulaire interne ou d’une de ses branches associee a des emboles septique a distance dont le point de depart est une angine a germes anaerobies. Il survient chez des patients jeunes sans antecedents et, en absence de traitement precoce, peut mettre en jeu le pronostic vital. Le role de l’imagerie, et notamment du scanner cervico-thoracique avec injection de produit de contraste iode est primordial pour le diagnostic et le bilan d’extension, comme nous le montrerons dans l’etude de trois cas recents.