Leila Khorashadi

Multimodality imaging for characterization, classification, and staging of malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is the most common primary malignancy of the pleura and is associated with asbestos exposure in approximately 80% of patients. The patient prognosis is poor, with a median survival of 9-17 months after diagnosis. However, improved survival and decreased morbidity and mortality have been demonstrated when the diagnosis is made in the early stages of disease and specific treatment strategies are implemented. A staging system that focuses on the extent of primary tumor (T), lymph node involvement (N), and metastatic disease (M) has been devised by the International Mesothelioma Interest Group and emphasizes factors related to overall survival. Radiologists should recognize the manifestations of MPM across multiple imaging modalities, translate these findings into the updated staging system, and understand the effects of appropriate staging on treatment and survival. Computed tomography (CT) remains the primary imaging modality used to evaluate MPM and efficiently demonstrates the extent of primary tumor, intrathoracic lymphadenopathy, and extrathoracic spread. However, additional imaging modalities, such as magnetic resonance (MR) imaging of the thorax and positron emission tomography (PET)/CT with fluorodeoxyglucose, have emerged in recent years and are complementary to CT for disease staging and evaluation of patients with MPM. Thoracic MR imaging is particularly useful for identifying invasion of the chest wall, mediastinum, and diaphragm, and PET/CT can accurately demonstrate intrathoracic and extrathoracic lymphadenopathy and metastatic disease.

Multimodality imaging of cardiothoracic lymphoma

Lymphoma is the most common hematologic malignancy and represents approximately 5.3% of all cancers. The World Health Organization published a revised classification scheme in 2008 that groups lymphomas by cell type and molecular, cytogenetic, and phenotypic characteristics. Most lymphomas affect the thorax at some stage during the course of the disease. Affected structures within the chest may include the lungs, mediastinum, pleura, and chest wall, and lymphomas may originate from these sites as primary malignancies or secondarily involve these structures after arising from other intrathoracic or extrathoracic sources. Pulmonary lymphomas are classified into one of four types: primary pulmonary lymphoma, secondary pulmonary lymphoma, acquired immunodeficiency syndrome-related lymphoma, and post-transplantation lymphoproliferative disorders. Although pulmonary lymphomas may produce a myriad of diverse findings within the lungs, specific individual features or combinations of features can be used, in combination with secondary manifestations of the disease such as involvement of the mediastinum, pleura, and chest wall, to narrow the differential diagnosis. While findings of thoracic lymphoma may be evident on chest radiography, computed tomography has traditionally been the imaging modality used to evaluate the disease and effectively demonstrates the extent of intrathoracic involvement and the presence and extent of extrathoracic spread. However, additional modalities such as magnetic resonance imaging of the thorax and (18)F-FDG PET/CT have emerged in recent years and are complementary to CT in the evaluation of patients with lymphoma. Thoracic MRI is useful in assessing vascular, cardiac, and chest wall involvement, and PET/CT is more accurate in the overall staging of lymphoma than CT and can be used to evaluate treatment response.

Imaging of Thoracic Neurogenic Tumors

OBJECTIVE Thoracic neurogenic neoplasms may be a diagnostic challenge both clinically and radiologically, ranging from benign, incidentally discovered tumors to aggressive, symptomatic malignancies. These tumors may originate from any nervous structure within the chest and are derived from cells of the nerve sheath, autonomic ganglia, or paraganglia. The nervous anatomy of the thorax is complex, and neurogenic tumors may be found in any mediastinal compartment or in the chest wall. Furthermore, neurogenic tumors may indicate one of many syndromes, particularly when they are multiple. CONCLUSION This article illustrates the complex anatomy of the nervous system within the chest and details important epidemiologic and pathophysiologic features as an approach to neurogenic tumors of the thorax. Key imaging features of neurogenic tumors occurring in the chest are identified, focusing on distinguishing characteristics and the relative advantages of available imaging modalities to further refine a differential diagnosis.

Tightrope walking: A new technique in ankle syndesmosis fixation

Over the past few years, several studies have demonstrated favorable clinical outcomes and low complication rates using the ankle Tightrope® syndesmosis fixation system. The traditional surgical procedure of screw fixation for syndesmosis injury is associated with high complication rates of loosening, screw fracture, nonanatomic fixation, and postoperative syndesmotic diastasis. It is expected that the Tightrope® technique will become more common practice given the recent successful reports, so it is important for radiologists to be aware of this novel surgical technique and its imaging appearance.

Idiopathic pulmonary haemosiderosis: spectrum of thoracic imaging findings in the adult patient.

Idiopathic pulmonary haemosiderosis (IPH) is a rare disease characterized by alveolar capillary haemorrhage resulting in deposition and accumulation of haemosiderin in the lungs. Although its precise pathophysiology remains unclear, several hypotheses have been proposed to explain the aetiology of the disorder, including autoimmune, environmental, allergic, and genetic theories. IPH is typically diagnosed in childhood, usually before the age of 10 years; however, this entity may be encountered in older patients given the greater awareness of the diagnosis, availability and utilization of advanced imaging techniques, and improved treatment and survival. The classic presentation of IPH consists of the triad of haemoptysis, iron-deficiency anaemia, and pulmonary opacities on chest radiography. The diagnosis is usually confirmed via bronchoscopy with bronchoalveolar lavage (BAL), at which time haemosiderin-laden macrophages referred to as siderophages, considered pathognomonic for IPH, may be identified. However, lung biopsy may ultimately be necessary to exclude other disease processes. For children with IPH, the disease course is severe and the prognosis is poor. However, adults generally have a longer disease course with milder symptoms and the prognosis is more favourable. Specific imaging features, although non-specific in isolation, may be identified on thoracic imaging studies, principally chest radiography and CT, depending on the phase of disease (acute or chronic). Recognition of these findings is important to guide appropriate clinical management.

Postpartum symphysis pubis diastasis

The pubic symphysis is a midline, nonsynovial joint that connects the right and left superior pubic rami. The interposed fibrocartilaginous disk is reinforced by a series of ligaments that attach to it. The joint allows very limited movement of approximately 0.5-1mm. Under hormonal stimulation during pregnancy, there is widening of the symphysis pubis and the sacroiliac joints. Diastasis wider than 15 mm is considered subdislocation and is generally associated with pain, swelling, and occasionally deformity. Most cases can be treated conservatively. However, internal or external surgical stabilization may occasionally be required.

Case records of the Massachusetts General Hospital. Case 32-2012. A 35-year-old man with respiratory and renal failure.

Dr. Omar H. Maarouf (Nephrology): A 35-year-old man was admitted to this hospital because of dyspnea, anemia, and renal failure. The patient had been well until several weeks before admission, when fatigue developed. Two days before admission, dyspnea developed and worsened, without fever, cough, or chest pain. Early on the day of admission, he went to an urgent care clinic affiliated with this hospital. On examination, the patient was in respiratory distress; the temperature was 37.1°C, the blood pressure 152/79 mm Hg, the pulse 102 beats per minute, the respiratory rate 36 breaths per minute, and the oxygen saturation 91% while he was breathing ambient air. The conjunctivae were pale. Auscultation of the chest revealed no rales or wheezing. Oxygen (15 liters per minute) was administered by face mask; the oxygen saturation initially rose to 95%, fell to 81% with oxygen (6 liters per minute), and rose to 100% with oxygen (15 liters per minute). He was transferred by ambulance to the emergency department at this hospital, arriving 50 minutes after his initial presentation. The patient reported fatigue, shortness of breath, and, during the previous 2 days, decreased urination. He did not have cough, chest pain, a change in symptoms with position, hemoptysis, fevers, chills, night sweats, headaches, visual loss, dry eyes, dry mouth, or joint pain. His wife reported that during the previous 6 months, the patient had had episodes of bilateral finger, ankle, and facial swelling, without pain or change in color. Four years before admission, he had been evaluated because of back and suprapubic pain, fatigue, and a temperature of 38.6°C. Urinalysis showed hematuria and proteinuria; other laboratory-test results are shown in Table 1. Culture of the urine grew 1000 to 10,000 colonies of mixed flora; testing for Chlamydia trachomatis and Neisseria gonorrhoeae was negative. Ceftriaxone was prescribed, and the patient was advised to follow up with his primary care provider, but he did not. Six years before admission, testing for rapid plasma reagin was positive at a titer of 1:8; testing for antibodies to Treponema pallidum and the human immunodeficiency virus (HIV) was negative, as was a Mantoux tuberculin skin test. The patient took no medications or herbal supplements, and he had no allergies. He was born in Central America, had immigrated to the United States 6 years before admission, was married with no children, and was physically active in his job. He had no history of recent travel, exposure to sick persons, blood transfusions, or previous surgery. He did not smoke, drink alcohol, or use illicit drugs.

Case 32-2012

Dr. Omar H. Maarouf (Nephrology): A 35-year-old man was admitted to this hospital because of dyspnea, anemia, and renal failure. The patient had been well until several weeks before admission, when fatigue developed. Two days before admission, dyspnea developed and worsened, without fever, cough, or chest pain. Early on the day of admission, he went to an urgent care clinic affiliated with this hospital. On examination, the patient was in respiratory distress; the temperature was 37.1°C, the blood pressure 152/79 mm Hg, the pulse 102 beats per minute, the respiratory rate 36 breaths per minute, and the oxygen saturation 91% while he was breathing ambient air. The conjunctivae were pale. Auscultation of the chest revealed no rales or wheezing. Oxygen (15 liters per minute) was administered by face mask; the oxygen saturation initially rose to 95%, fell to 81% with oxygen (6 liters per minute), and rose to 100% with oxygen (15 liters per minute). He was transferred by ambulance to the emergency department at this hospital, arriving 50 minutes after his initial presentation. The patient reported fatigue, shortness of breath, and, during the previous 2 days, decreased urination. He did not have cough, chest pain, a change in symptoms with position, hemoptysis, fevers, chills, night sweats, headaches, visual loss, dry eyes, dry mouth, or joint pain. His wife reported that during the previous 6 months, the patient had had episodes of bilateral finger, ankle, and facial swelling, without pain or change in color. Four years before admission, he had been evaluated because of back and suprapubic pain, fatigue, and a temperature of 38.6°C. Urinalysis showed hematuria and proteinuria; other laboratory-test results are shown in Table 1. Culture of the urine grew 1000 to 10,000 colonies of mixed flora; testing for Chlamydia trachomatis and Neisseria gonorrhoeae was negative. Ceftriaxone was prescribed, and the patient was advised to follow up with his primary care provider, but he did not. Six years before admission, testing for rapid plasma reagin was positive at a titer of 1:8; testing for antibodies to Treponema pallidum and the human immunodeficiency virus (HIV) was negative, as was a Mantoux tuberculin skin test. The patient took no medications or herbal supplements, and he had no allergies. He was born in Central America, had immigrated to the United States 6 years before admission, was married with no children, and was physically active in his job. He had no history of recent travel, exposure to sick persons, blood transfusions, or previous surgery. He did not smoke, drink alcohol, or use illicit drugs.

New and Improved Orthopedic Hardware for the 21st Century: Part 1, Upper Extremity

OBJECTIVE The purpose of this article is to provide a survey of new orthopedic products for use in the upper extremity. CONCLUSION Knowledge of the physiologic purpose, orthopedic trends, imaging findings, and complications is important in assessing new orthopedic devices.

Common Blind Spots on Chest CT: Where Are They All Hiding? Part 2, Extrapulmonary Structures

W671 axial images (Fig. 1). For example, findings such as dilated bowel loops suggestive of bowel obstruction or important skeletal abnormalities within the lower cervical or upper lumbar spine that warrant further investigation may not be seen on the axial images. The interpreting radiologist is responsible for all images in the study, including the scout view. The initial impression formed on the basis of the scout image, correlated immediately with the corresponding CT findings, can also help improve the radiologist’s ability to interpret chest radiograph.