Ludmila Guralnik

The additional value of PET/CT over PET in FDG imaging of oesophageal cancer

PurposeThe aim of this study was to assess the value of combined PET/CT compared with PET reviewed side-by-side with CT, in patients with oesophageal cancer, before and after surgery.MethodsForty-one FDG PET/CT studies were performed in 32 patients with oesophageal cancer, before surgery (n=18) or during follow-up after resection of the primary tumour (n=23). One hundred and fifteen sites suspicious for malignancy were evaluated. PET/CT was prospectively compared with PET reviewed side-by-side with CT, for detection, accurate localisation and characterisation of malignant sites. PET/CT performance in different anatomical regions was compared before and after surgery. The impact of fused data on patient management was retrospectively assessed.Results PET/CT had an incremental value over PET for interpretation of 25 of 115 sites (22%), changing the initial characterisation of ten sites to either malignant (n=1) or benign (n=9), and defining the precise anatomical location of 15 sites. PET/CT provided better specificity and accuracy than PET for detecting sites of oesophageal cancer (81% and 90% vs 59% and 83% respectively, p<0.01). Fusion was of special value for interpretation of cervical and abdomino-pelvic sites, for disease assessment in loco-regional lymph nodes before surgery and in regions of postoperative anatomical distortion. PET/CT had an impact on the further management of four patients (10%), by detecting nodal metastases that warranted disease upstaging (n=2) and by excluding disease in sites of benign uptake after surgery (n=2).ConclusionPET/CT improves the accuracy of FDG imaging in oesophageal cancer and provides data of diagnostic and therapeutic significance for further patient management.

Focused Helical CT Using Rectal Contrast Material Only as the Preferred Technique for the Diagnosis of Suspected Acute Appendicitis: A Prospective, Randomized, Controlled Study Comparing Three Different Techniques

PurposeFocused helical CT using rectal contrast material only has emerged recently as an accurate diagnostic tool for the evaluation of suspected acute appendicitis. This study was designed to prospectively compare the efficacy of rectal contrast CT to other commonly used contrast-enhanced and nonenhanced CT techniques for the detection of acute appendicitis.MethodsA total of 232 patients with clinically suspected appendicitis were randomly assigned to one of three focused helical CT techniques: noncontrast enhanced CT, CT using rectal contrast material only, and dual-contrast CT using both oral and intravenous material. All scans were interpreted by the on-call residents and reported immediately to the surgeon. The sensitivity, specificity, predictive values, and overall accuracy rates were compared between the protocols.ResultsOne hundred eleven patients (48 percent) had acute appendicitis. The sensitivity and specificity rates of rectal contrast CT were 93 and 95 percent, respectively, with overall accuracy of 94 percent. The sensitivity and specificity rates of dual-contrast CT were 100 and 89 percent, respectively, with overall accuracy of 94 percent. The sensitivity and specificity of noncontrast enhanced CT were 90 and 86 percent, respectively, but the overall accuracy was significantly lower (70 percent) compared with the other studies.ConclusionsRectal contrast CT is as accurate, although less sensitive, compared with dual-contrast CT and significantly superior to noncontrast-enhanced CT for the diagnosis of acute appendicitis. Rectal contrast CT may be performed rapidly, saves resources, and may avoid the diagnostic delay and potential allergic reactions associated with oral and intravenous-enhanced studies, and, therefore, may be the preferred initial technique in the diagnostic workup of suspected acute appendicitis.

Noninvasive diagnosis of solitary pulmonary lesions in cancer patients based on 2‐fluoro‐2‐deoxy‐D‐glucose avidity on positron emission tomography/computed tomography

2‐Fluoro‐2‐deoxy‐D‐glucose (FDG) imaging is highly accurate for assessing solitary pulmonary nodules (SPNs) in patients without known malignancy. In the current study, the authors evaluated FDG‐positron emission tomography/computed tomography (PET/CT) for the characterization of SPN in cancer patients.

Pulmonary Arteries Involvement in Takayasu's Arteritis: Two Cases and Literature Review

OBJECTIVES To review pulmonary arteritis (PA) complicated by pulmonary arterial hypertension (PAH) in Takayasus arteritis (TA). METHODS Two cases of PA and PAH in TA patients and similar cases published in the Medline database from 1975 to 2009 were reviewed. RESULTS Forty-six cases (females 89.1%, Asians 65%, mean age 34.6 years) were analyzed, 42.2% of which had PAH. Isolated PA was reported in 31.8%. Respiratory symptoms were presented as dyspnea (75.5%), chest pain (48.9%), hemoptysis (42.2%), and cough (17.7%). Hypertension, vascular bruits, and diminished/absent pulses were reported in 48.9% of patients. A diagnosis of PA was based on abnormal uptake on pulmonary perfusion scan and a finding of stenosis, narrowing, occlusion, and irregularity on computed tomography or magnetic resonance imaging, and/or pulmonary angiography. Patients were treated with glucocorticoids (77.5%), disease-modified antirheumatic drugs (35%), and warfarin (20%); only a few were treated with biological agents. Vascular procedures were performed in 52.5% of cases, on pulmonary arteries in 37.5% with good results. The outcome was death in 20.5% of PA patient and 33.3% in PAH patients. CONCLUSIONS TA may be complicated by life-threatening PA and PAH. Clinical signs are not specific and may be masked by involvement of the aorta and its branches. Treatment with glucocorticoids and disease-modified antirheumatic drugs has only partial effect, which may be intensified by biological agents. Invasive procedures on pulmonary arteries may be a complementary option. PA and PAH in TA patients should be recognized early and treated promptly for prevention of irreversible vascular damage.

Nitric Oxide Inhalation for Paraquat-Induced Lung Injury

BACKGROUND When ingested, concentrated paraquat can cause either rapid death from multisystem failure and cardiovascular shock or delayed death from progressive pulmonary fibrosis. Diquat ingestion does not usually cause pulmonary fibrosis, but produces early onset acute renal failure. CASE REPORT A 52-year-old male ingested approximately 50 mL of a solution containing 13% paraquat and 7% diquat (about 6650 mg of paraquat and 3500 mg of diquat), and subsequently developed adult respiratory distress syndrome and pulmonary fibrosis. Survival prediction employing the criteria of Hart et al. for paraquat plasma levels was 30%. From the probable amount of paraquat ingested, severe toxicity was expected. The clinical course was not consistent with significant diquat toxicity. Treatment included oral Fullers earth, forced diuresis, hemofiltration, N-acetylcysteine, methylprednisolone, cyclophosphamide, vitamin E, colchicine, and delayed continuous nitric oxide inhalation. The patient recovered and pulmonary function was subsequently normal. CONCLUSION It is unclear which, if any, of the above treatments contributed to recovery, but the encouraging outcome suggests a possible benefit of nitric oxide inhalation in paraquat poisoning which deserves further study.

CT diagnosis of traumatic bronchial rupture in children.

Abstract. Bronchial rupture is a rare and serious complication of blunt chest trauma in children. The diagnosis of this injury is challenging and requires a high degree of clinical suspicion. It is frequently associated with other severe injuries that may draw the focus of attention away from this potentially catastrophic but treatable injury. The radiographic findings of bronchial rupture have been reported in very few series. We report the findings in two children with bronchial rupture diagnosed by CT, in whom CT resulted in a significant change in patient management.

Left-sided perforated acute appendicitis in an adult with midgut malrotation: the role of computed tomography

We report a case of left-sided perforated acute appendicitis in the patient with midgut malrotation. Embryology, clinical findings, and radiological presentation are discussed. Highly prevalent disease presents here in the unusual location and thus in the unusual presentation. The emergency room physician and radiologist should be aware of these unique clinical presentations so that appropriate surgical intervention may be initiated promptly.

Propranolol as a treatment option in Gorham-Stout syndrome: a case report.

Gorham–Stout syndrome is a very rare syndrome characterized by progressive angiomatosis and lymphangiomas involving multiple organs. We describe herein a girl with progressive Gorham–Stout syndrome since the age of 13 years. Her disease involved the mediastinum, pericardium, vertebrae, ribs, and skull and did not respond to interferon and bisphosphonates. Propranolol administration was initiated at the age of 18 years and was associated with improvement in pulmonary function tests and involution of the mediastinal and hilar hemangiomatous lesions. The possible beneficial effect of propranolol in Gorham–Stout syndrome should be further investigated. Pediatr Pulmonol. 2014; 49:417–419.

Metabolic PET/CT guided lung lesion biopsies - impact on diagnostic accuracy and rate of sampling error

CT-guided fine-needle aspiration (FNA) of lung lesions is subject to sampling errors. The current study assessed whether information provided by 18F-FDG PET/CT will decrease the false-negative (FN) rate and thus improve the accuracy of CT-guided FNA. Methods: Data from 311 consecutive patients with lung nodules who underwent 18F-FDG PET/CT and CT-guided FNA within an interval of less than 30 d were retrospectively assessed. In-house–developed software was used to register CT images performed for the FNA procedure (CT FNA) with corresponding slices of the PET/CT study. The quality of registration was rated on a scale of 1 (excellent) to 5 (misregistration). Only cases scored 1 or 2 were further evaluated. The software provided the highest standardized uptake value (SUV) within the lesion and at the location of the tip of the aspirating needle. The distance between the tip and the area with the highest SUV within the lesion was measured. The mean distance from the tip of the needle to the focus with the highest SUV, as well as the mean difference between the maximum SUV in the whole lesion and at the needle tip, was calculated and compared for cases with true-positive (TP) and FN FNA results. Anatomic and metabolic parameters of lesions included in these 2 groups were also compared. Results: There were 267 patients (86%) with score 1 or 2 registration quality for CT FNA and PET/CT/CT images, including 179 TP (67%), 5 false-positive (FP, 2%), 49 true-negative (TN, 18%), and 34 FN (13%) FNA results. The distance between the location of the needle tip and the focus with the highest SUV in the lesion was significantly greater in the FN group (15.4 ± 14 mm) than in the TP group (5.9 ± 13.4 mm, P < 0.001). The maximum SUV at the location of the aspirating needle tip was significantly higher in the TP group, at 6.4 ± 6.4, than in the FN group, at 4 ± 4.7 (P < 0.05). Conclusion: The present results demonstrate a relationship between the degree of metabolism at the site of tissue-sampling aspiration in lung lesions and the accuracy of FNA results. Anatomy- and metabolism-based FNA guidance using information provided by both 18F-FDG PET and CT may improve the accuracy of histologic examinations, decrease the rate of FN results, and thus increase the probability of achieving a definitive diagnosis.

Accelerated pulmonary nodulosis and sterile pleural effusion in a patient with psoriatic arthropathy during methotrexate therapy: a case report.

Pulmonary nodulosis and sterile pleural exudates are well-known extra-articular manifestations in rheumatoid arthritis patients with a positive rheumatoid factor. In some patients, treatment with methotrexate has been postulated as the trigger of these complications. We report a patient with psoriatic arthropathy, negative RF, negative anticyclic citrulinated peptide antibodies but positive antibodies to cardiolipin who developed massive sterile pleural empyema and multiple cavitary pulmonary nodules during methotrexate treatment. We suggest that awareness of methotrexate-induced lung and pleural complications should be extended to other than rheumatoid arthritis diseases, not necessarily accompanied by rheumatoid factor or anticyclic citrulinated peptide antibodies.