Marcio M. Gomes

The radiological spectrum of pulmonary lymphoproliferative disease

Pulmonary lymphoproliferative disorders (LPD) are characterised by abnormal proliferation of indigenous cell lines or infiltration of lung parenchyma by lymphoid cells. They encompass a wide spectrum of focal or diffuse abnormalities, which may be classified as reactive or neoplastic on the basis of cellular morphology and clonality. The spectrum of reactive disorders results primarily from antigenic stimulation of bronchial mucosa-associated lymphoid tissue (MALT) and comprises three main entities: follicular bronchiolitis, lymphoid interstitial pneumonia and (more rarely) nodular lymphoid hyperplasia. Primary parenchymal neoplasms are most commonly extranodal marginal zone lymphomas of MALT origin (MALT lymphomas), followed by diffuse large B-cell lymphomas (DLBCLs) and lymphomatoid granulomatosis (LYG). Secondary lymphomatous parenchymal neoplasms (both Hodgkin and non-Hodgkin lymphomas) are far more prevalent than primary neoplasms. Acquired immune deficiency syndrome (AIDS)-related lymphoma (ARL) and post-transplantation lymphoproliferative disorder (PTLD) may also primarily affect the lung parenchyma. Modern advances in treatments for AIDS and transplant medicine are associated with an increase in the incidence of LPD and have heightened the need to understand the range of imaging appearance of these diseases. The multidetector CT (MDCT) findings of LPD are heterogeneous, thereby reflecting the wide spectrum of clinical manifestations of these entities. Understanding the spectrum of LPD and the various imaging manifestations is crucial because the radiologist is often the first one to suggest the diagnosis and has a pivotal role in differentiating these diseases. The current concepts of LPD are discussed together with a demonstration of the breadth of MDCT patterns within this disease spectrum.

Fine-needle aspiration biopsy versus core-needle biopsy in diagnosing lung cancer: a systematic review

BACKGROUND Lung cancer leads cancer-related mortality in the world. The objective of the present systematic review was to compare fine-needle aspiration biopsy (fnab) with core-needle biopsy (cnb) for diagnostic characteristics and yields for diagnosing lung cancer in patients with lung lesions. METHODS The medline and embase databases (from January 1, 1990, to September 14, 2009), the Cochrane Library (to Issue 4, 2009), and selected guideline Web sites were searched for relevant articles. RESULTS For overall diagnostic characteristics (benign vs. malignant) of fnab and cnb, the ranges of sensitivity were 81.3%-90.8% and 85.7-97.4% respectively; of specificity, 75.4%-100.0% and 88.6%-100.0%; and of accuracy, 79.7%-91.8% and 89.0%-96.9%. For specific diagnostic characteristics of fnab and cnb (identifying the histologic subtype of malignancies or the specific benign diagnoses), the ranges of sensitivity were 56.3%-86.5% and 56.5-88.7% respectively; of specificity, 6.7%-57.1% and 52.4%-100.0%; and of accuracy, 40.4%-81.2% and 66.7%-93.2%. Compared with fnab, cnb did not result in a higher complication rate (pneumothorax or hemoptysis). No study has yet compared the diagnostic yields of fnab and of cnb for molecular predictive-marker studies in patients with lung lesions. DISCUSSION AND CONCLUSIONS The evidence is currently insufficient to support a difference between fnab and cnb in identifying lung malignancies in patients with lung lesions. Compared with fnab, cnb might have a higher specificity to diagnose specific benign lesions. Well-designed, good-quality studies comparing fnab with cnb for diagnostic characteristics and yields in diagnosing lung cancer should be encouraged.

Manuka honey: histological effect on respiratory mucosa.

Background Chronic rhinosinusitis (CRS) is an inflammatory disease in which bacteria are commonly implicated often in the form of a biofilm. Manuka honey has been shown in vitro to be an effective treatment against two common CRS pathogens both in the planktonic and in the biofilm forms. The purpose of this study was to determine if the application of manuka honey to respiratory epithelium would result in histological evidence of epithelial injury. Methods Using a rabbit animal model, a nonrandomized controlled trial of four treatment regimes was performed with two rabbits in each group. The left nasal cavity was irrigated with a 1.5-mL manuka honey solution once daily and the right nasal cavity was not treated. Groups 1–3 were treated for 3, 7, and 14 consecutive days, respectively, and killed the morning after the last treatment. Group 4 was treated for 14 consecutive days followed by a 14-day washout period and then killed the following morning. The nasal respiratory mucosa was immediately harvested after death. The mucosa was examined by light microscopy for histological change in comparison with the control side. Results Cilia were not measured quantitatively but were equally present on the treated and untreated mucosa. There was no histological evidence of inflammation, epithelial injury, or significant morphological changes. Conclusion The application of a manuka honey solution to rabbit nasal respiratory mucosa over different treatment intervals did not show evidence of histological epithelial injury.

Aerogenous Metastases: A Potential Game Changer in the Diagnosis and Management of Primary Lung Adenocarcinoma

OBJECTIVE The purposes of this article are to summarize the relevant literature on aerogenous metastasis, explain the putative pathogenetic mechanism of aerogenous spread, present the characteristic imaging and pathologic features, and review the importance of aerogenous spread to staging and clinical management. CONCLUSION Cumulative evidence suggests that aerogenous spread may exist and is underrecognized. Imaging features are helpful in differentiating possible aerogenous spread of tumor from hematogenous and lymphatic metastases and from synchronous primary tumors. The putative occurrence of intrapulmonary aerogenous metastasis of lung cancer has staging, management, and prognostic implications.

Noninfectious Pulmonary Complications after Hematopoietic Stem Cell Transplantation: Practical Approach to Imaging Diagnosis

Hematopoietic stem cell transplantation (HSCT) is a widely available treatment for a variety of malignant and nonmalignant disorders. The treatment outcome is affected by the type of transplant and is limited by complications secondary to immunosuppression and treatment-related toxicity. Pulmonary complications are very common and follow a predictable timeline that reflects the immunologic status of the patient in the peritransplant period. Until recently, pulmonary complications were largely attributed to infectious causes. However, advances in diagnosis and treatment have led to a shift, and noninfectious complications have emerged as a major cause of morbidity and mortality in this population. With the increasing number of centers that perform HSCT, knowledge of posttransplant noninfectious pulmonary complications has become increasingly relevant. The basic principles of and indications for HSCT are described, and a timeline for the clinical, radiologic, and pathologic manifestations of noninfectious pulmonary complications is presented. Emphasis is given to high-resolution computed tomographic findings and the role of imaging in management of complications. A practical approach is provided to guide imaging interpretation and diagnosis of noninfectious pulmonary complications after HSCT.

Myopericytoma: A Pleural-Based Spindle Cell Neoplasm Off the Beaten Path

Myopericytoma is a recently described hemangiopericytoma-like neoplasm with myoid differentiation. These tumors are typically located in the subcutaneous and soft tissues of the extremities. The authors report a rare pleural-based pulmonary myopericytoma in a 58-year-old woman. The lesion was grossly homogeneous and well circumscribed. Microscopically, it was composed of densely packed spindle cells organized as whorls and short interlacing fascicles with a concentric perivascular distribution. Immunohistochemical reactions were positive for vimentin, smooth muscle actin (SMA), muscle-specific actin, and Bcl-2 and negative for desmin, h-caldesmon, cytokeratin, and CD34. Atypically, increased mitotic activity was noted, but no other malignant features were identified. The differential diagnoses are discussed with specific emphasis on solitary fibrous tumor of the pleura, which is the most common benign pleural-based spindle cell neoplasm and may be a diagnostic pitfall with potentially harmful consequences.

Spontaneous Pneumothorax and Lung Carcinoma: Should One Consider Synchronous Malignant Pleural Mesothelioma?

Abstract: We describe the clinical and pathologic findings of a 68-year-old smoker with previous asbestos exposure who presented with spontaneous hydropneumothorax and was diagnosed with synchronous undifferentiated lung carcinoma and incidental malignant pleural mesothelioma. The synchronous occurrence of these two neoplasms is an extremely rare event with fewer than 20 reported cases in the English literature. The accurate diagnosis of synchronous tumors can be extremely challenging and the identification of a concomitant mesothelioma in our case was not made until an extensive immunohistochemical analysis was done on the resection specimen. Spontaneous pneumothorax occurs much more commonly in patients with malignant mesothelioma than with primary lung carcinomas. Consequently, although synchronous pleural mesotheliomas and lung carcinomas are infrequent, this diagnosis should be considered when a patient with a lung mass and a history of asbestos exposure presents with spontaneous pneumothorax and pleural thickening on imaging. Identification of synchronous tumors is of critical importance for determining the patient’s stage and management and can have significant medicolegal implications should the patient seek compensation.

A Rare Case of Anaplastic Variant of Diffuse Large B-Cell Lymphoma Presenting as a Lung Primary

Primary pulmonary lymphoma is an uncommon neoplastic disorder representing approximately 0.5% to 1% of primary pulmonary malignancies. The vast majority are of low-grade, mucosa-associated lymphoid tissue type. Primary diffuse large B-cell lymphoma of the lung is rare, though cases of the centroblastic and immunoblastic variants have been described. We present herein an interesting case of an 80-year-old man who presented with both respiratory and constitutional symptoms and was found to have a 4.5 cm left hilar mass with bilateral hilar and mediastinal lymphadenopathy on imaging. Endobronchial biopsy revealed an aggressive large cell lymphoma, with scattered large, bizarre-shaped nuclei resembling Reed–Sternberg cells, positive for CD20, PAX5, CD30, and MUM-1, consistent with an anaplastic variant of diffuse large B-cell lymphoma. Imaging showed no evidence of extrathoracic disease. Standard treatment with cyclophosphamide/vincristine/prednisone and rituximab resulted in significant clinical and radiological response and the patient remains in remission 21 months later. To the best of our knowledge, this modified Ann Arbor stage II2E primary pulmonary lymphoma, is the first description in the English literature of anaplastic variant of diffuse large B-cell lymphoma presenting as a lung primary.

Factors influencing a specific pathologic diagnosis of non-small-cell lung carcinoma.

INTRODUCTION Historically, a non-small-cell lung carcinoma diagnosis, without pathologic subclassification, provided sufficient information to guide therapy. Evidence now demonstrates that pathologic subtype classification is central in selecting optimal treatment. This review aimed to identify factors associated with a specific pathologic diagnosis. METHODS All nonoperative cases of non-small-cell lung carcinoma (NSCLC) referred to the medical oncology divisions of the Ottawa Hospital Cancer Centre (2008) and Princess Margaret Hospital, Toronto (2007-2010) were identified. The charts were reviewed for demographics, diagnostic methods, and final diagnosis. Logistic regression was performed to identify variables associated with a specific diagnosis. RESULTS Of 739 patient records analyzed, 377 (51%) were men, 299 (40%) were aged over 70 years, and 510 (69%) had an Eastern Cooperative Oncology Group performance status of 0-2. Three hundred and eighty five (52%) of patients were diagnosed in a tertiary academic center. The lung primary was sampled in 503 (68%) of patients. Computed tomography-guided biopsy (n = 370, 50%) and bronchoscopy (n = 179, 24%) were the most common techniques. Four hundred and seventy seven (65%) of biopsies were cytologic specimens alone, and immunohistochemistry was performed in 337 (46%) of cases. The most common diagnoses were adenocarcinoma (n = 338, 46%), NSCLC not otherwise specified (n = 254, 34%), and squamous cell carcinoma (n = 115, 16%). Overall, 456 (62%) of patients received a specific pathologic diagnosis. Factors significantly associated with attaining a specific pathologic diagnosis were diagnosis outside an academic center (adjusted odds ratios [OR] 2.1 [95% CI, 1.41-3.14]; P = .0003), histologic laboratory samples (adjusted OR 1.58 [95% CI, 1.003-2.49]; P = .049), and immunohistochemical testing (adjusted OR 1.82 [95% CI, 1.25-2.70], P = .0021). CONCLUSIONS A significant minority of patients with NSCLC do not receive a specific pathologic diagnosis. In an era of individualized medicine, this may potentially impact optimal clinical management.

Thymic Epithelial Neoplasms: A 12-Year Canadian Regional Cancer Program Experience

BACKGROUND Thymic epithelial neoplasms are rare, with little prospective research to guide management. Surgery is the primary treatment modality for localized disease, but chemotherapy may be indicated in advanced disease. We performed a retrospective chart review of all cases over a 12-year period at our institution. PATIENTS AND METHODS With ethics approval, data collected included patient characteristics, histologic type (World Health Organization [WHO] criteria), staging (Masaoka system), paraneoplastic syndromes, treatment details, and outcomes. The primary analysis is descriptive. RESULTS Thymic epithelial neoplasms were identified in 76 patients: 46% women with a median age 60 years (range, 25-89 years), 93% with Eastern Cooperative Oncology Group performance status of 0 to 1. Myasthenia gravis was present in 21%. The distribution by WHO histologic classification was A, 15%; AB, 30%; B1, 16%; B2, 13%; B3, 17%; C, 7%; neuroendocrine thymic tumor (NETT), 1%; and unclassified, 1%. Of 64 patients who underwent operation, 53 underwent R0 resection. Eleven surgical patients received chemotherapy (induction, n = 6; adjuvant, n = 4; both, n = 1) and 27 received radiotherapy (induction, n = 2; adjuvant, n = 25). Twelve patients were not considered for surgery, and 3 patients received no therapy at all. Chemotherapy was received at some point in the disease course in 14 patients. Common first-line regimens were platinum/etoposide (n = 8), carboplatin/paclitaxel (n = 3), and CAP (cyclophosphamide, doxorubicin [Adriamycin], cisplatin [n = 2]). The first-line response rate (Response Evaluation in Solid Tumors [RECIST]) was 55%. After a median follow-up of 45 months, 59 (78%) patients remain alive. Thymoma was associated with superior overall survival compared with thymic carcinoma (P < .0001). CONCLUSION Although surgical resection is the mainstay of treatment for thymic epithelial neoplasms, it remains clear that these are chemosensitive diseases.