Penny Shaw

Guidelines for the use of imaging in the management of myeloma

In 2001, reference to the use of imaging in the British Committee for Standards in Haematology guidelines for the diagnosis and management of myeloma was confined to the standard use of plain X‐rays in the diagnostic skeletal survey and emergency use of computed tomography (CT) and magnetic resonance (MR) imaging in the setting of cord compression. Since then, there has been a steady rise in interest in the use of various imaging techniques in the management of myeloma. The purpose of imaging in the management of myeloma includes the assessment of the extent and severity of the disease at presentation, the identification and characterisation of complications, and the assessment of response to therapy. Plain radiography, CT, and MR imaging are generally established examination techniques in myeloma whilst positron emission tomography (PET) and 99Technetium sestamibi (MIBI) imaging are promising newer scanning techniques under current evaluation. These stand‐alone imaging guidelines discuss recommendations for the use of each modality of imaging at diagnosis and in the follow up of patients with myeloma.

Surveillance for the detection of early lung cancer in patients with bronchial dysplasia

Background: The natural history of bronchial preinvasive lesions and the risk of developing lung cancer in patients with these lesions are not clear. Previous studies have treated severe dysplasia and carcinoma in situ (CIS) on the assumption that most will progress to invasive carcinoma. Aims: To define the natural history of preinvasive lesions and assess lung cancer risk in patients with these lesions. Hypothesis: Most preinvasive lesions will not progress to invasive carcinoma but patients with these lesions will be at high risk. Methods: A cohort of patients with preinvasive lesions underwent fluorescence bronchoscopy every 4–12 months and computed tomography of the chest annually. The main end point was the development of invasive carcinoma. Results: 22 patients with 53 lesions were followed up for 12–85 months. 11 cancers were diagnosed in 9 patients. Of the 36 high-grade lesions (severe dysplasia and CIS), 6 progressed to invasive cancers. 5 separate cancers developed at remote sites in patients with high-grade lesions. All cancers were N0M0 and curative treatment was given to 8 of the 9 patients. The cumulative risk of developing lung cancer in a patient with a high-grade lesion was 33% and 54% at 1 and 2 years, respectively. Of the 17 low-grade lesions, none progressed to invasive carcinoma. Conclusions: Although the risk of malignant progression of individual preinvasive lesions is relatively small, patients with high-grade lesions are at high risk of lung cancer. Surveillance facilitated early detection and treatment with curative intent in most patients.

Pleural effusions in patients with AIDS

Objective: To describe the range of pathology causing pleural effusions in HIV infected patients with acute respiratory episodes and to attempt to identify whether any associated radiological abnormalities enabled aetiological discrimination. Methods: Prospective study of chest radiographs of 58 consecutive HIV infected patients with pleural effusion and their microbiological, cytological, and histopathological diagnoses. Results: A specific diagnosis was made in all cases. Diagnoses were Kaposis sarcoma, 19 patients; parapneumonic effusion, 16 patients; tuberculosis, eight patients; Pneumocystis carinii pneumonia, six patients; lymphoma, four patients; pulmonary embolus, two patients; and heart failure, aspergillus/leishmaniasis, and Cryptococcus neoformans, one case each. Most effusions (50/58) were small. Bilateral effusions were commoner in Kaposis sarcoma (12/19) and lymphoma (3/4) than in parapneumonic effusion (3/16). Concomitant interstitial parenchymal shadowing did not aid discrimination. A combination of bilateral effusions, focal air space consolidation, intrapulmonary nodules, and/or hilar lymphadenopathy suggests Kaposis sarcoma. Unilateral effusion with focal air space consolidation suggests parapneumonic effusion if intrapulmonary nodules are absent: if miliary nodules and/or mediastinal lymphadenopathy are detected, this suggests tuberculosis. Conclusions: A wide variety of infectious and malignant conditions cause pleural effusions in HIV infected patients, the most common cause in this group was Kaposis sarcoma. The presence of additional radiological abnormalities such as focal air space consolidation, intrapulmonary nodules, and mediastinal lymphadenopathy aids aetiological discrimination.

Retinoic Acid Syndrome: Pulmonary Computed Tomography (CT) Findings

We report the pulmonary computed tomography (CT) findings in three patients with acute promyelocytic leukaemia who developed the retinoic acid syndrome following all-trans retinoic acid (ATRA) therapy. The most consistent CT findings were small, irregular peripheral nodules in the lung fields and pleural effusions. Two of the patients also showed evidence of reticular and ground glass shadowing as well as abnormal anterior mediastinal soft tissue. We report for the first time an association between ATRA and pneumothorax. We conclude that routine CT scanning may provide a sensitive means of early detection or monitoring of the syndrome and thereby may facilitate its management.

Lobar or segmental consolidation on chest radiographs of patients with HIV infection

PURPOSE To correlate chest radiographic abnormalities with diagnoses in HIV infected patients presenting with acute respiratory symptoms and lobar or segmental consolidation. MATERIALS AND METHODS Retrospective review of chest radiographs of 53 HIV infected patients with lobar or segmental consolidation, and their microbiological and cytological diagnoses. RESULTS A specific diagnosis was made in 35 patients of which 12 had Pneumocystis carinii pneumonia (including four co-infections) and 23 had bacterial pneumonias (10 of these were due to Streptococcus pneumoniae and four to Mycobacterium tuberculosis). Microbiological and cytological tests were negative in 18 patients. Non-specific radiographic features included bronchial wall thickening (79%), reticulonodular or reticular change (55%), effusions (38%) and lymphadenopathy (25%); effusions favoured a bacterial aetiology. Ten of the 12 cases with P. carinii pneumonia had upper lobe consolidation (three of these had received inhaled pentamadine). Of 13 other cases of upper lobe consolidation, eight were due to pyogenic infection and only one to M. tuberculosis alone. CONCLUSION A wide variety of causative agents may produce lobar or segmental consolidation in HIV infected individuals, and the most common cause is bacterial infection. Where there is upper lobe consolidation P. carinii pneumonia should be considered in the differential diagnosis.

Progressive symptoms and signs following institution of highly active antiretroviral therapy and subsequent antituberculosis therapy: immune reconstitution syndrome or infection?

A 36 year old man presented with weight loss, cough, fever, and exertional dyspnoea shortly after a diagnosis of HIV infection. Symptoms and initial radiological abnormalities worsened after highly active antiretroviral therapy was started. An eventual diagnosis was established but multiple problems occurred throughout the treatment period. Differentiation between immune reconstitution inflammatory syndrome and an infective cause was problematic.

High prevalence of malignancy in HIV-positive patients with mediastinal lymphadenopathy: a study in the era of antiretroviral therapy.

Mediastinal lymphadenopathy (MLN) in human immunodeficiency virus (HIV) infection has a wide spectrum of aetiologies with different prognoses and treatments. The decision to pursue a histopathological diagnosis represents a clinical challenge as patients present with non‐specific symptoms. This study aimed to determine the aetiology and predictive factors of MLN in a cohort of HIV‐infected patients in the combination antiretroviral therapy (cART) era.

Progressive neuropsychiatric problems following institution of highly active antiretroviral therapy

A 31 year old HIV infected woman developed neuropsychiatric problems soon after starting highly active antiretroviral therapy (HAART). Despite modifying and subsequently stopping HAART her condition progressively worsened. Cranial magnetic resonance imaging revealed multiple areas of abnormal signal suggestive of either a vasculitis or demyelination.

Inferior vena cava filters for HIV infected patients with pulmonary embolism and contraindications to anticoagulation

Objectives: To describe the mode of presentation, interventions, and outcome of HIV infected patients with pulmonary embolism and a contraindication to anticoagulation, who were treated with a birds nest filter. Methods: Retrospective review of case records and imaging department database at UCL Hospitals, London, UK. Results: Three patients had pulmonary embolism and contraindications to anticoagulation. Contraindications were concomitant intracerebral pathology in two patients (one also had bleeding from gastric Kaposis sarcoma and the other was cognitively impaired with HIV associated dementia complex) and alcohol induced liver disease/binge drinking in the third patient. Anticoagulation was avoided by introducing a birds nest filter into the inferior vena cava via the common femoral vein. During follow up (7, 8, and 21 months) no complications or recurrent pulmonary emboli occurred. Conclusion: The birds nest inferior vena cava filter has a role in preventing further pulmonary emboli in HIV infected patients with contraindications to anticoagulation.

A retrospective study of disease recurrence post thoracotomy for non-small cell lung cancer

Background Surgery is the treatment of choice for early stage non-small cell lung cancer (NSCLC). However, curative intent is commonly not achieved due to inaccurate clinical staging and disease recurrence. Aim We aimed to determine the incidence of futile thoracotomies (FT) in patients with NSCLC following surgery with curative intent. In addition, we wished to identify prognostic factors that predicted FT. Methods In this analytical retrospective cohort study, thoracotomy cases between October 2003 and September 2008 at a single institution were identified. Confirmed cases of primary NSCLC only were included. A thoracotomy was deemed futile if any one of the following criteria were met: pathologically confirmed N2, N3, or M1 disease, an exploratory thoracotomy, or a thoracotomy in a patient who developed recurrent disease or died within 1 year of surgery. When a PET scan was performed, the SUVmax of the primary tumour was reported by a radiologist blinded to the clinical information. Case notes and hospital systems were interrogated for evidence of recurrence and survival. Statistical analysis was performed with STATA version 10 for Windows. Results We identified 171 consecutive patients with NSCLC who underwent lung resection with curative intent. 105 (61%) were male and mean age at the time of surgery was 66 years. 134 (78%) had lobectomy, 8 bi-lobectomy, 19 pneumonectomy and 10 sub-lobar resection (segmentectomy or wedge resection). Overall 46 (27%) underwent FT. Nine patients (5.2%) had clinically unsuspected N2 disease at pathological staging. An SUVmax of the primary tumour greater than 8 was associated with an increased risk of FT (RR 2.35 (p=0.03)) (Abstract P222 Table 1). The presence of lymphovascular invasion was also associated with a increased risk of FT (RR 1.71 (p=0.04)). Those with a primary tumour greater than or equal to 3 cm in size had a RR of 1.91 (p=0.02) of FT. Conclusions Between 2003 and 2008, 27% of patients at our cardiothoracic centre for lung cancer underwent a futile thoracotomy. High SUVmax, the presence of lymphovascular invasion and tumour size ≥3 cm are predictors of FT. Future, prospective studies employing adjuvant chemotherapy in these patient groups are warranted.