Roberta Polverosi

High-resolution CT of nontuberculous mycobacteria pulmonary infection in immunocompetent, non-HIV-positive patients

PurposeThe objective of this study was to demonstrate that nontuberculous mycobacteria (NTM) pulmonary infections are not so infrequent and that the diagnosis may be suggested on the basis of the high-resolution computed tomography (HRCT) pattern alone.Materials and methodsWe retrospectively reviewed HRCT scans of 29 patients (9 men, 18 women; mean age 63 years, range 38–88 years) with positive culture from bronchial wash. Mycobacterium avium complex (MAC) was present in all (with the exception of one in whom the NTM was indistinct). In six patients, MAC was associated with M. chelonae, M. kansasii, M. fortuitum or M. xenopi. In one of these patients, MAC was associated with both M. fortuitum and M. chelonae. All patients had had nonspecific symptoms of pulmonary infection for a time ranging from 6 months to 12 years. Previous tuberculous infection was present in five patients (18.5%). Eleven patients had other pulmonary diseases (40.8%), and 12 had associated systemic diseases (44.4%).ResultsHRCT findings were apical fibrotic scarring (n=8; 29.6%), consolidations (n=16; 59.2%), single/multiple nodules >1 cm (n=8, multiple; 29.6%), cavitations (n=7; 25.9%), ground glass appearance (n=3; 11.1%), reticular/reticulonodular pattern (n=6; 22.2%), bronchiectasis (n=25; 92.5%), centrilobular nodules (tree in bud) (n=24; 88.8%), air trapping (n=8; 29.6%), lymphadenopathy >1 cm, also with calcification (n=13, 3 with calcification; 48.1%) and pleural effusion (n=2; 7.4%). In 3/7 patients with nodules >1 cm and with cavitations, the “feeding bronchus sign” (a patent bronchus running into a cavitation) was present. Lesions were in the upper lobes in 23 (85.1%), middle lobe/lingula in 25 (92.5%) and lower lobes in 18 (66.6%) patients. The findings were diffuse in 13 (48.1%) cases and patchy in 17 (62.9%).ConclusionsHRCT findings are essential for the diagnosis of NTM pulmonary infection. The presence of bronchiectasis, cavitary nodules with feeding bronchus sign and tree-in-bud nodules in the middle lobe and lingula are suggestive of NTM infection, thus assisting the physician in the diagnostic workup of these patients.RiassuntoObiettivoScopo di questo lavoro è di dimostrare come l’infezione da micobatteri non tubercolari (NTM) non sia così infrequente e come sia possibile suggerirla al clinico e al microbiologo, a volte solo sulla base del pattern in tomografia computerizzata ad alta risoluzione (HRCT).Materiali e metodiSono stati rivalutati retrospettivamente gli esami HRCT di 27 pazienti (9 maschi e 18 femmine; età media 63 anni, range 38–88 anni) con diagnosi microbiologica (esame colturale del broncoaspirato) di infezione da NTM. In tutti i pazienti era presente il M. avium complex (MAC), tranne in uno in cui il NTM è rimasto indefinito; in 6 pazienti vi era associazione di MAC con M. chelone, M. kansasii, M. fortuitum o M. xenopi. In uno di questi vi era l’associazione di MAC sia con M. fortuitum che M. chelone. In tutti erano presenti sintomi aspecifici di patologia polmonare (dispnea, tosse, a volte con escreato, febbre o febbricola, calo ponderale e astenia) con durata variabile da 6 mesi a 12 anni. Pregressa infezione tubercolare era presente in 5 pazienti (18,5%), 11 pazienti (40,8%) avevano fattori di rischio rappresentati da pre-esistenti malattie polmonari e 12 (44,4%) da malattie sistemiche, anche in associazione tra loro.RisultatiI segni HRCT riscontrati sono stati esiti cicatriziali agli apici (8, 29,6%), addensamenti parenchimali (16, 59,2%), nodulo solitario/multipli con diametro >1 cm (8 multipli, 29,6%), cavitazioni dei noduli (7/8, 87,5%), vetro smerigliato (3, 11,1%), quadro reticolare/reticolo-nodulare (6, 22,2%), bronchiettasie (25, 92,5%), noduli centrolobulari (albero con gemme) (24, 88,8%), air trapping (8, 29,6%), linfonodi con diametro >1 cm ed eventuali calcificazioni (13, 3 con calcificazioni, 48,1%), versamento pleurico (2, 7,4%). In 3 dei 7 pazienti con noduli maggiori di 1 cm e con cavitazione è stato individuato il feedings bronchus sign, cioè la presenza di un bronco dilatato con pareti ispessite, a contatto con il nodulo escavato. Le lesioni interessavano i lobi superiori in 23 (85,1%), i lobo medio/lingula in 25 (92,5%) e i lobi inferiori in 18 (66,6%) pazienti. La diffusione delle lesioni è stata uniforme in 13 (48,1%) casi e a carta geografica in 17 (62,9%).ConclusioniSi può affermare che l’HRCT è metodica fondamentale nel riconoscimento e nella diagnosi di infezione polmonare da NTM. La presenza di bronchiettasie, di noduli escavati con il feedings bronchus sign e di noduli centrolobulari ad albero con gemme, con distribuzione prevalente nel lobo medio e nella lingula devono suggerire la possibilità di infezione da NMT, e orientare così il clinico verso la ricerca del germe responsabile.

Undifferentiated connective tissue disease presenting with prevalent interstitial lung disease: Case report and review of literature

Undifferentiated connective tissue diseases (UCTDs) are clinical entities characterised by signs and symptoms suggestive of a systemic autoimmune disease, which do not fulfil the diagnostic criteria for a defined connective tissue disease. Lung involvement can complicate the course and management of the disease, often determining a worse outcome. Respiratory dysfunction as the first clinical manifestation has seldom been reported.We describe a case of a female patient who developed significant respiratory dysfunction as the principal clinical sign. Video-assisted thoracoscopy was performed and a histological pattern of nonspecific interstitial pneumonia (NSIP) was found. A pathological diagnosis suggested careful follow-up with extensive immunological screening which then detected Raynauds phenomenon and positivity of antinuclear antibodies. After a multidisciplinary discussion (pneumologist, radiologist, pathologist and rheumatologist) a final diagnosis of NSIP associated with UCTD was made. The diagnosis of UCTD should be considered when NSIP is diagnosed even in cases with evident first clinical manifestations of severe respiratory dysfunction. A multidisciplinary approach in the field of interstitial lung disease with NSIP, also including rheumatologic expertise, is fundamental to achieve a prompt and correct diagnosis.

Necrotizing sarcoid granulomatosis with an uncommon manifestation: clinicopathological features and review of literature

We report a rare case of an incidental diagnosis of necrotizing sarcoid granulomatosis (NSG) in a 60-y-old non-smoking male. The patient was admitted to the hospital for sudden back pain. Chest x-ray revealed areas of parenchymal consolidation and high-resolution computed tomography demonstrated a pulmonary nodular pattern with no lymph node enlargement. All laboratory and pulmonary function tests were normal. Bronchoscopy with bronchoalveolar lavage showed no sign of infection or specific inflammation. The diagnosis of NSG was made by histopathological examination of a surgical lung biopsy and by excluding other causes of granulomatous disease. In paucisymptomatic/asymptomatic patients, as in our case, therapy is not necessary, with a good prognosis and complete recovery. NSG is a rare systemic disease similar to sarcoidosis and Wegeners granulomatosis with a benign clinical course and should always be considered for patients with nodular pulmonary lesions even with subclinical or uncommon features.

Typical and atypical pattern of pulmonary sarcoidosis at high-resolution CT: relation to clinical evolution and therapeutic procedures

AimThis study was done to evaluate the importance of high-resolution CT (HRCT) in defining pattern and extent of disease and establishing the clinical and therapeutic pathway in sarcoidosis.Materials and methodsA retrospective analysis of 56 patients with pulmonary involvement of sarcoidosis was performed. Two groups were identified: 39 patients exhibiting a typical HRCT pattern and 17 patients with an atypical pattern. Inclusion criteria were the presence of radiological documentation (HRCT) of disease, clinical and radiological follow-up of 1xa0year and the beginning of any therapy within 1xa0month from the diagnosis.ResultsAmong subjects not receiving therapy, the comparison between the two groups showed that the radiological findings remained stable in subjects with a typical pattern, while they worsened in more than 70xa0% of cases with atypical appearance. Therapy was more effective in patients with a typical pattern. Recurrences occurred in both groups, but more often in patients with a typical pattern. One patient not receiving treatment experienced clinical worsening. Re-evaluation of HRCT within 1xa0year revealed no correlation between clinical deterioration and radiological changes.ConclusionsThe findings of this study suggest that persistence of the inflammatory process rather than the radiological pattern at onset is a prognostic factor for recurrence.

Synovial sarcoma: CT imaging of a rare primary malignant tumour of the thorax

PurposeThis paper presents computed tomography (CT) features of three patients with primary synovial sarcoma of the lung (PSSL) who came to our attention and underwent surgery; reviews of the literature on this rare thoracic tumour are also presented.Materials and methodsThe patients, all men, with a mean age of 58 years, underwent clinical and radiological re-evaluation after receiving a histological diagnosis. None of the patients had multifocal disease or other concomitant neoplasms. All patients had undergone both chest X-rays and computed tomography, and two had also been studied with positron emission tomography (PET)-CT. Two patients underwent surgical removal of the tumour, whereas the third initially underwent surgery (following an incorrect diagnosis) and then thoracoscopic biopsy of the pleural lesions that subsequently arose.ResultsIn each case, chest X-rays showed changes, with the presence of pulmonary masses noted in all patients. In one patient, pleural effusion was also visible. CT scans showed parenchymal masses that were largely of a colliquative nature (in two out of three patients). Ipsilateral pleural effusion was present in two patients, associated in one with solid nodules within the pleura. Mediastinal lymphadenopathy, which was not radiologically significant, was present in only one patient. The two patients who also underwent PET-CT examination showed pathological tracer uptake confined to the lesion site without other thoracoabdominal or musculoskeletal localisations. CT-guided biopsy, performed in one patient only, was positive for mesenchymal tumour. In the two patients who underwent surgery, a definitive diagnosis of monophasic synovial sarcoma of the lung was made. The diagnosis of monophasic synovial sarcoma in the third patient was confirmed using thoracoscopic biopsyDiscussionBoth in the cases described and in those identified in the literature review, standard chest X-rays mainly showed a parenchymal mass of pleural origin with either irregular or well-defined margins. CT characteristics are more definite, with evidence of a mass with regular and sharply defined margins, occasionally polycyclic, with inhomogeneous density due to the presence of colliquative areas within the tumour.ConclusionsAlthough PSSL is a rare tumour, a pulmonary mass of inhomogeneous density, associated with pleural effusion but without lymphadenopathy, detected in an asymptomatic or poorly symptomatic patient, should lead to PSSL being considered in the differential diagnosis, provided that metastases from the more common synovial sarcomas of the musculoskeletal system have been excluded.RiassuntoObiettivoIn questo lavoro vengono descritte le caratteristiche in tomografia computerizzata (TC) del sarcoma sinoviale primitivo del polmone (PPSS) in 3 casi arrivati alla nostra osservazione e sottoposti ad intervento chirurgico, in associazione alla revisione della letteratura relativa a questo raro tumore toracico.Materiali e metodiI pazienti, maschi, con età media di 58 anni, sono stati rivalutati clinicamente e radiologicamente. Nessun paziente era portatore di neoplasie in altra sede. Tutti avevano eseguito sia la radiografia del torace sia la TC e 2 anche la tomografia a emissione di positroni (PET)-TC. Due pazienti sono stati operati con asportazione della neoplasia e 1 è stato prima operato (con diagnosi diversa da quella definitiva) e poi sottoposto a toracoscopia con biopsia delle lesioni pleuriche successivamente comparse.RisultatiLa radiografia del torace era risultata positiva, con presenza di masse polmonari in tutti i pazienti; in uno era riconoscibile anche versamento pleurico. Gli esami TC hanno messo in evidenza masse parenchimali in gran parte colliquate (2 su 3 pazienti). Versamento pleurico omolaterale era presente in 2 pazienti e in uno di questi sono stati riscontrati noduli solidi a livello della pleura. Adenopatie mediastiniche, peraltro non significative, erano presenti in un solo paziente. Nei 2 pazienti sottoposti anche a PET-TC, l’esame dimostrava patologico accumulo del tracciante solo nella sede della lesione, senza altre localizzazioni toraco-addominali o muscolo-scheletriche. La biopsia sotto guida TC eseguita in un solo paziente era risultata positiva per tumore mesenchimale. Nei 2 pazienti operati la diagnosi definitiva è stata di sarcoma sinoviale monofasico del polmone. Il terzo paziente ha avuto la conferma diagnostica di sarcoma sinoviale monofasico dalle biopsie toracoscopicheDiscussioneSia nei casi descritti che nella revisione della letteratura la radiografia standard del torace dimostra principalmente una massa parenchimale a margini sia irregolari che netti, a base pleurica. Le caratteristiche TC sono più definite: è sempre presente una massa a margini netti e contorni regolari, a volte policiclici, con densità disomogenea per presenza di aree di colliquazione all’interno.ConclusioniSebbene il PPSS sia un tumore raro, la presenza di una massa polmonare a densità disomogenea, associata spesso a versamento pleurico ma senza adenopatie, in un paziente asintomatico o paucisintomatico deve indurre a considerare anche questa neoplasia nel range delle diagnosi differenziali dei tumori polmonari, escludendo la presenza di metastasi a partenza dai più frequenti sarcomi sinoviali a carico dell’apparato muscolo-scheletrico.

Conflicting or complementary role of computed tomography (CT) and positron emission tomography (PET)/CT in the assessment of thymic cancer and thymoma: our experience and literature review

To evaluate the role of computed tomography (CT) and positron emission tomography (PET)/CT in patients with thymic cancer and thymoma at initial staging.

Indeterminate Lung Nodules in Cancer Patients: Pretest Probability of Malignancy and the Role of18F-FDG PET/CT

OBJECTIVEnThe purpose of this study was to determine likelihood of malignancy for indeterminate lung nodules identified on CT comparing two standardized models with (18)F-FDG PET/CT.nnnMATERIALS AND METHODSnFifty-nine cancer patients with indeterminate lung nodules (solid tumors; diameter, ≥5 mm) on CT had FDG PET/CT for lesion characterization. Mayo Clinic and Veterans Affairs Cooperative Study models of likelihood of malignancy were applied to solitary pulmonary nodules. High probability of malignancy was assigned a priori for multiple nodules. Low (<5%), intermediate (5-60%), and high (>60%) pretest malignancy probabilities were analyzed separately. Patients were reclassified with PET/CT. Histopathology or 2-year imaging follow-up established diagnosis. Outcome-based reclassification differences were defined as net reclassification improvement. A null hypothesis of asymptotic test was applied.nnnRESULTSnThirty-one patients had histology-proven malignancy. PET/CT was true-positive in 24 and true-negative in 25 cases. Negative predictive value was 78% and positive predictive value was 89%. On the basis of the Mayo Clinic model (n=31), 18 patients had low, 12 had intermediate, and one had high pretest likelihood; on the basis of the Veterans Affairs model (n=26), 5 patients had low, 20 had intermediate, and one had high pretest likelihood. Because of multiple lung nodules, 28 patients were classified as having high malignancy risk. PET/CT showed 32 negative and 27 positive scans. Net reclassification improvements respectively were 0.95 and 1.6 for Mayo Clinic and Veterans Affairs models (both p<0.0001). Fourteen of 31 (45.2%) and 12 of 26 (46.2%) patients with low and intermediate pretest likelihood, respectively, had positive findings on PET/CT for the Mayo Clinic and Veterans Affairs models, respectively. Of 15 patients with high pretest likelihood and negative findings on PET/CT, 13 (86.7%) did not have lung malignancy.nnnCONCLUSIONnPET/CT improves stratification of cancer patients with indeterminate pulmonary nodules. A substantial number of patients considered at low and intermediate pretest likelihood of malignancy with histology-proven lung malignancy showed abnormal PET/CT findings.

Imaging of pancreatic metastases from renal cell carcinoma

BackgroundTo describe the main imaging characteristics of pancreatic metastases from renal cell carcinoma (RCC) with particular attention to CT features, underlining possible criteria for a differential diagnosis.Methods15 patients have been included in this study. 14 patients underwent multislice CT with triphasic acquisition (unenhanced, pancreatic parenchymal and portal venous phases). In 9 cases a delayed phase (120xa0sec) was also acquired. 5 patients underwent MRI, before and after administration of gadolinium.ResultsThe mean time interval between nephrectomy and recurrence was 7.5xa0years (range 1-17xa0years). On CT metastases avidly enhanced in the parenchymal phase and then demonstrated a significant wash-out, approaching isodensity to the normal pancreatic parenchyma in the portal phase. In the portal phase 20 of the 25 lesions found in the arterial phase were recognizable. On non-enhanced scans, only 13 of the 25 lesions were detected.On MRI, with the limitations due to the paucity of cases, the metastatic foci appeared hypointense to normal pancreatic tissue on T1-weighted images, and hyperintense on T2- and diffusion-weighted images. After gadolinium, the behaviour was similar to that reported for CT, except for one patient in whom two metastatic foci presented a signal intensity almost isointense to the surrounding parenchyma, accompanied also by an unusual lowering of the signal on DWI (diffusion-weighted imaging) with high b-values. Compared to CT, with MRI the lesions appeared all detectable even on non-enhanced acquisitions.ConclusionRenal Cell Carcinomas require a prolonged CT or MRI follow-up.In patients with RCC history, an early arterial or a pancreatic parenchymal phase is always mandatory, as pancreatic metastases typically present themselves as hypervascular lesions. This behavior is similar to that of neuroendocrine tumors, while the other primary pancreatic tumors tend to be hypovascular.

Extrapleural and cardiophrenic lymph nodes: prevalence, clinical significance and diagnostic value.

PurposeThe aim of this study was to evaluate the prevalence, clinical meaning and diagnostic value of extrapleural and cardiophrenic nodes occasionally observed on computed tomography (CT) scans of the chest.Materials and methodsWe included 750 consecutive patients who underwent CT of the chest for different clinical purposes (340 nonneoplastic patients, 270 with extrathoracic neoplasms, 120 with intrathoracic neoplasms, 20 with pleural metastasis) and 91 patients with histologically proven malignant pleural mesothelioma (MPM). For each group of patients, we analysed the presence of extrapleural and cardiophrenic nodes, their number (single or multiple) and their size.ResultsThe prevalence of cardiophrenic nodes between 6 and 10xa0mm and >10xa0mm was significantly higher in patients with MPM (28.6 and 26.4xa0%, respectively) than in all other categories of patients, except for patients with pleural metastasis (30 and 25xa0%, respectively). The prevalence of extrapleural nodes, independently from their size, was significantly higher in patients with MPM (68xa0%) compared with all other groups, including patients with pleural metastasis (5xa0%; pxa0<xa00.0001).ConclusionsCardiophrenic nodes >5xa0mm and extrapleural nodes of any size have a significant diagnostic value in malignant pleural disease, either primary or secondary, whereas they are extremely rare in other neoplastic or nonneoplastic diseases.

A 40-Year-Old Man With Hemolytic Anemia, Ig Deficiency, and Bilateral Pulmonary Infiltrates

A 40-year-old, white, nonsmoking man was admitted to the hospital in the Department of Gastroenterology with hemolytic anemia and jaundice associated with dry cough of 2 months in duration and fatigue. Pneumonia of the right lower lobe and lingular segment was diagnosed 2 months prior to hospital admission, for which the patient received a course of macrolides. There was no relevant occupational or travel history. No medications were taken on a regular basis. On hospital admission, he was afebrile and acyanotic; on examination, chest auscultation was normal and abdominal evaluation showed splenomegaly then confirmed by abdominal ultrasound.