Sonia L. Betancourt

Lipoid Pneumonia: Spectrum of Clinical and Radiologic Manifestations

OBJECTIVE Lipoid pneumonia results from accumulation of lipids in the alveoli and can be either exogenous or endogenous in cause based on the source of the lipid. Exogenous lipoid pneumonia is caused by inhalation or aspiration of animal fat or vegetable or mineral oil. Endogenous lipoid pneumonia is usually associated with bronchial obstruction. The purpose of this article is to review the pathogenesis and clinical and radiologic manifestations of exogenous and endogenous lipoid pneumonia. CONCLUSION The ability to recognize the radiologic manifestations of lipoid pneumonia is important because, in the appropriate clinical setting, these findings can be diagnostic.

New era of radiotherapy: An update in radiation-induced lung disease

Over the last few decades, advances in radiotherapy (RT) technology have improved delivery of radiation therapy dramatically. Advances in treatment planning with the development of image-guided radiotherapy and in techniques such as proton therapy, allows the radiation therapist to direct high doses of radiation to the tumour. These advancements result in improved local regional control while reducing potentially damaging dosage to surrounding normal tissues. It is important for radiologists to be aware of the radiological findings from these advances in order to differentiate expected radiation-induced lung injury (RILD) from recurrence, infection, and other lung diseases. In order to understand these changes and correlate them with imaging, the radiologist should have access to the radiation therapy treatment plans.

Tumors of the Pulmonary Artery and Veins

The pulmonary vasculature may be involved by different primary and secondary tumors. Poorly differentiated and undifferentiated sarcomas are the most common primary tumors of the pulmonary arteries. They tend to affect the large caliber pulmonary vessels and present with predominantly intraluminal growth. Pulmonary and mediastinal metastasis are common, and prognosis is poor. Clinical and imaging manifestations may mimic those of pulmonary embolism. Dyspnea, chest pain, cough, and hemoptysis are the most common presenting symptoms. Primary sarcomas arising from the central pulmonary veins are less common than their arterial counterpart. Secondary involvement of the pulmonary arteries and veins by primary and metastatic pulmonary malignancies is more common. Tumoral embolism may also affect the pulmonary arteries. They may develop from different intrathoracic and extrathoracic malignancies and may be indistinguishable from venous thromboembolism. It may manifest as cor pulmonale with right cardiac strain and dilated pulmonary arteries. Computed tomography, magnetic resonance imaging, and fluorodeoxyglucose positron emission tomography may help in the differentiation between these 2 conditions.

Endoscopic Ultrasound Estimates for Tumor Depth at the Gastroesophageal Junction Are Inaccurate: Implications for the Liberal Use of Endoscopic Resection

BACKGROUND Endoscopic resection is increasingly utilized for treating early stage esophageal cancer, and endoscopic ultrasound (EUS) frequently guides treatment selection. Studies report greater than 80% sensitivity and 90% specificity, but our experience suggests less accuracy at the gastroesophageal (GE) junction. The objective of this study is to determine the accuracy of EUS for depth of GE junction cancer and the potential treatment implications. METHODS A retrospective review of a prospective database was performed for patients from 1995 to 2014 with GE junction esophageal cancer that underwent EUS staging and resection (surgical or endoscopic) without neo-adjuvant therapy. Patient, tumor, EUS, and pathologic characteristics were examined. RESULTS For the 181 patients that met criteria, the median age was 66 years, 17% were female, 91% white, and 98% had adenocarcinoma. Concordance between EUS (u) T and pathologic (p) T was 48%, with 23% under-staged and 29% over-staged. The EUS was accurate in the following: uT0 6% (1 of 18); uT1a 56% (23 of 41); uT1b 58% (41 of 71); uT2 10% (2 of 21); and uT3 70% (21 of 30). Inaccurate EUS depth had potential to lead to over-treatment in 38% (27 of 71) of uT1b and 76% (16 of 21) of uT2. In 50% of pT1a tumors, EUS depth was T1b or greater. Logistic regression revealed tumor length (continuous variable) to be associated with inaccurate uT (p = 0.016). Accurately staged tumors were significantly longer than inaccurately staged tumors (2.7 vs 1.7 cm, p = 0.011). CONCLUSIONS Early to intermediate GE junction tumors are frequently over-staged. This highlights the importance of diagnostic endoscopic resection for determining accurate tumor depth and selecting correct therapy.

Thoracic Manifestations of Inflammatory Bowel Disease

OBJECTIVE The purpose of this article is to present the spectrum of inflammatory bowel disease manifestations in the chest, including the airways, lung parenchyma, pulmonary vasculature, and serosal surfaces. CONCLUSION The spectrum of inflammatory bowel disease manifestations in the chest is broad, and the manifestations may mimic other diseases. Knowledge of these manifestations in conjunction with pertinent clinical data is essential for establishing the correct diagnosis and treatment.

Imaging Evaluation of Malignant Chest Wall Neoplasms

Neoplasms of the chest wall are uncommon lesions that represent approximately 5% of all thoracic malignancies. These tumors comprise a heterogeneous group of neoplasms that may arise from osseous structures or soft tissues, and they may be malignant or benign. More than 50% of chest wall neoplasms are malignancies and include tumors that may arise as primary malignancies or secondarily involve the chest wall by way of direct invasion or metastasis from intrathoracic or extrathoracic neoplasms. Although 20% of chest wall tumors may be detected at chest radiography, chest wall malignancies are best evaluated with cross-sectional imaging, principally multidetector computed tomography (CT) and magnetic resonance (MR) imaging, each of which has distinct strengths and limitations. Multidetector CT is optimal for depicting bone, muscle, and vascular structures, whereas MR imaging renders superior soft-tissue contrast and spatial resolution and is better for delineating the full extent of disease. Fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT is not routinely performed to evaluate chest wall malignancies. The primary functions of PET/CT in this setting include staging of disease, evaluation of treatment response, and detection of recurrent disease. Ultrasonography has a limited role in the evaluation and characterization of superficial chest wall lesions; however, it can be used to guide biopsy and has been shown to depict chest wall invasion by lung cancer more accurately than CT. It is important that radiologists be able to identify the key multidetector CT and MR imaging features that can be used to differentiate malignant from benign chest lesions, suggest specific histologic tumor types, and ultimately guide patient treatment. (©)RSNA, 2016.

The ‘wandering appendicolith’

Acute appendicitis is a common pediatric surgical emergency. Successful surgical appendectomy requires removal of the appendix and its contents. A retained appendicolith is a complication that occurs when the appendicolith is expulsed from the appendix as a result of perforation or failure of removal during surgery. An ectopic appendicolith can migrate to a variety of ectopic locations, acting as a nidus for abscess. Clinical presentation may be delayed by days, weeks or even months after surgery. We present and discuss an unusual case of empyema caused by migration of an appendicolith into the chest cavity. Management of these retained appendicoliths requires drainage of the abscess and extraction of the appendicolith.

Outcomes after endoscopic mucosal resection or esophagectomy for submucosal esophageal adenocarcinoma

Objectives: Endoscopic mucosal resection (EMR) is a diagnostic and potentially therapeutic option for patients with submucosal esophageal adenocarcinoma. However, there are significant concerns regarding the risk of lymph node metastasis. Our purpose was to construct a comparative effectiveness analysis comparing recurrence patterns after therapeutic EMR or esophagectomy. Methods: Patients who underwent therapeutic EMR or esophagectomy from 2007 to 2015 with pathologically staged submucosal adenocarcinoma were identified from a departmental database. Cancer‐related outcomes were compared among an unmatched as well as a propensity matched cohort. Risk stratification was also used to compare results among those with a low, medium, or high risk of nodal metastasis. Results: Seventy‐two patients met criteria for analysis, among whom 23 underwent therapeutic EMR with esophageal preservation and 49 underwent esophagectomy. Median follow‐up was 43 months. Patients who underwent esophagectomy had larger, deeper tumors. Esophageal preservation was associated with an increased risk of local recurrence (P = .01), but not distant recurrence (P = .44). After propensity matching, there continued to be no difference in distant recurrence rate (P = .66). In a risk‐stratified analysis, low‐risk patients showed no recurrences or cancer‐related deaths, however, high‐risk patients showed a trend toward increased distant recurrence after therapeutic EMR. Conclusions: Esophageal preservation after therapeutic EMR was associated with an increased risk of local recurrence. Among low‐risk patients, either strategy resulted in excellent cancer control. However, among high‐risk patients, esophageal preservation showed a trend toward increased distant failure. These findings should prompt further investigation to determine optimal treatment for patients with submucosal esophageal adenocarcinoma.

Multimodality imaging findings in carcinoid tumors: A head-to-toe spectrum

Carcinoid tumors are a rare biologically heterogeneous group of neuroendocrine tumors with a spectrum ranging from benign indolent to aggressive metastatic tumors. They belong to the category of amine precursor uptake and decarboxylase tumors, or apudomas. The most common sites for primary locations are the gastrointestinal and respiratory tracts; however, any organ can be involved. The clinical presentation depends on location, aggressiveness, production of biologically active amines and peptides, paraneoplastic syndromes, and tendency for metastasis. Their reported age-adjusted incidence has increased in recent years, partly due to improved detection at radiologic imaging and endoscopy. Not a ll neuroendocrine cell tumors are carcinoids. Numerous systems have been proposed regarding their nomenclature and classification. Cross-sectional and functional imaging plays an important role in diagnosis, lesion characterization, and staging. Awareness of nomenclature, classification, common sites of involvement, and imaging presentation are pivotal for making the diagnosis. Knowledge of the diverse clinical, pathologic, and radiologic spectrum of carcinoid tumors involving various organs of the body is important for diagnosis and patient management. ©RSNA, 2017.

Potential Pitfalls in Interpretation of Positron Emission Tomography/Computed Tomography Findings in the Thorax

Introduction F (FDG) positron emission tomography (PET)/computed tomography (CT) is widely used in current clinical practice. Most of the PET/CT applications in the thorax involve the evaluation of solitary pulmonary nodules for malignancy, staging and restaging of oncologic patients, assessment of treatment response following therapy, and identification of residual or recurrent disease. These functions reflect the fact that cancer cells demonstrate increased uptake of glucose and glucose analogues such as FDG, as well as an increased rate of glycolysis. Although FDG undergoes uptake by the same transporter proteins as glucose, it becomes sequestered in cancer cells owing to its inability to participate in glycolytic pathways. The standardized uptake value (SUV) based on body weight, defined as the ratio of radiotracer accumulation (mCi/mL) in the area of interest divided by the injected dose (mCi) normalized by the patient’s bodyweight (g), is themost common semiquantitativemethod of evaluating abnormalities on PET/CT. Studies have suggested that an SUV cutoff of 2.5 can be used to separate benign from malignant abnormalities.