1
|
Wang A, Su H, Duan Y, Jiang K, Li Y, Deng M, Long X, Wang H, Zhang M, Zhang Y, Cao Y. Pulmonary Hypertension Caused by Fibrosing Mediastinitis. JACC: ASIA 2022; 2:218-234. [PMID: 36338410 PMCID: PMC9627819 DOI: 10.1016/j.jacasi.2021.11.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 12/02/2022]
Abstract
Pulmonary hypertension (PH) is a progressive and severe disorder in pulmonary hemodynamics. PH can be fatal if not well managed. Fibrosing mediastinitis (FM) is a rare and benign fibroproliferative disease in the mediastinum, which may lead to pulmonary vessel compression and PH. PH caused by FM (PH-FM) is a pathologic condition belonging to group 5 in the World Health Organization PH classification. PH-FM has a poor prognosis because of a lack of effective therapeutic modalities and inappropriate diagnosis. With the development of percutaneous pulmonary vascular interventional therapy, the prognosis of PH-FM has been greatly improved in recent years. This article provides a comprehensive review on the epidemiology, pathophysiologic characteristics, clinical manifestations, diagnostic approaches, and treatment modalities of PH-FM based on data from published reports and our medical center with the goal of facilitating the diagnosis and treatment of this fatal disease. PH-FM, as a type of rare condition in group 5 PH, has a poor prognosis because of a lack of effective therapeutic modalities and frequent misdiagnosis and underdiagnosis. The most prevalent trigger of FM is H-FM in the United States and TB-FM in China. Imaging findings, including mismatched perfusion defects in the V/Q scan, FM dyad, and FM triad are important diagnostic clues, and clinical classification facilitates decision making in diagnosis and therapeutics. Because of the limited efficacy of drug therapy as well as the uncertain effectiveness and high risk of surgical treatment, endovascular interventional modality is currently the preferred therapeutic option, although procedure-related complications and intrastent restenosis after PV intervention need to be addressed.
Collapse
|
2
|
Spectrum of [ 18F]FDG-PET/CT Findings in Benign Lymph Node Pathology. Mol Imaging Biol 2021; 23:469-480. [PMID: 33512649 PMCID: PMC8277624 DOI: 10.1007/s11307-020-01576-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 01/18/2023]
Abstract
Diffuse lymphadenopathy has a long differential diagnosis that includes both malignant and benign causes. As part of the lymphadenopathy work-up, many patients undergo [18F]FDG-PET/CT for purposes of ruling out malignancy. FDG-avid lymph nodes, however, are not specific for malignancy. This review will illustrate the spectrum of nodal findings on FDG-PET/CT with correlation to other cross-sectional imaging and clinical history in patients with representative infectious, inflammatory, and benign lymphoproliferative disorders. These findings are important for the nuclear medicine radiologist to understand, as they can represent common pitfalls in the work-up of lymphadenopathy. While FDG-PET/CT may be limited in ascertaining a definitive diagnosis in a disease process as the cause of lymphadenopathy, it can help to narrow this differential and rule out certain diseases in the correct clinical context.
Collapse
|
3
|
Rahman WT, Wale DJ, Viglianti BL, Townsend DM, Manganaro MS, Gross MD, Wong KK, Rubello D. The impact of infection and inflammation in oncologic 18F-FDG PET/CT imaging. Biomed Pharmacother 2019; 117:109168. [PMID: 31334700 PMCID: PMC7104808 DOI: 10.1016/j.biopha.2019.109168] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/22/2019] [Accepted: 06/25/2019] [Indexed: 12/30/2022] Open
Abstract
Sites of infection and inflammation can be misleading in oncology PET/CT imaging because these areas commonly show 18F-FDG activity. Caution in the interpretation must be taken to avoid the misdiagnosis of malignancy. Utilization of both CT findings as well as patient history can help differentiate benign infectious and inflammatory processes from malignancy, although occasionally additional work-up may be required. This article discusses the mechanism of 18F-FDG uptake in infection and inflammation with illustrative examples.
Collapse
Affiliation(s)
- W Tania Rahman
- Nuclear Medicine Division, Department of Radiology, University of Michigan Hospital, Ann Arbor, MI, USA
| | - Daniel J Wale
- Nuclear Medicine Division, Department of Radiology, University of Michigan Hospital, Ann Arbor, MI, USA; Nuclear Medicine Service, Department of Veterans Affairs Health System, Ann Arbor, MI, USA.
| | - Benjamin L Viglianti
- Nuclear Medicine Division, Department of Radiology, University of Michigan Hospital, Ann Arbor, MI, USA; Nuclear Medicine Service, Department of Veterans Affairs Health System, Ann Arbor, MI, USA
| | - Danyelle M Townsend
- Division of Drug Discovery and Pharmaceutical Sciences, Medical University of South Carolina, USA
| | - Matthew S Manganaro
- Nuclear Medicine Division, Department of Radiology, University of Michigan Hospital, Ann Arbor, MI, USA
| | - Milton D Gross
- Nuclear Medicine Division, Department of Radiology, University of Michigan Hospital, Ann Arbor, MI, USA; Nuclear Medicine Service, Department of Veterans Affairs Health System, Ann Arbor, MI, USA
| | - Ka Kit Wong
- Nuclear Medicine Division, Department of Radiology, University of Michigan Hospital, Ann Arbor, MI, USA
| | - Domenico Rubello
- Department of Nuclear Medicine, Radiology, Neuroradiology, Interventional Radiology, Pathology, Santa Maria della Misericordia Hospital, Rovigo, Italy.
| |
Collapse
|
4
|
Garrana SH, Buckley JR, Rosado-de-Christenson ML, Martínez-Jiménez S, Muñoz P, Borsa JJ. Multimodality Imaging of Focal and Diffuse Fibrosing Mediastinitis. Radiographics 2019; 39:651-667. [PMID: 30951437 DOI: 10.1148/rg.2019180143] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Fibrosing mediastinitis is a rare benign but potentially life-threatening process that occurs because of proliferation of fibrotic tissue in the mediastinum. The focal subtype is more common and typically is associated with an abnormal immunologic response to Histoplasma capsulatum infection. Affected patients are typically young at presentation, but a wide age range has been reported, without a predilection for either sex. The diffuse form may be idiopathic or associated with autoimmunity, usually affects middle-aged and/or elderly patients, and is more common in men. For both subtypes, patients present with signs and symptoms related to obstruction or compression of vital mediastinal structures. The most common presenting signs and symptoms are cough, dyspnea, recurrent pneumonia, hemoptysis, and pleuritic chest pain. Patients with the diffuse subtype may have additional extrathoracic symptoms depending on the other organ systems involved. Because symptom severity is variable, treatment should be individualized with therapies tailored to alleviate compression of the affected mediastinal structures. Characteristic imaging features of fibrosing mediastinitis include infiltrative mediastinal soft tissue (with or without calcification) with compression or obstruction of mediastinal vascular structures and/or the aerodigestive tract. When identified in the appropriate clinical setting, these characteristic features allow the radiologist to suggest the diagnosis of fibrosing mediastinitis. Careful assessment is crucial at initial and follow-up imaging for exclusion of underlying malignancy, assessment of disease progression, identification of complications, and evaluation of treatment response. Online supplemental material is available for this article. ©RSNA, 2019.
Collapse
Affiliation(s)
- Sherief H Garrana
- From the Department of Radiology, Saint Luke's Hospital of Kansas City, University of Missouri in Kansas City, 4401 Wornall Rd, Kansas City, MO 64111 (S.H.G., J.R.B., M.L.R.d.C., S.M.J., J.J.B.); and Ameripath, Kansas City, Mo (P.M.)
| | - Jennifer R Buckley
- From the Department of Radiology, Saint Luke's Hospital of Kansas City, University of Missouri in Kansas City, 4401 Wornall Rd, Kansas City, MO 64111 (S.H.G., J.R.B., M.L.R.d.C., S.M.J., J.J.B.); and Ameripath, Kansas City, Mo (P.M.)
| | - Melissa L Rosado-de-Christenson
- From the Department of Radiology, Saint Luke's Hospital of Kansas City, University of Missouri in Kansas City, 4401 Wornall Rd, Kansas City, MO 64111 (S.H.G., J.R.B., M.L.R.d.C., S.M.J., J.J.B.); and Ameripath, Kansas City, Mo (P.M.)
| | - Santiago Martínez-Jiménez
- From the Department of Radiology, Saint Luke's Hospital of Kansas City, University of Missouri in Kansas City, 4401 Wornall Rd, Kansas City, MO 64111 (S.H.G., J.R.B., M.L.R.d.C., S.M.J., J.J.B.); and Ameripath, Kansas City, Mo (P.M.)
| | - Phillip Muñoz
- From the Department of Radiology, Saint Luke's Hospital of Kansas City, University of Missouri in Kansas City, 4401 Wornall Rd, Kansas City, MO 64111 (S.H.G., J.R.B., M.L.R.d.C., S.M.J., J.J.B.); and Ameripath, Kansas City, Mo (P.M.)
| | - John J Borsa
- From the Department of Radiology, Saint Luke's Hospital of Kansas City, University of Missouri in Kansas City, 4401 Wornall Rd, Kansas City, MO 64111 (S.H.G., J.R.B., M.L.R.d.C., S.M.J., J.J.B.); and Ameripath, Kansas City, Mo (P.M.)
| |
Collapse
|
5
|
Kang H, Jung MJ. Aggressive and progressive fibrosing mediastinitis involving the thoracic spine mimicking malignancy: A case report. Radiol Case Rep 2019; 14:490-494. [PMID: 30805073 PMCID: PMC6374615 DOI: 10.1016/j.radcr.2019.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/03/2019] [Accepted: 02/03/2019] [Indexed: 11/11/2022] Open
Abstract
Fibrosing mediastinitis is an uncommon benign disorder in which a chronic inflammatory reaction results in diffuse fibrosis of the mediastinum, potentially compromising the airways, great vessels and other mediastinal structures. Herein we describe a progressive course of fibrosing mediastinitis in a 72-year-old man. Computed tomography images depicted a diffuse, infiltrative, soft tissue mass involving the esophagus and superior vena cava in the mediastinum. Magnetic resonance imaging revealed destruction of the adjacent thoracic spine. Positron emission tomography-computed tomography also revealed increased metabolism in the periphery of the mass.
Collapse
Affiliation(s)
- Hee Kang
- Department of Radiology, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, South Korea
| | - Min Jung Jung
- Department of Pathology, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, South Korea
| |
Collapse
|
6
|
Wu Z, Jarvis H, Howard LS, Wright C, Kon OM. Post-tuberculous fibrosing mediastinitis: a review of the literature. BMJ Open Respir Res 2017; 4:e000174. [PMID: 28725444 PMCID: PMC5501238 DOI: 10.1136/bmjresp-2016-000174] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/08/2017] [Accepted: 03/13/2017] [Indexed: 12/12/2022] Open
Abstract
Fibrosing mediastinitis (FM) is a rare disease where there is thickening of the fibrous tissue in the mediastinum. While histoplasmosis is the the most common recognised cause, the link with tuberculosis (TB) has been rarely documented. We review the link between TB and FM, and describe a case of probable TB-related FM.Our case is of a 74-year-old man who presented with breathlessness 3 years after fully treated TB. Scans revealed a calcified soft tissue mass within the mediastinum, and a diagnosis of fibrosing mediastinitis resulting in pulmonary hypertension was made. Tests for histoplasmosis and IgG4 staining were negative. Surgical intervention was not felt to be beneficial, and he was treated with prednisolone and mycophenolate mofetil.In the review, we highlight the two forms of mediastinitis—granulomatous versus fibrous, and how these two entities may be on a spectrum of disease progression. We also explore the prevalence, clinical presentation, pathogenesis, imaging techniques and treatment options of TB-related FM.
Collapse
Affiliation(s)
- Zhe Wu
- Department of Respiratory Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Hannah Jarvis
- Imperial Clinical Respiratory Research Unit, Imperial College London, London, UK
| | - Luke S Howard
- National Pulmonary Hypertension Service, Imperial College Healthcare NHS Trust, London, UK
| | - Corrina Wright
- Department of Cytopathology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Onn Min Kon
- Department of Respiratory Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| |
Collapse
|
7
|
Bharadwaj R, Madakshira MG, Bharadwaj P, Sidhu HS. Sclerosing Mediastinitis Presenting as Complete Heart Block. J Clin Diagn Res 2017; 11:ED12-ED14. [PMID: 28658779 DOI: 10.7860/jcdr/2017/26349.9786] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 02/23/2017] [Indexed: 12/24/2022]
Abstract
Sclerosing Mediastinitis (SM) is a rare condition which is characterized by the presence of dense fibrosis which infiltrates and encroaches upon various structures in the mediastinal cavity. Depending on the extent and the predominant organ of involvement, the patient presents with symptomatology of dysphagia, superior vena cava compression syndrome or dyspnoea. However, the involvement of the heart is rarely seen. Aetiologies of SM are several, with infections being the most common. We discuss a case of SM involving the oesophagus, descending aorta, hilum of lungs and the heart secondary to mucormycosis in an immunocompetent male.
Collapse
Affiliation(s)
- Reena Bharadwaj
- Professor and Head, Department of Pathology, Armed Forces Medical College, Pune, Maharashtra, India
| | - Manoj Gopal Madakshira
- Assistant Professor, Department of Pathology, Armed Forces Medical College, Pune, Maharashtra, India
| | - Prashant Bharadwaj
- Professor and Head, Department of Cardiology, Military Hospital, Cardio Thoraic Center, Pune, Maharashtra, India
| | - Hardeep Singh Sidhu
- Classified Specialist, Department of Pathology, Military Hospital, Cardio Thoraic Center, Pune, Maharashtra, India
| |
Collapse
|
8
|
Rossi GM, Emmi G, Corradi D, Urban ML, Maritati F, Landini F, Galli P, Palmisano A, Vaglio A. Idiopathic Mediastinal Fibrosis: a Systemic Immune-Mediated Disorder. A Case Series and a Review of the Literature. Clin Rev Allergy Immunol 2016; 52:446-459. [DOI: 10.1007/s12016-016-8584-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
9
|
Jain N, Chauhan U, Puri SK, Agrawal S, Garg L. Fibrosing mediastinitis: when to suspect and how to evaluate? BJR Case Rep 2016; 2:20150274. [PMID: 30364448 PMCID: PMC6195926 DOI: 10.1259/bjrcr.20150274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 09/30/2015] [Accepted: 10/28/2015] [Indexed: 11/05/2022] Open
Abstract
Fibrosing mediastinitis (FM), which is also known as mediastinal fibrosis or sclerosing mediastinitis, is an uncommon, benign and progressive condition characterized by an invasive proliferation of fibrous tissue within the mediastinum. Tuberculosis and histoplasmosis are the major causes of the granulomatous variety, while non-granulomatous FM is an idiopathic reaction to autoimmune syndromes, drugs and radiation. Contrast-enhanced CT is the investigation of choice that can diagnose, and assess the extent and the severity of involvement. We are presenting a case of FM in a young female who presented with complaints of breathlessness, occasional cough and diffuse chest pain for 3 months.
Collapse
Affiliation(s)
- Neeraj Jain
- Department of Radiodiagnosis, G B Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Udit Chauhan
- Department of Radiodiagnosis, G B Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Sunil Kumar Puri
- Department of Radiodiagnosis, G B Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Sachin Agrawal
- Department of Radiodiagnosis, G B Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Lalit Garg
- Department of Radiodiagnosis, G B Institute of Postgraduate Medical Education and Research, New Delhi, India
| |
Collapse
|
10
|
Gorospe L, Ayala-Carbonero AM, Fernández-Méndez MÁ, Arrieta P, Muñoz-Molina GM, Cabañero-Sánchez A, Mañas-Baena E. Idiopathic fibrosing mediastinitis: spectrum of imaging findings with emphasis on its association with IgG4-related disease. Clin Imaging 2015; 39:993-9. [DOI: 10.1016/j.clinimag.2015.07.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 07/06/2015] [Accepted: 07/10/2015] [Indexed: 12/19/2022]
|
11
|
Sonavane SK, Milner DM, Singh SP, Abdel Aal AK, Shahir KS, Chaturvedi A. Comprehensive Imaging Review of the Superior Vena Cava. Radiographics 2015; 35:1873-92. [DOI: 10.1148/rg.2015150056] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
12
|
Kaya H, Rider K, Cho AH, Schwartz A, Alrehaili G, Ahari J. The role of PET scan in monitoring the progression of fibrosing mediastinitis. Clin Imaging 2015; 40:177-9. [PMID: 26414539 DOI: 10.1016/j.clinimag.2015.07.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 07/25/2015] [Indexed: 01/06/2023]
Abstract
We present the case of a 31-year-old man who presented with acute chest pain. Computed tomography scan showed a mediastinal mass engulfing right main-stem bronchus and another mass surrounding descending aorta. Positron emission tomography (PET) scan showed high mass metabolic activity. Histopathological evaluation revealed fibroinflammatory scarring. He was diagnosed with idiopathic fibrosing mediastinitis, started on prednisone and tamoxifen treatment, and monitored with serial PET scans. Nine months after treatment initiation, paraaortic abnormality had resolved and mediastinal mass had regressed.
Collapse
Affiliation(s)
- Hatice Kaya
- Department of Pulmonary, Critical Care and Sleep Medicine, The George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC 20037, USA; Department of Pulmonary, Gulhane Military Medical Academy, General Tevfik Saglam Caddesi, Etlik, Ankara 06010, Turkey.
| | - Katherine Rider
- Department of Pulmonary, Critical Care and Sleep Medicine, The George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC 20037, USA.
| | - Alexander H Cho
- Department of Pulmonary, Critical Care and Sleep Medicine, The George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC 20037, USA.
| | - Arnold Schwartz
- Department of Pathology, The George Washington University, 900 23rd Street NW, Washington, DC 20037, USA.
| | - Ghadah Alrehaili
- Department of Pulmonary, Critical Care and Sleep Medicine, The George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC 20037, USA.
| | - Jalil Ahari
- Department of Pulmonary, Critical Care and Sleep Medicine, The George Washington University, 2150 Pennsylvania Avenue NW, Washington, DC 20037, USA.
| |
Collapse
|
13
|
Schade MA, Mirani NM. Fibrosing mediastinitis: an unusual cause of pulmonary symptoms. J Gen Intern Med 2013; 28:1677-81. [PMID: 23807725 PMCID: PMC3832713 DOI: 10.1007/s11606-013-2528-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 03/12/2013] [Accepted: 06/07/2013] [Indexed: 11/24/2022]
Abstract
Fibrosing mediastinitis (FM), also known as granulomatous or sclerosing mediastinitis, is an uncommon but serious cause of chest symptoms. Due to an infectious or inflammatory challenge, production of collagen occurs in the confined space of the mediastinum. Collagen formation leads to compression of vital structures, resulting in cough, chest pain and dyspnea. The majority of cases of FM occur as a result of prior exposure to Histoplasma capsulatum. The following is a case of a previously healthy young woman who presented with a 3-month history of cough, chest pain and trouble breathing, and was subsequently found to have fibrosing mediastinitis. Fibrosing mediastinitis should be considered in the differential diagnosis of cough, chest pain and dyspnea, primarily when findings such as increased venous pressure are present on physical exam and hilar abnormalities are seen on chest radiograph. Clinical presentation, diagnosis and management of fibrosing mediastinitis are discussed.
Collapse
|
14
|
McNeeley MF, Chung JH, Bhalla S, Godwin JD. Imaging of Granulomatous Fibrosing Mediastinitis. AJR Am J Roentgenol 2012; 199:319-327. [DOI: 10.2214/ajr.11.7319] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Michael F. McNeeley
- Department of Radiology, University of Washington Medical Center, 1959 Pacific Ave NE, Box 357115, Seattle, WA 98195
| | | | - Sanjeev Bhalla
- Mallinckrodt Institute of Radiology at Washington University, St. Louis, MO
| | - J. David Godwin
- Department of Radiology, University of Washington Medical Center, 1959 Pacific Ave NE, Box 357115, Seattle, WA 98195
| |
Collapse
|
15
|
Peikert T, Colby TV, Midthun DE, Pairolero PC, Edell ES, Schroeder DR, Specks U. Fibrosing mediastinitis: clinical presentation, therapeutic outcomes, and adaptive immune response. Medicine (Baltimore) 2011; 90:412-423. [PMID: 22033450 DOI: 10.1097/md.0b013e318237c8e6] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Fibrosing mediastinitis (FM) is a rare disorder characterized by the invasive proliferation of fibrous tissue within the mediastinum. FM frequently results in the compression of vital mediastinal structures and has been associated with substantial morbidity and mortality. Its pathogenesis remains unknown. However, in North America most cases are thought to represent an immune-mediated hypersensitivity response to Histoplasma capsulatum infection. To characterize the clinical disease spectrum, natural disease progression, responses to therapy, and overall survival, we retrospectively analyzed all 80 consecutive patients with a diagnosis of FM evaluated at Mayo Clinic, Rochester, MN, from 1998 to 2007. Furthermore, we characterized the adaptive immune response in 15 representative patients by immunohistochemistry. The majority of patients presented with nonspecific respiratory symptoms due to the compression of mediastinal broncho-vascular structures. Chest radiographic imaging most frequently revealed localized, invasive, and frequently calcified right-sided mediastinal masses. Most patients had radiographic or serologic evidence of previous histoplasmosis. In contrast to earlier reports summarizing previously reported FM cases, the clinical course of our patients appeared to be more benign and less progressive. The overall survival was similar to that of age-matched controls. There were only 5 deaths, 2 of which were attributed to FM. These differences may reflect publication bias associated with the preferential reporting of more severely affected FM patients in the medical literature, as well as the more inclusive case definition used in our consecutive case series. Surgical and nonsurgical interventions effectively relieved symptoms caused by the compression of mediastinal vascular structures in these carefully selected patients. In contrast, antifungal and antiinflammatory agents appeared ineffective. Histologic examination and immunostaining revealed mixed inflammatory infiltrates consistent with a fibroinflammatory tissue response in these histoplasmosis-associated FM cases. The immune cell infiltrates included large numbers of CD20-positive B lymphocytes. As B lymphocytes may contribute to the pathogenesis of the disease, therapeutic B-cell depletion should be investigated as a therapeutic strategy for FM.
Collapse
Affiliation(s)
- Tobias Peikert
- From Division of Pulmonary and Critical Care Medicine (TP, DEM, ESE, US); Emeritus staff, Division of General Thoracic Surgery (PCP); Division of Biostatistics (DRS), Mayo Clinic, Rochester, Minnesota; and Department of Laboratory Medicine and Pathology (TVC), Mayo Clinic Scottsdale, Scottsdale, Arizona
| | | | | | | | | | | | | |
Collapse
|
16
|
Incidental Detection of Unsuspected Pulmonary Embolism on Oncologic FDG PET/CT Imaging. Clin Nucl Med 2011; 36:720-2. [DOI: 10.1097/rlu.0b013e318219b102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
17
|
Onuki T, Ishikawa S, Matsuoka T, Iguchi K, Inagaki M. Dual-phase FDG-PET Imaging Shows Suspected Malignancy That Histological Examination Later Confirmed as Sclerosing Mediastinitis: Report of a Case. Ann Thorac Cardiovasc Surg 2011; 17:304-6. [DOI: 10.5761/atcs.cr.09.01533] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Accepted: 04/16/2010] [Indexed: 11/16/2022] Open
|
18
|
|