CT Characteristics and Pathologic Basis of Solitary Cystic Lung Cancer

A case of adenocarcinoma presenting with cystic lesion and recurrent pneumothoraces

BACKGROUND

In this paper, a rare case is reported, where the patient is a 74-year-old man. He suffered from recurrent pneumothorax within half a year and experienced a relapse after receiving conservative treatments.

CASE PRESENTATION

Diagnostic workup revealed a cystic lesion in the right middle lobe, which has been interpreted as a bulla during the initial chest CT scan. Due to recurrent pneumothorax and poor response to the conservative treatments, the patient underwent bullectomy and pleurodesis. The pathology showed that the wall of the cystic lesion was invasive adenocarcinoma.

CONCLUSIONS

This case highlights the importance of monitoring cystic lesions in the lungs, especially in patients with a history of smoking and emphysema.

Wolf in sheep's clothing: a case of primary lung adenosquamous carcinoma mimicking traumatic pulmonary pseudocyst

BACKGROUND

Traumatic pulmonary pseudocyst is a rare "cystlike" lung lesion that typically develops following blunt chest trauma. It differs from lung cancer associated with cystic airspaces in terms of pathogenic mechanisms, clinical manifestations, and radiological features. Furthermore, there are few reports of the diagnostic bias between traumatic pulmonary pseudocyst and lung cancer associated with cystic airspaces. Here, we present a rare case of lung cancer associated with cystic airspaces that mimicks traumatic pulmonary pseudocyst.

CASE PRESENTATION

A 61-year-old man with no chest medical or surgical history, no chest radiologic examination within the last five years, and no smoking history had an air-filled "cystlike" lesion surrounded by solid components and ground-glass opacities in the middle third of the right upper lobe of the lung during a computed tomography evaluation following blunt chest trauma. He was initially diagnosed with traumatic pulmonary pseudocyst and treated conservatively. On the third post-trauma day, he experienced hemoptysis, which was successfully treated with intravenous hemostatic medication. On the ninth post-trauma day, he exhibited a significant hemoptysis and a moderate dyspnea. A subsequent chest computed tomography scan demonstrated that the solid components had entered the lesion's cavity and significantly expanded, and the surrounding ground-glass opacities had slightly enlarged. A contrast-enhanced chest computed tomography scan and a three-dimensional reconstruction computed tomography image confirmed that the solid components were a hematoma caused by damage to the right upper pulmonary vein. A right upper lobectomy was performed based on the concern about severe intrapulmonary bleeding. An intraoperative frozen section analysis showed significant bleeding in the lung parenchyma. Adenosquamous carcinoma was unexpectedly identified during the postoperative pathological examination of the resected specimen. A diagnosis of primary lung adenosquamous carcinoma was made. He was discharged on the seventh postoperative day and followed up for two years without any recurrence.

CONCLUSIONS

The potential of lung cancer associated with cystic airspaces should be considered for "cystlike" lung lesions discovered in elderly patients after blunt chest trauma. A comprehensive review of the medical history, meticulous analysis of the radiological findings, and close monitoring can help clinicians reduce the risk of diagnostic bias.

The impact of cystic lesions on the postoperative prognosis of non-small cell lung cancer: a comparative study

AIM

Due to the rarity of lung cancer with cystic imaging manifestations, we explore the clinical features and survival prognosis of such tumors.

MATERIALS AND METHODS

Imaging characteristics were used to categorize 3,556 patients who underwent surgery for isolated primary lung cancer into one of three groups: those with cystic lung cancer (149), solid lung cancer (1,399), and ground-glass lung cancer (1,160). Propensity score matching by sex and age was performed to analyze the differences in clinical characteristics of lung cancer among the three groups and the correlation between clinical characteristics of cystic lesions and progression-free survival (PFS).

RESULTS

The three groups of patients differed in various aspects, including pathological type, smoking history, tumor stage, type of surgery, histological grading, and PFS (P < 0.05). The results of the multifactorial analysis indicated that lung cancer type, pathological type, lymph node metastasis, tumor stage, and histologic grading were independent prognostic factors for lung cancer (P < 0.05). After comparison, there was a difference in prognosis between cystic lung cancer and ground-glass lung cancer (P < 0.05).

CONCLUSION

The clinical features of cystic lung cancer are significantly different from those of ground-glass lung cancer and solid lung cancer. Cystic lesions are independent influencing factors affecting lung cancer, and the prognosis of cystic lung cancer is worse than that of ground-glass lung cancer.

A nomogram combining CT-based radiomic features with clinical features for the differentiation of benign and malignant cystic pulmonary nodules

BACKGROUND

Currently, the differentiation between benign and malignant cystic pulmonary nodules poses a significant challenge for clinicians. The objective of this retrospective study was to construct a predictive model for determining the likelihood of malignancy in patients with cystic pulmonary nodules.

METHODS

The current study involved 129 patients diagnosed with cystic pulmonary nodules between January 2017 and June 2023 at the Neijiang First People's Hospital. The study gathered the clinical data, preoperative imaging features of chest CT, and postoperative histopathological results for both cohorts. Univariate and multivariate logistic regression analyses were employed to identify independent risk factors, from which a prediction model and nomogram were developed. In addition, The model's performance was assessed through receiver operating characteristic (ROC) curve analysis, calibration curve analysis, and decision curve analysis (DCA).

RESULTS

A cohort of 129 patients presenting with cystic pulmonary nodules, consisting of 92 malignant and 37 benign lesions, was examined. Logistic data analysis identified a cystic airspace with a mural nodule, spiculation, mural morphology, and the number of cystic cavities as significant independent predictors for discriminating between benign and malignant cystic lung nodules. The nomogram prediction model demonstrated a high level of predictive accuracy, as evidenced by an area under the ROC curve (AUC) of 0.874 (95% CI: 0.804-0.944). Furthermore, the calibration curve of the model displayed satisfactory calibration. DCA proved that the prediction model was useful for clinical application.

CONCLUSION

In summary, the risk prediction model for benign and malignant cystic pulmonary nodules has the potential to assist clinicians in the diagnosis of such nodules and enhance clinical decision-making processes.

Computed tomography characteristics of cN0 primary non-small cell lung cancer predict occult lymph node metastasis

RATIONALE

Occult lymph node metastasis (OLNM) is frequently found in patients with resectable non-small cell lung cancer (NSCLC), despite using diagnostic methods recommended by guidelines.

OBJECTIVES

To evaluate the risk of OLNM in NSCLC patients using the radiologic characteristics of the primary tumor on computed tomography (CT).

METHODS

We retrospectively reviewed clinicopathologic features of 2042 clinical T1-4N0 NSCLC patients undergoing curative intent pulmonary resection. Unique radiological features (i.e., air-bronchogram throughout the whole tumor, heterogeneous ground-glass opacity (GGO), mainly cystic appearance, endobronchial location), percentage of solid portion, and shape of tumor margin were analyzed via a stepwise approach. We used multivariable logistic regression to assess the relationship between OLNM and tumor characteristics.

RESULTS

Compared with the other unique features, endobronchial tumors were associated with the highest risk of OLNM (OR = 3.9, 95% confidence interval (CI) = 2.29-6.62), and heterogeneous GGO and mainly cystic tumors were associated with a low risk of OLNM. For tumors without unique features, the percentage of the solid portion was measured, and solid tumors were associated with OLNM (OR = 2.49, 95% CI = 1.86-3.35). Among part-solid tumors with solid proportion > 50%, spiculated margin, and peri-tumoral GGO were associated with OLNM.

CONCLUSIONS

The risk of OLNM could be assessed using radiologic characteristics on CT. This could allow us to adequately select optimal candidates for invasive nodal staging procedures (INSPs) and complete systematic lymph node dissection.

CLINICAL RELEVANCE STATEMENT

These data may be helpful for clinicians to select appropriate candidates for INSPs and complete surgical systematic lymph node dissection in NSCLC patients.

KEY POINTS

Lymph node metastasis status plays a key role in both prognostication and treatment planning. Solid tumors, particularly endobronchial tumors, were associated with occult lymph node metastasis (OLNM). The risk of OLNM can be assessed using radiologic characteristics acquired from CT images.

Incidental pulmonary nodules - current guidelines and management

BACKGROUND

 Due to the greater use of high-resolution cross-sectional imaging, the number of incidental pulmonary nodules detected each year is increasing. Although the vast majority of incidental pulmonary nodules are benign, many early lung carcinomas could be diagnosed with consistent follow-up. However, for a variety of reasons, the existing recommendations are often not implemented correctly. Therefore, potential for improvement with respect to competence, communication, structure, and process is described.

METHODS

 This article presents the recommendations for incidental pulmonary nodules from the current S3 guideline for lung cancer (July 2023). The internationally established recommendations (BTS guidelines and Fleischner criteria) are compared and further studies on optimized management were included after a systematic literature search in PubMed.

RESULTS AND CONCLUSION

 In particular, AI-based software solutions are promising, as they can be used in a support capacity on several levels at once and can lead to simpler and more automated management. However, to be applicable in routine clinical practice, software must fit well into the radiology workflow and be integrated. In addition, "Lung Nodule Management" programs or clinics that follow a high-quality procedure for patients with incidental lung nodules or nodules detected by screening have been established in the USA. Similar structures might also be implemented in Germany in a future screening program in which patients with incidental pulmonary nodules could be included.

KEY POINTS

  · Incidental pulmonary nodules are common but are often not adequately managed. · The updated S3 guideline for lung cancer now includes recommendations for incidental pulmonary nodules. · Competence, communication, structure, and process levels offer significant potential for improvement.

CITATION FORMAT

· Glandorf J, Vogel-Claussen J, . Incidental pulmonary nodules - current guidelines and management. Fortschr Röntgenstr 2024; 196: 582 - 590.

Emergency right lower lobectomy for severe pulmonary abscess in a pregnant woman at the 25th week of gestation: a case report

BACKGROUND

Pulmonary abscess is a severe infection commonly seen in patients with chronic obstructive pulmonary disease, interstitial pneumonia, immune deficiency disease, drug-induced immunocompromised state, and congenital pulmonary disease. The treatment strategy in pregnant women with a pulmonary abscess is considered challenging since adverse effects on the fetus must be avoided to ensure safe delivery.

CASE PRESENTATION

A 34-year-old female patient at 24 weeks of gestation (G2P1) was admitted to the Department of Obstetrics and Gynecology due to sudden right chest pain. The patient had no significant medical history, including congenital anomalies, and no history of drug addiction or smoking. Laboratory data indicated high levels of inflammation (white blood cell 12,000/µL, C-reactive protein 16.0 mg/dL), and computed tomography demonstrated a large intrapulmonary cyst located in the middle of the right lower lobe, with some fluid collection. As the patient had no medical history of congenital pulmonary anomalies, she was initially diagnosed with a pulmonary cyst infection and treated with intravenous antibiotics. However, the infection did not resolve for over a week, and a spike in fever developed after admission. There was no definitive evidence concerning the risk of preterm delivery and fetal abortion during non-obstetric surgery. However, to control the severely infected pulmonary abscess that was refractory to antibiotics and obtain a pathological diagnosis while saving the life of both the mother and fetus, we elected to perform an emergent right lower lobectomy by open thoracotomy with a fissureless maneuver after receiving informed consent. Postoperatively, the infection gradually improved, and the patient was discharged on the 16th postoperative day without any major complications in the mother or fetus. Although she later experienced coronavirus disease-19 at 29 weeks of gestation, a boy was born at 40th weeks of gestation without any complications. Pathologically, no infectious agents, malignancies, or congenital anomalies other than lung abscesses associated with the pulmonary infarction were observed. The mother and child were healthy 1 year postoperatively.

CONCLUSIONS

We experienced a rare case of a pulmonary abscess in a pregnant woman who needed an emergent right lower lobectomy to control the severe infection and obtain a correct pathological diagnosis. Under cooperation from an obstetrician and anesthesiologist, emergency pulmonary resection can be performed safely for serious abscess formation even for pregnant women who have several months left until delivery.

Exploring the molecular and immune-landscape of lung cancer associated with cystic airspaces

To explore the molecular biological characteristics of lung cancer associated with cystic airspaces (LCCA) and its potential roles on prognosis. A total of 165 LCCAs and 201 non-LCCAs were enrolled in this study. Bulk RNA sequencing was implemented in eight LCCAs and nine non-LCCAs to explore the differentially expressed genes. TCGA data were used to analyze LCCA-specific genes that associated with overall survival (OS). The median age was 60 (IQR 53 to 65) years in LCCA cohort. We found LCCA were predominant in men and had less visceral pleura invasion (VPI) or lympho-vascular invasion (LVI). Moreover, LCCA presented with higher histological heterogeneity. Kaplan-Meier analysis showed that patients of age more than 60 and positive VPI had significantly less PFS in LCCA. Cox regression suggested that LCCA, micropapillary subtype proportion and VPI were the independent risk factors for PFS. LCCA had up-regulated pathways associated with EMT, angiogenesis and cell migration. In addition, LCCA displayed higher levels of immunosuppressor infiltration (M2 macrophages, CAFs and MDSCs) and distinct cell death and metabolic patterns. BCR/TCR repertoire analysis revealed less BCR richness, clonality and high-abundance shared clonotypes in LCCA. Finally, Cox regression analysis identified that four cystic-specific genes, KCNK3, NRN1, PARVB and TRHDE-AS1, were associated with OS of lung adenocarcinoma (LUAD). And cystic-specific risk scores (CSRSs) were calculated to construct a nomogram, which performance well. Our study for the first time indicated significantly distinct molecular biological and immune characteristics between LCCA and non-LCCA, which provide complementary prognostic values in early-stage non-small cell lung cancer (NSCLC).

Solitary lung adenocarcinoma: follow-up CT, pathological-molecular characteristics, and surgical prognosis for different morphological classifications

OBJECTIVE

To investigate the dynamic changes during follow-up computed tomography (CT), histological subtypes, gene mutation status, and surgical prognosis for different morphological presentations of solitary lung adenocarcinomas (SLADC).

MATERIALS AND METHODS

This retrospective study compared dynamic tumor changes and volume doubling time (VDT) in 228 patients with SLADC (morphological types I-IV) who had intermittent growth during follow-ups. The correlation between the morphological classification and histological subtypes, gene mutation status, and surgical prognosis was evaluated.

RESULTS

Among the 228 patients, 66 (28.9%) were classified as type I, 123 (53.9%) as type II, 16 (7%) as type III, and 23 (10.1%) as type IV. Type I had the shortest VDT (254 days), followed by types IV (381 days) and III (501 days), and then type II (993 days) (p < 0.05 each). Type I had a greater proportion of solid/micropapillary-predominant pattern than type II, and the lepidic-predominant pattern was more common in type II and III than in type I (p < 0.05 each). Furthermore, type II and IV SLADCs were correlated with positive epidermal growth factor receptor mutation (p < 0.05 each). Lastly, the Kaplan-Meier curves showed that the disease-free survival was longest for patients with type II tumors, followed by those with type III and IV tumors, and then those with type I tumors (p < 0.001 each).

CONCLUSION

A good understanding of the natural progression and pathological-molecular characteristics of different morphological SLADC types can help make accurate diagnoses, develop individual treatment strategies, and predict patient outcomes.

CRITICAL RELEVANCE STATEMENT

A good understanding of the natural progression and pathological-molecular characteristics of different morphological solitary lung adenocarcinoma types can help make accurate diagnoses, develop individual treatment strategies, and predict patient outcomes.

KEY POINTS

• Type I-IV solitary lung adenocarcinomas exhibit varying natural progression on serial CT scans. • Morphological classification of solitary lung adenocarcinomas predicts histological subtype, gene status, and surgical prognosis. • This classification of solitary lung adenocarcinomas may help improve diagnostic, therapeutic, and prognosticating abilities.

Lung adenocarcinoma associated with cystic airspaces: Predictive value of CT features in assessing pathologic invasiveness

OBJECTIVES

Lung adenocarcinoma associated with cystic airspaces (LACA) is a unique entity with limited understanding. Our aim was to evaluate the radiological characteristics of LACA and to study which criteria were predictive of invasiveness.

METHODS

A retrospective monocentric analysis of consecutive patients with pathologically confirmed LACA was performed. The diagnosed adenocarcinomas were classified into preinvasive (atypical adenomatous hyperplasia, adenocarcinoma in situ, or minimally invasive adenocarcinoma) and invasive adenocarcinomas. Eight clinical features and twelve CT features were evaluated. Univariable and multivariable analyses were performed to analyse the correlation between invasiveness, and CT and clinical features. The inter-observer agreement was evaluated using κ statistics and intraclass correlation coefficients. The predictive performance of the model was evaluated using the area under the receiver operating characteristic curve (AUC).

RESULTS

A total of 252 patients with 265 lesions (128 men and 124 women; mean age, 58.0 ± 11.1 years) were enrolled. Multivariable logistic regression indicated that multiple cystic airspaces (OR, 5.599; 95 % CI, 1.865-16.802), irregular shape of cystic airspace (OR, 3.236; 95 % CI, 1.073-9.761), entire tumour size (OR, 1.281; 95 % CI, 1.075-1.526), and attenuation (OR, 1.007; 95 % CI, 1.005-1.010) were independent risk factors for invasive LACA. The AUC of the logistic regression model was 0.964 (95 % CI, 0.944-0.985).

CONCLUSION

Multiple cystic airspaces, irregular shape of cystic airspace, entire tumour size, and attenuation were identified as independent risk factors for invasive LACA. The prediction model gives a good predictive performance, providing additional diagnostic information.

Pneumonic-type invasive mucinous adenocarcinoma and infectious pneumonia: clinical and CT imaging analysis from multiple centers

Background

Pneumonic-type invasive mucinous adenocarcinoma (IMA) was often misdiagnosed as pneumonia in clinic. However, the treatment of these two diseases is different.

Methods

A total of 341 patients with pneumonic-type IMA (n = 134) and infectious pneumonia (n = 207) were retrospectively enrolled from January 2017 to January 2022 at six centers. Detailed clinical and CT imaging characteristics of two groups were analyzed and the characteristics between the two groups were compared by χ2 test and Student’s t test. The multivariate logistic regression analysis was performed to identify independent predictors. Receiver operating characteristic curve analysis was used to determine the diagnostic performance of different variables.

Results

A significant difference was found in age, fever, no symptoms, elevation of white blood cell count and C-reactive protein level, family history of cancer, air bronchogram, interlobular fissure bulging, satellite lesions, and CT attenuation value (all p < 0.05). Age (odds ratio [OR], 1.034; 95% confidence interval [CI] 1.008–1.061, p = 0.010), elevation of C-reactive protein level (OR, 0.439; 95% CI 0.217–0.890, p = 0.022), fever (OR, 0.104; 95% CI 0.048–0.229, p < 0.001), family history of cancer (OR, 5.123; 95% CI 1.981–13.245, p = 0.001), air space (OR, 6.587; 95% CI 3.319–13.073, p < 0.001), and CT attenuation value (OR, 0.840; 95% CI 0.796–0.886, p < 0.001) were the independent predictors of pneumonic-type IMA, with an area under the curve of 0.893 (95% CI 0.856–0.924, p < 0.001).

Conclusion

Detailed evaluation of clinical and CT imaging characteristics is useful for differentiating pneumonic-type IMA and infectious pneumonia.

Thoracic Imaging in China: Yesterday, Today, and Tomorrow

Thoracic imaging has been revolutionized through advances in technology and research around the world, and so has China. Thoracic imaging in China has progressed from anatomic observation to quantitative and functional evaluation, from using traditional approaches to using artificial intelligence. This article will review the past, present, and future of thoracic imaging in China, in an attempt to establish new accepted strategies moving forward.

Case Report: Misdiagnosis of Lung Carcinoma in Patients with Shrunken Lung Cyst After High Altitude Travel

Background

Lung cancer associated with cystic airspace is a rare disease, and the imaging understanding of lung cancer with cystic cavity is still unclear. Little is known in the literature on whether cystic lung cancer is caused by emphysema or ruptured bullae.

Case Reports

We report the case of a 50-year-old female patient after finishing a business trip in November 2021, when another chest CT demonstrated an unexpected reduction in the cyst, with a solid mural nodule on the posterior wall. The airspace of the cyst is only about 13 mm × 12 mm × 6 mm in size. The size of the mural nodule in the posterior wall is about 10 mm × 6 mm × 5 mm. The patient felt anxious due to suspicion of lung cancer. 2.5 months after the last chest CT, she accepted minimally invasive thoracoscopic surgery on the posterior basal segment of the left lower lobe. The postoperative pathology showed benign lesions.

Conclusion

For radiologists, it is important to recognize the process from lung cysts or bullae to LC-CAS, especially the morphological changes of the cyst airspace and the cyst wall, in order to identify the malignant features of lung cysts in time.

Solitary Pulmonary Nodule Evaluation: Pearls and Pitfalls

Lung nodules are frequently encountered while interpreting chest CTs and are challenging to detect, characterize, and manage given they can represent both benign or malignant etiologies. An understanding of features associated with malignancy and causes of interpretive pitfalls is helpful to avoid misdiagnoses. This review addresses pertinent topics related to the etiologies for missed lung nodules on radiography and CT. Additionally, CT imaging technical pitfalls and challenges in addition to issues in the evaluation of nodule morphology, attenuation, and size will be discussed. Nodule management guidelines will be addressed as well as recent investigations that further our understanding of lung nodules.

Differential diagnosis of localized pneumonic-type lung adenocarcinoma and pulmonary inflammatory lesion

BACKGROUND

In clinical practice, a number of delayed diagnoses of localized pneumonic-type lung adenocarcinoma (L-PLADC) mimicking pneumonia have been identified due to the lack of knowledge regarding the radiological findings associated with this condition. Here, we defined L-PLADC as a special type of lung adenocarcinoma that presents as a focal consolidation involving < 50% of the area of a lobe and aimed to investigate the differential clinical and imaging features between L-PLADC and localized pulmonary inflammatory lesion (L-PIL).

RESULTS

The data of 120 patients with L-PLADC and 125 patients with L-PIL who underwent contrast-enhanced chest computed tomography (CT) scan were retrospectively analyzed. For clinical characteristics, older age, women, nonsmokers, and no symptom were more common in L-PLADC (all p < 0.001). With regard to CT features, air bronchogram, irregular air bronchogram, ground-glass opacity (GGO) component, and pleural retraction were more frequently observed in L-PLADC, while necrosis, satellite lesions, halo sign, bronchial wall thickening, interlobular septa thickening, pleural attachment, and pleural thickening were more commonly seen in L-PIL (all p < 0.001). Multivariate analysis showed age ≥ 58 years, female sex, GGO component, irregular air bronchogram, pleural retraction, and the absence of necrosis and pleural attachment were the most effective variations associated with L-PLADC with an AUC of 0.979. Furthermore, an external validation cohort containing 62 patients obtained an AUC of 0.929.

CONCLUSIONS

L-PLADC and L-PIL have different clinical and imaging characteristics. An adequate understanding of these differential features can contribute to the early diagnosis of L-PLADC and the subsequent therapeutic strategy.

Pneumonic-type lung adenocarcinoma with different ranges exhibiting different clinical, imaging, and pathological characteristics

Background

Pneumonic-type lung adenocarcinoma (PLADC) with different ranges might exhibit different imaging and clinicopathological features. This study divided PLADC into localized PLADC (L-PLADC) and diffuse PLADC (D-PLADC) based on imaging and aimed to clarify the differences in clinical, imaging, and pathologic characteristics between the two new subtypes.

Results

The data of 131 patients with L-PLADC and 117 patients with D-PLADC who were pathologically confirmed and underwent chest computed tomography (CT) at our institute from December 2014 to December 2020 were retrospectively collected. Patients with L-PLADC were predominantly female, non-smokers, and without respiratory symptoms and elevated white blood cell count and C-reactive protein level, whereas those with D-PLADC were predominantly male, smokers, and had respiratory symptoms and elevated white blood cell count and C-reactive protein level (all p < 0.05). Pleural retraction was more common in L-PLADC, whereas interlobular fissure bulging, hypodense sign, air space, CT angiogram sign, coexisting nodules, pleural effusion, and lymphadenopathy were more frequent in D-PLADC (all p < 0.001). Among the 129 patients with surgically resected PLADC, the most common histological subtype of L-PLADC was acinar-predominant growth pattern (76.7%, 79/103), whereas that of D-PLADC was invasive mucinous adenocarcinoma (80.8%, 21/26). Among the 136 patients with EGFR mutation status, L-PLADC had a significantly higher EGFR mutation rate than D-PLADC (p < 0.001).

Conclusions

L-PLADC and D-PLADC have different clinical, imaging, and pathological characteristics. This new imaging-based classification may help improve our understanding of PLADC and develop personalized treatment plans, with concomitant implications for patient outcomes.

Cystic Primary Lung Cancer: Evolution of Computed Tomography Imaging Morphology Over Time

PURPOSE

Primary lung cancers associated with cystic airspaces are increasingly being recognized; however, there is a paucity of data on their natural history. We aimed to evaluate the prevalence, pathologic, and imaging characteristics of cystic lung cancer in a regional thoracic surgery center with a focus on the evolution of computed tomography morphology over time.

MATERIALS AND METHODS

Consecutive patients referred for potential surgical management of primary lung cancer between January 2016 and December 2018 were included. Clinical, imaging, and pathologic data were collected at the time of diagnosis and at the time of the oldest computed tomography showing the target lesion. Descriptive analysis was carried out.

RESULTS

A total of 441 cancers in 431 patients (185 males, 246 females), median age 69.6 years (interquartile range: 62.6 to 75.3 y), were assessed. Overall, 41/441 (9.3%) primary lung cancers were cystic at the time of diagnosis. The remaining showed solid (67%), part-solid (22%), and ground-glass (2%) morphologies. Histopathology of the cystic lung cancers at diagnosis included 31/41 (76%) adenocarcinomas, 8/41 (20%) squamous cell carcinomas, 1/41 (2%) adenosquamous carcinoma, and 1/41 (2%) unspecified non-small cell lung carcinoma. Overall, 8/34 (24%) cystic cancers at the time of diagnosis developed from different morphologic subtype precursor lesions, while 8/34 (24%) cystic precursor lesions also transitioned into part-solid or solid cancers at the time of diagnosis.

CONCLUSIONS

This study demonstrates that cystic airspaces within lung cancers are not uncommon, and may be seen transiently as cancers evolve. Increased awareness of the spectrum of cystic lung cancer morphology is important to improve diagnostic accuracy and lung cancer management.

Computed Tomography Morphological Classification of Lung Adenocarcinoma and Its Correlation with Epidermal Growth Factor Receptor Mutation Status: A Report of 1075 Cases

Background

Many delayed diagnoses of lung adenocarcinoma (LADC) are identified due to poor understanding of protean imaging findings. Moreover, clarifying the relationship between computed tomography (CT) morphological classification and epidermal growth factor receptor (EGFR) mutations of LADC might inform therapeutic decision-making while obtaining pathological specimens is difficult. Here, we retrospectively analyzed CT manifestations of LADC and investigated the morphological classification of tumors in relation to EGFR mutation status.

Methods

We included 1075 LADC patients undergoing chest CT and EGFR genotype examinations from January 2013 to January 2019. CT morphological characteristics of tumors were carefully evaluated and their correlation with EGFR mutation status was analyzed using the chi-squared test.

Results

Tumors were divided into eight types: I (peripheral solid nodule/mass; 526/1075, 48.93%), II (central solid nodule/mass; 220/1075, 20.47%), III (subsolid nodule/mass; 92/1075, 8.56%), IV (focal consolidation; 32/1075, 2.98%), V (cystic airspace; 14/1075, 1.30%), VI (multiple lesions with similar appearances to I–V; 85/1075, 7.91%), VII (diffuse consolidation; 53/1075, 4.93%), VIII (occult lesion usually obscured by nonobstructive atelectasis; 53/1075, 4.93%). Type III and IV tumors were more frequent in patients with EGFR mutation, whereas type II and VII tumors were more common in patients without EGFR mutation (all P < 0.05). However, we did not identify any significant associations between other tumor types and EGFR mutation status (all P > 0.05). Among patients with type VI tumors, EGFR mutation status was closely related to tumor density (all P < 0.05). Furthermore, type VII tumors were associated with 19 deletion mutation positive and non-L858R mutation positive (all P < 0.05).

Conclusion

LADC can be categorized into eight types based on CT imaging. Improving our understanding of the morphological classification and correlation with EGFR mutation status may contribute to the accurate diagnosis of LADC, while suggesting the presence of underlying EGFR genetic mutations.

Prognosis of lung cancer associated with cystic airspaces: A propensity score matching analysis

OBJECTIVE

The association between the morphological characteristics and survival outcome of lung cancer associated with cystic airspaces (LCCAs) is unclear due to rarity of this disease. The current study attempted to compare the survival outcome between LCCAs and non-LCCAs and investigate the correlation between imaging features and prognosis of LCCA.

METHOD

Of 10,835 patients diagnosed with non-small cell lung carcinoma (NSCLC) between January 2015 and December 2016, 123 patients with LCCA were included. The non-LCCA group comprised 3136 patients with primary solitary adenocarcinoma or squamous cell lung cancer. Propensity score matching (PSM) was performed for age, sex, tumor size, tumor stage, and lymph node involvement in a 1:1 ratio between the LCCAs and non-LCCAs, and the correlation between radiological features and recurrence-free survival (RFS) was analyzed.

RESULT

The computed tomography (CT) lesion size was found to be higher in all LCCA subtypes, particularly in Type III (a cystic airspace with a mural nodule) and Type IV (mixed) LCCAs (3.09 and 3.65 cm, respectively), than in non-LCCAs (2 cm) after PSM. Three-year RFS in the LCCA group was higher than in the non-LCCA group (Type I- IV LCCAs: 100%, 84%, 77% and 83%, respectively vs. non-LCCAs: 77%). However, statistically significant difference was only found in comparison between LCCA Type I (thin-walled) and non-LCCA groups (P = 0.026). Type III lung cancer exhibited the worst survival among all four LCCA subtypes.

CONCLUSIONS

The CT lesion size and pathologic tumor size varied significantly across LCCAs. Type I LCCAs exhibited better survival than non-LCCAs, whereas Type III LCCAs exhibited the worst survival rate among the four LCCA subtypes.

Incidental Lung Nodules on Cross-sectional Imaging: Current Reporting and Management

Pulmonary nodules are the most common incidental finding in the chest, particularly on computed tomographs that include a portion or all of the chest, and may be encountered more frequently with increasing utilization of cross-sectional imaging. Established guidelines address the reporting and management of incidental pulmonary nodules, both solid and subsolid, synthesizing nodule and patient features to distinguish benign nodules from those of potential clinical consequence. Standard nodule assessment is essential for the accurate reporting of nodule size, attenuation, and morphology, all features with varying risk implications and thus management recommendations.

Clinical Value and Pathologic Basis of Cystic Airspace Within Subsolid Nodules Confirmed as Lung Adenocarcinomas by Surgery

PURPOSE

To investigate the clinical value and pathologic basis of cystic airspace within lung adenocarcinomas manifesting as subsolid nodules.

PATIENTS AND METHODS

A retrospective study was conducted on a total of 541 surgically confirmed lung adenocarcinomas manifesting as subsolid nodules in computed tomography images, including 87 cases with cystic airspace and 454 cases without cystic airspace. The pathologic characteristics of the cases with and without cystic airspace were compared. The investigation of the pathologic structure of cystic airspace was attempted on the postoperative paraffin sections.

RESULTS

There was a significant difference in the containing of cystic airspace between preinvasive and invasive adenocarcinomas (10.5 vs 26.6%; P < .001). Multivariate analysis indicated that cystic airspace is an independent predictor of invasive adenocarcinomas (odds ratio, 3.220; 95% confidence interval, 1.822-5.687). Nodules containing multiple cystic airspaces are more likely to be invasive adenocarcinomas than nodules with a single cystic airspace (47.1 vs 72.2%; P < .05). On paraffin sections, the walls of the cystic airspace seemed to be mainly composed of atypical hyperplasia and/or tumor cells on the surface and the remaining smooth muscle cells and stroma below, which is similar to the structure of bronchi.

CONCLUSIONS

Cystic airspace may be a reliable predictor of invasive adenocarcinomas, the classification method based on the number of cystic airspaces might be suitable for the computed tomography-based typing of cystic airspace within subsolid nodules. Cystic airspace may derive from the destroyed and enlarged bronchi owing to the growth or infiltration of atypical hyperplasia and/or tumor cells.

Molecular profiling in lung cancer associated with cystic airspaces

'Lung cancer associated with cystic airspaces' is a rare radiological entity that is more frequently encountered on imaging studies and is gaining more attention since the widespread use of CT for lung cancer screening. Numerous aspects of this entity remain unraveled, including molecular profiling. The goal of this observational retrospective single-center case series is to investigate the molecular profile of lung cancers presenting with this specific morphology in a Caucasian population. Between January 2014 and May 2017, 13 patients were presented at the Multidisciplinary Thoracic Oncology Tumor Board with imaging findings consistent with 'lung cancer associated with cystic airspaces'. Electronic medical files were reviewed for patient characteristics, stage, histopathological findings and - in particular - molecular profiling. Histopathological diagnosis showed adenocarcinoma in 11 patients in our series. Mutational analysis in 10 showed different molecular alterations: an EGFR exon 18 mutation, ROS1 rearrangement and BRAF mutation in one patient each. Two patients showed KRAS mutations. With 5 out of 10 patients with an adenocarcinoma presenting with cystic airspace morphology showing a molecular alteration, this may indicate that in this subgroup, molecular profiling is mandatory, regardless of smoking history.

Pulmonary mucosa-associated lymphoid tissue lymphoma: CT findings and pathological basis

BACKGROUND

Pulmonary mucosa-associated lymphoid tissue lymphoma (MALToma) is the most frequent subset of primary pulmonary lymphoma. This study aimed to identify radiologic characteristics of pulmonary MALToma based on computed tomography (CT) observations and pathologic features, and further investigate its prognosis.

METHODS

Sixty-six patients (55.4 ± 10.9 years; 51.5% male) diagnosed as pulmonary MALToma by pathology were retrospectively enrolled. According to distributions and features of lesions shown on CT, patients were divided into three patterns, including single nodular/mass, multiple nodular/mass, and pneumonia-like consolidative.

RESULTS

Variety of the location and extent of the lymphomatous infiltration accounted for different characteristics demonstrated at CT. The pneumonia-like consolidative pattern was the most frequent pattern observed in 42 patients (63.6%), followed by single nodular/mass (21.2%) and multiple nodular/mass (15.2%). CT features included air bronchogram (72.7%), well-marginated halo sign (53.0%), coarse spiculate with different lengths (72.7%), angiogram sign (77.1% of 35 patients), peribronchovascular thickening (48.5%), irregular cavitation (16.7%) and pulmonary cyst (7.6%). The estimated 5-year cumulative overall survival rate of pulmonary MALToma was 100.0%.

CONCLUSIONS

Pulmonary MALToma demonstrates several characteristics at CT. Identification of the significant pulmonary abnormalities of this indolent disease entity might be helpful for early diagnosis and optimal treatment.

Clinicopathologic and Longitudinal Imaging Features of Lung Cancer Associated With Cystic Airspaces: A Systematic Review and Meta-Analysis

BACKGROUND. Lung cancer (LC) associated with cystic airspaces is an uncommon presentation that is underrecognized on imaging. Additionally, understanding of its underlying pathology and risk factors is limited, which can contribute to delays in diagnosis. OBJECTIVE. The purpose of this analysis was to systematically review, analyze, and synthesize the medical literature to determine the imaging features of LC associated with cystic airspaces. EVIDENCE ACQUISITION. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included published research reporting the clinical, pathologic, and imaging features of LC associated with cystic airspaces. We then performed a pooled analysis of continuous and categoric data with respect to patient clinical characteristics, tumor pathologic features, underlying driver mutation, CT features, and evolution of these features over time. EVIDENCE SYNTHESIS. The analysis included eight original observational studies with a combined total of 341 patients with LC associated with cystic airspaces (weighted mean age, 61.8 years; range, 30-87 years; 135 women and 206 men). Most patients were current or previous smokers (127/192 [66.1%]). The most common histologic finding was adenocarcinoma (289/328 [88.1%]) followed by squamous cell carcinoma (30/328 [9.1%]). The most common driver mutations were EGFR (46/122 [37.7%]) and KRAS (21/122 [17.2%]). The cysts in LC associated with cystic airspaces commonly had nonuniform (104/114 [91.2%]) and thick (83/222 [37.4%]) walls, irregular margins (53/142 [37.3%]), and were unilocular (173/272 [63.6%]). Most cysts had a nodular component (210/328 [64.0%]). Over time, most cysts showed development or enlargement of the nodular component (61/89 [68.5%]), approximately half showed wall thickening (43/89 [48.3%]), and a minority evolved into completely solid lesions (11/89 [12.4%]). The size of the cystic component increased in 36 of 89 patients (40.4%), decreased in 28 (31.5%), and remained stable in 24 (27.0%). CONCLUSION. LC associated with cystic airspaces occurs most commonly as adeno-carcinoma and is seen in both smokers and nonsmokers. The cysts associated with LC show wall thickening and mural nodularity, which may evolve over time. LC associated with cystic airspaces can be indolent, and long-term surveillance with imaging should be considered if cysts are not resected. CLINICAL IMPACT. Familiarity with the imaging features and temporal evolution of LC associated with cystic airspaces can minimize delays in LC diagnosis. Future management guidelines should include protocols for follow-up and management of cystic lung lesions identified during diagnostic and LC screening CT.

Diagnostic Accuracy of CT-Guided Core Needle Biopsy for Thin-Walled Cavitary Pulmonary Lesions

OBJECTIVE. The purpose of this article is to evaluate the accuracy of and complications with CT-guided percutaneous core needle biopsy (CNB) of thin-walled cavitary pulmonary lesions. MATERIALS AND METHODS. This retrospective study involved 32 CNBs in 30 patients who had thin-walled cavitary pulmonary lesions (wall thickness < 5 mm) and underwent CT-guided CNB. After the 30 patient records were evaluated for the diagnostic accuracy, sensitivity, and specificity of CT-guided CNB, the results were compared with the final diagnosis after surgery or clinical follow-up. Each patient was reviewed for complications including pneumothorax, thoracotomy tube insertion, hemorrhage, and hemoptysis. RESULTS. The final diagnosis indicated 19 malignant and 11 benign lesions. Two lesions with indeterminate biopsy results (anthracofibrosis and focal interstitial thickening) were excluded. The sensitivity, specificity, and diagnostic accuracy of thin-walled cavities were 89.5%, 100%, and 93.3%, respectively. There were no statistical differences in the accuracy, sensitivity, or specificity according to wall thickness, cavity size, or lesion depth. Chest CT immediately after biopsy revealed mild pneumothorax in seven patients and moderate to severe pneumothorax requiring placement of a thoracotomy tube in one patient. CT after biopsy indicated mild parenchymal hemorrhage in 15 patients and hemoptysis in one patient. CONCLUSION. CT-guided CNB is a useful and accurate diagnostic technique for biopsy of a pulmonary thin-walled cavity.

Missed Lung Cancers on Chest Radiograph: An Illustrative Review of Common Blind Spots on Chest Radiograph with Emphasis on Various Radiologic Presentations of Lung Cancers

Missed lung cancers on chest radiograph (CXR) may delay the diagnosis and affect the prognosis. CXR is the primary imaging modality to evaluate the lungs and mediastinum in daily practice. The purpose of this article is to review chest radiographs for common blind spots and highlight the importance of various radiologic presentations in primary lung cancer to avoid significant diagnostic errors on CXR.

A Non-Enzymatic Sensor Based on Trimetallic Nanoalloy with Poly (Diallyldimethylammonium Chloride)-Capped Reduced Graphene Oxide for Dynamic Monitoring Hydrogen Peroxide Production by Cancerous Cells

Catching cancer at an early stage is necessary to make it easier to treat and to save people's lives rather than just extending them. Reactive oxygen species (ROS) have sparked a huge interest owing to their vital role in various biological processes, especially in tumorigenesis, thus leading to the potential of ROS as prognostic biomarkers for cancer. Herein, a non-enzymatic biosensor for the dynamic monitoring of intracellular hydrogen peroxide (H2O2), the most important ROS, via an effective electrode composed of poly (diallyldimethylammonium chloride) (PDDA)-capped reduced graphene oxide (RGO) nanosheets with high loading trimetallic AuPtAg nanoalloy, is proposed. The designed biosensor was able to measure H2O2 released from different cancerous cells promptly and precisely owing to the impressive conductivity of RGO and PDDA and the excellent synergistic effect of the ternary alloy in boosting the electrocatalytic activity. Built upon the peroxidase-like activity of the nanoalloy, the developed sensor exhibited distinguished electrochemical performance, resulting in a low detection limit of 1.2 nM and a wide linear range from 0.05 μM to 5.5 mM. Our approach offers a significant contribution toward the further elucidation of the role of ROS in carcinogenesis and the effective screening of cancer at an early stage.