Pictorial essay of radiological features of benign intrathoracic masses

Chronic Cough: a Symptom between Pulmonary and Psychogenic Disease. A Case of Misdiagnosed Endobronchial Hamartoma

Endobronchial hamartoma is a benign mesenchymal tumor. It contains fat, cartilage and even bone tissue. It can be asymptomatic or cause respiratory symptoms such as cough and pneumonias. We report a case of a 68-year-old male who suffered from cough for the last four years. During this period of time, he was treated with different therapeutic approaches, including antibiotics, inhaled corticosteroids, pregabaline and bronchodilators, without clinical improvement. Allergic and gastrointestinal diseases were excluded. Pulmonary function tests were all normal. His symptoms had been attributed to anxiety disorder as psychogenic cough. However, a chest computed tomography (CT) was never conducted. Chest CT and bronchoscopy revealed an endobronchial hamartoma. Its endoscopical removal led to impressive remission of symptoms.

Bronchoscopic Management of Endobronchial Atypical Carcinoid With Argon Plasma Coagulation and Laser: A Rare Case With Literature Review

Atypical carcinoid belongs to a spectrum of neuroendocrine tumors that can present as central airway obstruction. We treated a 58-year-old female who presented with recurrent pneumonia. Flexible bronchoscopy showed complete obstruction of the tumor in the right lower lobe. The tumor was excised by electrocautery snare followed by laser and argon plasma coagulation (APC). Endobronchial biopsy showed atypical carcinoid with lymph node metastasis. Succeeding bronchoscopic management, the patient's symptoms improved. In our patient, bronchoscopy with laser and APC was performed to prevent tumor recurrence after resection and reduce the risk of recurrent postobstructive pneumonia. Surveillance computed tomography at six months showed no evidence of recurrence. Bronchoscopic management should be considered in poor surgical candidates or patients with metastatic disease.

Pulmonary infarction mimicking a lung mass: a case report

Pulmonary infarction usually appears as a wedge-shaped opacity with its base placed laterally. Rarely, pulmonary infarctions may appear as a well-defined rounded opacity mimicking lung cancer and surgical lung biopsy may often be required for definitive diagnosis. We report a patient who was admitted with submassive pulmonary embolism who had an incidental finding of a well-defined opacity in computed tomography (CT) scan. The lesion was avid on positron emission tomography (PET) scan and the patient was a smoker. So, we investigated him further with a percutaneous and later a thoracoscopic lung biopsy. Tumour-like pulmonary infarction is often a challenge for the clinicians.

Clinical efficacy of acetylcysteine combined with tetrandrine tablets on patients with silicosis and its effect on exercise tolerance and pulmonary function

Clinical efficacy of acetylcysteine combined with tetrandrine tablets in the treatment of silicosis was investigated to observe the exercise tolerance and pulmonary function of the patients. The clinical data of 248 cases of silicosis patients treated in Branch of Tai'an City Central Hospital were retrospectively analyzed in this study, including 116 cases with conventional therapy (control group), and 132 cases treated with acetylcysteine and tetrandrine tablets on the basis of conventional therapy (observation group). The chest tightness, chest pain, cough and sputum production were evaluated by the St. George Respiratory questionnaire (SGRQ); and side effects after treatment were recorded. Exercise tolerance was measured by 6-min walk test (6MWT) and pulmonary function was measured by pulmonary function instrument. The symptoms of chest tightness, chest pain, cough and sputum production in the observation group and the control group after 8 months of treatment were significantly lower than those before treatment (P<0.05), and that in the observation group after treatment was significantly higher than that in the control group (P<0.05). The incidence of side effects of the drug in the observation group was significantly lower than that in the control group (P<0.05). The 6MWT, forced vital capacity (FVC) and forced expiratory volume in 1 sec (FEV1) in the observation group and the control group after treatment were significantly higher than those before treatment (P<0.001); the 6MWT in the observation group after treatment was significantly higher than that in the control group (P<0.001). In conclusion, acetylcysteine combined with tetrandrine tablets on the basis of conventional therapy in treatment of silicosis is more effective than conventional therapy alone, which can also improve exercise tolerance, pulmonary function and clinical symptoms such as chest tightness, chest pain, cough, sputum production of silicosis patients, and is helpful for clinical application.

Pleural lipomatosis: An often-forgotten intrathoracic tumor

Lipomas are benign mesenchymal neoplasms that arise from adipocytes. Most lipomas are found in the subcutaneous tissue; however, they can be present throughout the body. Lipomas arising from the thoracic pleura are exceptionally rare, with only approximately 20 cases ever reported in the literature. While typically asymptomatic, pleural lipomas may cause compressive symptoms such as nonproductive cough, chest pain, and dyspnea if they reach adequate size. A CT scan is usually sufficient for the diagnosis and typically reveals well-defined nodules with homogenous fat attenuation of approximately -50 to -150 Hounsfield units. Management is dependent on various factors including tumor size and location, associated symptoms, and age of the patient. Pleural lipomatosis, although exceedingly rare, should be maintained in the differential diagnosis for any well-defined, fat-attenuating pleural mass identified on conventional radiologic studies. Here we report a case of pleural lipomatosis associated with bilateral pleural effusions identified in an 83-year-old male presenting with acute onset dyspnea.

Real-time intraprocedural 18F-FDG PET/CT-guided biopsy using automated robopsy arm (ARA) in the diagnostic evaluation of thoracic lesions with prior inconclusive biopsy results: initial experience from a tertiary health care centre

OBJECTIVE

The aim of this study was to assess the feasibility and appraise the diagnostic utility of real time ¹⁸F-FDG PET/CT-guided biopsy under automated robopsy arm (ARA) guidance for the evaluation of thoracic lesions with prior inconclusive biopsy results.

METHODS

PET/CT-guided biopsy of thoracic lesions was performed in patients who had at least one previous inconclusive biopsy. A total of 25 patients (male:female-18 males, 7 females; age: range, 13-75; mean, 53.7) were included in this study. All these patients underwent percutaneous needle biopsies under real-time PET/CT guidance using ARA (ROBIO-EX, Perfint healthcare Pvt Ltd, Chennai, India) needle navigation technique. Histopathology and clinical follow-up results were reviewed for assessing the accuracy of procedures.

RESULTS

Adequate representative tissue sample could be retrieved in all the patients. No major procedure-related complications were encountered in any patient. Of the 25 procedures, 21 lesions were positive for malignancy and benign findings were observed in the other 4 lesions on histopathology. None of the patients required further biopsy in arriving at a final diagnosis. Overall diagnostic yield of the procedure was 100%.

CONCLUSION

Real time ¹⁸F-FDG PET/CT guidance for percutaneous biopsies of lung and mediastinal lesions is a feasible technique with potential utility in patients with previous inconclusive biopsy results. Advances in knowledge: ¹⁸F-FDG PET/CT guidance reduces the sampling errors by specifically targeting areas of viability and avoiding necrosis/atelectasis. A navigational tool like ARA is thought to help in accurately targeting these areas.

Endobronchial hamartoma; a rare structural cause of chronic cough

Pulmonary hamartomas are rare benign tumors consisting of multiple mesenchymal cell lines like cartilage, bone and fat. We discuss an interesting case of a 53-year-old male patient, who was referred to our clinic for persistent cough. Chest X-ray revealed a left suprahilar density associated with plate like atelectasis, which on chest CT was found to be a densely calcified nodule, causing narrowing of the left upper lobe (LUL) bronchus with calcified bilateral hilar lymph nodes. A bronchoscopy revealed a smooth endobronchial mass with calcification, which was removed. Histopathology revealed pulmonary hamartoma.

Dynamic CT imaging of volumetric changes in pulmonary nodules correlates with physical measurements of stiffness

BACKGROUND AND PURPOSE

A major challenge in CT screening for lung cancer is limited specificity when distinguishing between malignant and non-malignant pulmonary nodules (PN). Malignant nodules have different mechanical properties and tissue characteristics ('stiffness') from non-malignant nodules. This study seeks to improve CT specificity by demonstrating in rats that measurements of volumetric ratios in PNs with varying composition can be determined by respiratory-gated dynamic CT imaging and that these ratios correlate with direct physical measurements of PN stiffness.

METHODS AND MATERIALS

Respiratory-gated MicroCT images acquired at extreme tidal volumes of 9 rats with PNs from talc, matrigel and A549 human lung carcinoma were analyzed and their volumetric ratios (δ) derived. PN stiffness was determined by measuring the Young's modulus using atomic force microscopy (AFM) for each nodule excised immediately after MicroCT imaging.

RESULTS

There was significant correlation (p=0.0002) between PN volumetric ratios determined by respiratory-gated CT imaging and the physical stiffness of the PNs determined from AFM measurements.

CONCLUSION

We demonstrated proof of concept that PN volume changes measured non-invasively correlate with direct physical measurements of stiffness. These results may translate clinically into a means of improving the specificity of CT screening for lung cancer and/or improving individual prognostic assessments based on lung tumor stiffness.

Magnetic resonance imaging of the mediastinum, chest wall and pleura in children

The acceptance of applications for the use of chest MRI in children has been somewhat slow and selective. The use of MRI to image chest wall lesions is likely the most common and widely used indication, aside from the widespread and somewhat sophisticated use of MRI in imaging the cardiovascular structures of the chest. In this respect, fairly standard variations of T1-W, T2-W and contrast-enhanced imaging can be used, similar to the sequences used for musculoskeletal lesions elsewhere in the body. Imaging of the anterior mediastinal masses should be performed in conjunction with a detailed pre-test clinical examination to determine potential cardiovascular compromise. MRI in the setting of middle mediastinal adenopathy, congenital mediastinal cysts or posterior mediastinal masses, however, has been shown to be more effective and more comprehensive than multidetector CT. Although sonographic imaging is the initial modality of choice for pleural abnormalities, MR imaging is extremely effective and clinically useful in the setting of a potentially ambiguous sonographic examination. Faster imaging protocols are likely to increase the acceptance of MRI to replace multidetector CT for many pediatric chest lesions.

Endobronchial Hamartoma Subtotally Occluding the Right Main Bronchus and Mimicking Bronchial Carcinoid Tumor

Hamartomas are very rarely identified as an endobronchial lesion. Herein, we describe a peculiar case of a 55-year-old woman with persistent cough and increasing dyspnea and radiological detection of a solid lesion subtotally occluding the main right bronchus. Despite the radiological and radiometabolic (18-fluoro-2-deoxy-d-glucose positron emission tomography/computer tomography scan) features were highly suspected for bronchial carcinoid, the definitive diagnosis after endoscopic removal was indicative of an endobronchial hamartoma. When considering differential diagnosis of an endobronchial lesion, the physicians should take firmly in mind such rare entity and, accordingly, bronchoscopy and bronchoscopic biopsy should be done as first step in management of all cases presenting with endobronchial lesions.