Imatinib Treatment of Lymphangiomatosis (Generalized Lymphatic Anomaly).

Lymphangiomatosis (eg, generalized lymphatic anomaly) is an abnormal proliferation of lymphatic endothelial cells. It is often a childhood disease, but it may present in adulthood by infiltrating organs and cause obstruction, bleeding, or disruption of lymphatic flow. Pulmonary involvement may be mild or cause diffuse interstitial lung disease, airway obstruction, hemoptysis, chylothorax, chylopericardium, and culminate in respiratory failure. Treatment has been limited to surgical resection or drainage procedures because there is no accepted effective systemic therapy. This report presents a patient with lymphangiomatosis and life-threatening hemoptysis in whom positive immunostaining forc-KITsuggested upregulation of tyrosine kinase and whose disease was controlled with imatinib.

Surgical lung biopsy in adult respiratory distress syndrome: a meta-analysis.

BACKGROUND: Adult respiratory distress syndrome (ARDS) has a high mortality rate and consumes considerable health care resources. It is not clear whether specimens obtained from open lung biopsy (OLB) in ARDS provide a specific diagnosis, alter therapy, or affect outcome. This meta-analysis attempts to determine whether OLB is safe, provides a specific diagnosis, changes therapy, or affects survival. METHODS: A computerized search was performed of Medline and PubMed from January 1988 to December 2012 of English language studies of acute respiratory failure and diffuse pulmonary infiltrates that evaluated OLB in primarily adult mechanically ventilated patients. Of 194 abstracts retrieved, 64 articles were reviewed; 130 articles were excluded because they did not evaluate OLB. After applying the selection criteria, 24 articles were included. RESULTS: OLB in ARDS provided a specific diagnosis in 84% of patients and altered management in 73%. Hospital mortality was 43%. The complication rate for OLB in ARDS was 22%, but death from OLB was rare. CONCLUSIONS: OLB in ARDS is a potentially productive procedure that provides a specific diagnosis and leads to a change in management in high proportions of patients. ARDS has a high mortality rate, which OLB does not appear to increase. Owing to a lack of randomized controlled trials, a survival advantage of OLB in ARDS could not be demonstrated.

Outcomes of unresected ground-glass nodules with cytology suspicious for adenocarcinoma.

BACKGROUND: Five-year survival rates for resected stage I adenocarcinoma approach 100%. Given previous studies describing the prolonged indolent natural history of ground-glass lesions suspicious for early adenocarcinoma, our purpose in this study was to determine if outcomes were different among patients who were observed for radiographic and biopsy suspected early adenocarcinoma compared with those who were resected immediately. METHODS: We identified 63 patients with no prior history of lung adenocarcinoma who had undergone computer tomography-guided fine-needle aspiration of ground-glass opacities with cytology concerning for new early adenocarcinoma between January 2002 and December 2011. We compared the clinical outcomes of patients who were resected after abnormal cytology results and those who opted for watchful waiting. RESULTS: Sixteen patients elected to observe their ground-glass nodules despite having suspicious cytology results, whereas 47 opted for immediate resection. Of the 16 observed patients, six (37.5%) ultimately demonstrated growth or increase solid component of the ground-glass nodule. Five of these patients elected for definitive therapy by surgical resection or radiation. There were no occurrences of distant metastasis or lung cancer-associated deaths in the observed group. Of the 47 resected patients, two developed metastatic disease, five developed new cancers in remaining lung, and three developed progression in existing ground-glass nodules. CONCLUSIONS: Ground-glass lesions that were observed after biopsy did not demonstrate any increased rates of metastasis or cancer-related deaths and delayed resection does not seem to have a negative effect on outcomes.

Lung cancer associated with cystic airspaces.

OBJECTIVE: The objectives of this study were to determine the frequency of lung cancers associated with a discrete cystic airspace and to characterize the morphologic and pathologic features of the cancer and the cystic airspace. MATERIALS AND METHODS: We reviewed all diagnosed cases of lung cancer resulting from baseline screening (n=595) and annual screening (n=111) in the International Early Lung Cancer Action Program to identify those abutting or in the wall of a cystic airspace. We also reviewed the pathologic specimens. RESULTS: A total of 26 lung cancers were identified abutting or in the wall of a cystic airspace. Of these, 13 were identified at baseline (13/595, 2%) and 13 at annual screening (13/111, 12%), which was significant (p<0.0001). The median circumferential portion of wall involved was less for the annual cancers than for the baseline ones, but this difference did not reach significance (90° vs 240°, p=0.07). The diagnosis was adenocarcinoma in all but three cases. Histologic analysis showed that the cystic space was a bulla, a fibrous walled cyst without a defined lining, or a pleural bleb and that in all but one case, the tumor was eccentric relative to the airspace and the wall of the airspace was unevenly thickened. CONCLUSION: At annual repeat CT screening, the finding of an isolated cystic airspace with increased wall thickness should raise the suspicion of lung cancer.

Radiographic and clinical characterization of false negative results from CT-guided needle biopsies of lung nodules.

INTRODUCTION: Computed tomography-guided transthoracic fine-needle aspiration (FNA) is a highly sensitive technique for diagnosing malignancy in pulmonary nodules; however, there is great uncertainty regarding the reliability of a benign result. The goal of this study was to characterize the clinical, radiologic, and technical variables associated with a false negative result. METHODS: We performed a consecutive series review of patients who had an initial benign result from an FNA between January 2002 and December 2004. Medical charts were reviewed to identify patients with false negative and true negative results and determine which variables were associated with a missed diagnosis. RESULTS: One hundred and seventy patients underwent an FNA biopsy yielding an initial benign result and had adequate clinical follow-up. Eighteen of these proved to be false negatives and 152 were true negative. Compared with the patients with true negatives, those with false negative results had significantly larger nodules (mean, 27 mm versus 17 mm, p = 0.04), fewer imaging adjustments per needle pass (4.5 versus 6.4, p = 0.01), a higher proportion in whom the needle tip was not documented within the lesion (24% versus 5%, p =0.04), and a higher pneumothorax rate at any point during the procedure (50% versus 22%, p =0.04). When these variables were considered jointly, pneumothorax (p = 0.006), solitary nodule (p = 0.04), and the radiologist who performed the procedure (p = 0.04) were significant predictors of false negative results. CONCLUSIONS: Factors that were associated with false negative results include increased size of lesion, fewer adjustments of the needle, lack of positive cultures, and the occurrence of a pneumothorax. A benign FNA biopsy result should have the procedure reviewed to ensure the results are reliable.

Lung cancers diagnosed at annual CT screening: volume doubling times.

PURPOSE: To empirically address the distribution of the volume doubling time (VDT) of lung cancers diagnosed in repeat annual rounds of computed tomographic (CT) screening in the International Early Lung Cancer Action Program (I-ELCAP), first and foremost with respect to rates of tumor growth but also in terms of cell types. MATERIALS AND METHODS: All CT screenings in I-ELCAP from 1993 to 2009 were performed according to HIPAA-compliant protocols approved by the institutional review boards of the collaborating institutions. All instances of first diagnosis of primary lung cancer after a negative screening result 7-18 months earlier were identified, with symptom-prompted diagnoses included. Lesion diameter was calculated by using the measured length and width of each cancer at the time when the nodule was first identified for further work-up and at the time of the most recent prior screening, 7-18 months earlier. The length and width were measured a second time for each cancer, and the geometric mean of the two calculated diameters was used to calculate the VDT. The χ(2) statistic was used to compare the VDT distributions. RESULTS: The median VDT for 111 cancers was 98 days (interquartile range, 108). For 56 (50%) cancers it was less than 100 days, and for three (3%) cancers it was more than 400 days. Adenocarcinoma was the most frequent cell type (50%), followed by squamous cell carcinoma (19%), small cell carcinoma (19%), and others (12%). Lung cancers manifesting as subsolid nodules had significantly longer VDTs than those manifesting as solid nodules (P < .0001). CONCLUSION: Lung cancers diagnosed in annual repeat rounds of CT screening, as manifest by the VDT and cell-type distributions, are similar to those diagnosed in the absence of screening.

Emphysema scores predict death from COPD and lung cancer.

OBJECTIVE: Our objective was to assess the usefulness of emphysema scores in predicting death from COPD and lung cancer. METHODS: Emphysema was assessed with low-dose CT scans performed on 9,047 men and women for whom age and smoking history were documented. Each scan was scored according to the presence of emphysema as follows: none, mild, moderate, or marked. Follow-up time was calculated from time of CT scan to time of death or December 31, 2007, whichever came first. Cox regression analysis was used to calculate the hazard ratio (HR) of emphysema as a predictor of death. RESULTS: Median age was 65 years, 4,433 (49%) were men, and 4,133 (46%) were currently smoking or had quit within 5 years. Emphysema was identified in 2,637 (29%) and was a significant predictor of death from COPD (HR, 9.3; 95% CI, 4.3-20.2; P < .0001) and from lung cancer (HR, 1.7; 95% CI, 1.1-2.5; P = .013), even when adjusted for age and smoking history. CONCLUSIONS: Visual assessment of emphysema on CT scan is a significant predictor of death from COPD and lung cancer.

Ordinal scoring of coronary artery calcifications on low-dose CT scans of the chest is predictive of death from cardiovascular disease.

PURPOSE: To assess the usefulness of ordinal scoring of the visual assessment of coronary artery calcification (CAC) on low-dose computed tomographic (CT) scans of the chest in the prediction of cardiovascular death. MATERIALS AND METHODS: All participants consented to low-dose CT screening according to an institutional review board-approved protocol. The amount of CAC was assessed on ungated low-dose CT scans of the chest obtained between June 2000 and December 2005 in a cohort of 8782 smokers aged 40-85 years. The four main coronary arteries were visually scored, and each participant received a CAC score of 0-12. The date and cause of death was obtained by using the National Death Index. Follow-up time (median, 72.3 months; range, 0.3-91.9 months) was calculated as the time between CT and death, loss to follow-up, or December 31, 2007, whichever came first. Logistic regression analysis was used to determine the risk of mortality according to CAC category adjusted for age, pack-years of cigarette smoking, and sex. The same analysis to determine the hazard ratio for survival from cardiac death was performed by using Cox regression analysis. RESULTS: The rate of cardiovascular deaths increased with an increasing CAC score and was 1.2% (43 of 3573 subjects) for a score of 0, 1.8% (66 of 3569 subjects) for a score of 1-3, 5.0% (51 of 1015 subjects) for a score of 4-6, and 5.3% (33 of 625 subjects) for a score of 7-12. With use of subjects with a CAC score of 0 as the reference group, a CAC score of at least 4 was a significant predictor of cardiovascular death (odds ratio [OR], 4.7; 95% confidence interval: 3.3, 6.8; P < .0001); when adjusted for sex, age, and pack-years of smoking, the CAC score remained significant (OR, 2.1; 95% confidence interval: 1.4, 3.1; P = .0002). CONCLUSION: Visual assessment of CAC on low-dose CT scans provides clinically relevant quantitative information as to cardiovascular death.

Elevated carcinoembryonic antigen and sarcoidosis masquerading as metastatic colon cancer.

When patients with colorectal cancer are monitored after resection of primary or metastatic disease, an elevated carcinoembryonic antigen (CEA) level is usually an indicator of recurrent disease. Positron emission tomography (PET) scans are often used to locate the site of recurrences when computed tomography scans do not show the presence of disease. This case highlights an important cause of a falsely elevated CEA with abnormal PET imaging.

Survival of patients with stage I lung cancer detected on CT screening.

BACKGROUND: The outcome among patients with clinical stage I cancer that is detected on annual screening using spiral computed tomography (CT) is unknown. METHODS: In a large collaborative study, we screened 31,567 asymptomatic persons at risk for lung cancer using low-dose CT from 1993 through 2005, and from 1994 through 2005, 27,456 repeated screenings were performed 7 to 18 months after the previous screening. We estimated the 10-year lung-cancer-specific survival rate among participants with clinical stage I lung cancer that was detected on CT screening and diagnosed by biopsy, regardless of the type of treatment received, and among those who underwent surgical resection of clinical stage I cancer within 1 month. A pathology panel reviewed the surgical specimens obtained from participants who underwent resection. RESULTS: Screening resulted in a diagnosis of lung cancer in 484 participants. Of these participants, 412 (85%) had clinical stage I lung cancer, and the estimated 10-year survival rate was 88% in this subgroup (95% confidence interval [CI], 84 to 91). Among the 302 participants with clinical stage I cancer who underwent surgical resection within 1 month after diagnosis, the survival rate was 92% (95% CI, 88 to 95). The 8 participants with clinical stage I cancer who did not receive treatment died within 5 years after diagnosis. CONCLUSIONS: Annual spiral CT screening can detect lung cancer that is curable.

CT screening for lung cancer: the value of short-term CT follow-up.

BACKGROUND: Although CT screening for lung cancer results in a diagnosis of stage I > 80% of the time, benign noncalcified nodules are also found. We recognized that some nodules appeared to represent infectious bronchopneumonia or other inflammatory processes, as they resolved on follow-up CT, sometimes after antibiotic therapy. To determine the extent to which short-term CT radiographic follow-up might shorten the workup of nodules, we reviewed our experience with baseline and annual repeat CT screenings performed subsequent to the original Early Lung Cancer Action Project series. METHODS: The initial CT of 1,968 consecutive baseline and 2,343 annual repeat screenings performed from 1999 to 2002 was reviewed. We identified all those recommended for antibiotics on the initial CT who had a follow-up CT within 2 months and determined whether the nodule(s) resolved, decreased in size, remained unchanged, or grew. We then determined whether further follow-up resulted in a diagnosis of cancer. RESULTS: At baseline, among the 41 individuals who had follow-up CT within 2 months of the initial CT, 12 patients (29%) had complete or partial resolution; none of them subsequently received a diagnosis of lung cancer. On annual repeat screening, among the 39 individuals who had follow-up CT within 2 months of the initial CT, 29 patients (74%) had complete or partial resolution; none of them subsequently received a diagnosis of lung cancer. Among the 29 patients with nodules at baseline that were unchanged or grew, a total of 15 cancers were subsequently diagnosed; among the 10 patients on annual repeat scanning, there were 2 cancers. CONCLUSIONS: In asymptomatic individuals undergoing CT screening for lung cancer, short-term follow-up CT within 2 months with or without antibiotics may circumvent the need for further evaluation in some individuals, particularly on annual repeat screening.

Managing the small pulmonary nodule discovered by CT.

OBJECTIVES: To review the Early Lung Cancer Action Project experience and the medical literature from 1993 to 2003 on detection of the small, noncalcified pulmonary nodule by CT in order to formulate a management algorithm for these nodules. DESIGN: Prospective noncomparative study of smokers without prior malignancy and a review of the medical literature of CT screening of lung cancer. INTERVENTIONS: Chest CT and, where appropriate, CT observation for nodule growth, antibiotics, CT-guided fine-needle aspiration (FNA) biopsy, fiberoptic bronchoscopy, and video-assisted thoracoscopic surgery (VATS). RESULTS: The following factors influence the probability of malignancy in a CT-detected, small, noncalcified pulmonary nodule: size, change in size, age, smoking history, density, number of nodules, gender, circumstance of the CT, spirometry, occupational history, and endemic granulomatous disease. The two diagnostic techniques most useful in evaluating the CT-detected, small, noncalcified nodule are short-term observation of nodule growth by CT and CT-guided FNA. Due to small nodule size and the frequent finding of nonsolid or part-solid nodules, positron emission tomography, fiberoptic bronchoscopy, and VATS were less useful. CONCLUSIONS: Pulmonologists are frequently asked to evaluate the CT-detected, small, noncalcified nodule invisible on standard chest radiography. Immediate biopsy is justified if the likelihood of cancer is high, but if that likelihood is low or intermediate, a period of observation by CT is appropriate. VATS or thoracotomy are rarely necessary for a diagnosis of lung cancer in the CT-detected small pulmonary nodule.

CT screening for lung cancer: suspiciousness of nodules according to size on baseline scans.

PURPOSE: To assess the frequency with which a particular, possibly optimal work-up of noncalcified nodules less than 5.0 mm in diameter identified on initial computed tomographic (CT) images at baseline screening leads to a diagnosis of malignancy prior to first annual repeat screening, compared with a possibly optimal work-up of larger nodules. MATERIALS AND METHODS: Two series of baseline CT screenings in high-risk people were retrospectively reviewed. The first series (n = 1,000) was performed in 1993-1998; the second (n = 1,897), in 1999-2002. In each series, cases in which the largest noncalcified nodule detected was less than 5.0 mm in diameter and those in which it was 5.0-9 mm were reviewed to determine whether diagnostic work-up prior to first annual repeat screening showed or would have shown nodule growth and led or would have led to a diagnosis based on biopsy or surgical specimens. RESULTS: The frequency with which malignancy was or could have been diagnosed when the largest noncalcified nodule was less than 5.0 mm in diameter was 0 of 378, whereas when the largest noncalcified nodule was 5.0-9 mm in diameter, the frequency was 13 or 14 of 238. If persons with only nodules smaller than 5.0 mm had merely been referred for first annual repeat screening without immediate further work-up, the referrals for such work-up would have been reduced by 54% (from 817 [28%] to 385 [13%] of 2,897). CONCLUSION: In modern CT screening for lung cancer at baseline, detected noncalcified nodules smaller than 5.0 mm in diameter do not justify immediate work-up but only annual repeat screening to determine whether interim growth has occurred.

Overdiagnosis in chest radiographic screening for lung carcinoma: frequency.

BACKGROUND: The pattern of results in the Mayo Lung Project (MLP), which is the basis for the prevailing recommendations against radiographic screening for lung carcinoma, has led to the assertion that up to 50% of the diagnosed cases of early-stage disease in that trial may have represented overdiagnosed, indolent cases. This finding suggests the possibility of such a high frequency of overdiagnosis in chest radiographic lung carcinoma screening in general. In the current study, the authors analyzed data from the MLP and its counterpart study at Memorial Sloan-Kettering Cancer Center (MSK) to estimate the frequency of overdiagnosis in these studies. METHODS: For the cases diagnosed as Stage I in the MLP and the MSK studies, the doubling times of tumor volumes were calculated. The calculations were based on size measurements recorded by the original investigators from chest radiographs taken during the course of each study. RESULTS: The median doubling times were 101 days in the MLP and 144 days in the MSK, times that are somewhat shorter than those reported in published series of adenocarcinoma cases diagnosed outside screening, and only 5% had doubling times exceeding 400 days. CONCLUSIONS: The hypothesis that early-stage lung tumors diagnosed on chest radiography during lung carcinoma screening may frequently be overdiagnosed, indolent cases needs to be rejected.

Mammographic screening: no reliable supporting evidence?

Much confusion is being generated by the conclusion of a recent review that "there is no reliable evidence that screening for breast cancer reduces mortality." In that review, however, there was no appreciation of the appropriate mortality-related measure of screening's usefulness; and correspondingly, there was no estimation of the magnitude of this measure. We take this measure to be the proportional reduction in case-fatality rate, and studied its magnitude on the basis of the only valid and otherwise suitable trial. We found reliable evidence of fatality reduction, apparently substantial in magnitude.