Targeted Lung Health Check: breast related incidental findings-imaging appearances and lessons learned.

OBJECTIVE: The introduction of Targeted Lung Health Checks (TLHC) to screen for lung cancer has highlighted that incidental findings are common and require management strategies. This study analyses retrospectively, incidentally detected breast lesions reported as part of the TLHC referred to the Breast Cancer clinicians. METHODS: All participants with incidental breast nodules referred to the Breast Cancer team in the first year of screening were reviewed. RESULTS: Fifty-two participants (48 female; 92.3%) were referred to the Breast Multidisciplinary Team Meeting for assessment of 43 breast nodules, 8 breast asymmetry/dense breasts, and 2 likely breast related metastatic disease. One participant declined breast team referral. For the 42 breast nodules investigated, the final diagnoses were 5 breast carcinomas, 10 normal breast tissue, and 27 benign nodules. One male patient was diagnosed with breast carcinoma. The 29 breast nodules classified as smooth and well defined were all benign. No malignancy was demonstrated in the group with asymmetric or dense breast tissue. Metastatic breast carcinoma was confirmed in two participants. Twenty-six out of thirty-seven (54%) females had prior breast screening mammograms precluding further investigation. CONCLUSION: Incidental breast nodules are common on THLC scans. Smooth, sharply defined breast nodules are likely to be benign but low-dose CT is poor at accurately assessing breast nodules. Agreed breast referral pathways prior to starting the Lung Cancer Screening programme are recommended. Access to screening mammograms can reduce referrals to the Breast clinic. ADVANCES IN KNOWLEDGE: Lessons learned from TLHC pilot studies can be useful to sites commencing national TLHC programme.

Accessory cardiac bronchus with associated lung parenchyma: rare congenital tracheobronchial anomaly.

Accessory cardiac bronchus (ACB) has been described mainly as case reports finding (frequency 0.08%-0.39%). Even though 50% of all ACBs have a blind extremity, imaging studies have demonstrated that some develop into a series of bronchioles with cystic degeneration or a ventilated lobule demarcated by an anomalous fissure and extremely rare with an abnormal pulmonary artery. In this case, ACB was demonstrated on several imaging methods arising from the intermediate bronchus's medial wall with correspondent blood vessels and fissure. Although an ACB is not a pathological entity and most patients with ACB are asymptomatic, it can become symptomatic due to recurrent infection, empyema, hemoptysis, and malignant transformation.  In conclusion, both pulmonologists and radiologists should recognize normal bronchial anatomy and developmental bronchial anomalies, as these may be important to establish a correct diagnosis.

Pseudoaneurysm as an Etiological Cause of Hemoptysis in Extensive Tuberculosis.

Hemoptysis is a life-threatening emergency and a possible first sign of pulmonary tuberculosis. Minor hemoptysis, as a possible clinical aspect of adult tuberculosis, usually has limited course and in most cases, is resolved with antitubercular therapy. However, massive hemoptysis is a life-threatening condition associated with a mortality rate of >50% in the absence of well-timed and proper handling. Hence, prompt diagnosis and early interventions are essential. In this study, we present a rare case of pseudoaneurysm causing massive hemoptysis in a patient with pulmonary tuberculosis.

Implementing Lung Cancer Screening in Europe: Taking a Systems Approach.

Lung cancer is the leading cause of cancer death in Europe. Screening by means of low-dose computed tomography (LDCT) can shift detection to an earlier stage and reduce lung cancer mortality in high-risk individuals. However, to date, Poland, Croatia, Italy, and Romania are the only European countries to commit to large-scale implementation of targeted LDCT screening. Using a health systems approach, this article evaluates key factors needed to enable the successful implementation of screening programs across Europe. Recent literature on LDCT screening was reviewed for 10 countries (Belgium, Croatia, France, Germany, Italy, the Netherlands, Poland, Spain, Sweden, and United Kingdom) and complemented by 17 semistructured interviews with local experts. Research findings were mapped against a health systems framework adapted for lung cancer screening. The European policy landscape is highly variable, but potential barriers to implementation are similar across countries and consistent with those reported for other cancer screening programs. While consistent quality and safety of screening must be ensured across all screening centers, system factors are also important. These include appropriate data infrastructure, targeted recruitment methods that ensure equity in participation, sufficient capacity and workforce training, full integration of screening with multidisciplinary care pathways, and smoking cessation programs. Stigma and underlying perceptions of lung cancer as a self-inflicted condition are also important considerations. Building on decades of implementation research, governments now have a unique opportunity to establish effective, efficient, and equitable lung cancer screening programs adapted to their health systems, curbing the impact of lung cancer on their populations.

Risk factors for nontuberculous mycobacterial pulmonary disease (NTM-PD) in Croatia.

BACKGROUND: The incidence, geographical distribution and clinical relevance of different nontuberculous mycobacteria (NTM) in Croatia are well described. There are few data on the risk factors for developing NTM pulmonary disease (NTM-PD) in this setting. METHODS: We conducted a retrospective cohort study on all Croatian residents with NTM isolated from respiratory samples in the period from 2006 to 2015 with follow-up to 2018. The American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines were used to establish NTM-PD diagnosis. Clinical, radiological and treatment data were collected from hospital records. RESULTS: Risk analysis calculations were made on the 439 isolation episodes that were classified as definitive NTM-PD (n = 137) or no disease (n = 302). Female gender, presence of bronchiectasis, low BMI and long-term systemic corticosteroid treatment were independent risk factors associated with NTM-PD. Hemoptysis and malaise were presenting symptoms independently associated with NTM-PD. Chronic obstructive pulmonary disease (COPD) and low/moderate dose inhaled corticosteroid (ICS) treatment were not associated with NTM-PD. High dose ICS treatment was a significant risk factor for developing NTM-PD (aOR = 4.73, CI 1.69-13.23 p = 0.003). CONCLUSION: The NTM-PD patients in Croatia are similar to those in other published cohorts in terms of their characteristics and risk factors. The significant dose-dependent association between ICS use and NTM-PD adds to the body of evidence suggesting that high dose ICS use is associated with NTM-PD.

Nodular distribution pattern on chest computed tomography (CT) in patients diagnosed with nontuberculous mycobacteria (NTM) infections.

BACKGROUND: This study evaluated the prevalence of spreading pathways in nontuberculous mycobacteria (NTM) pulmonary infections according to nodular distribution patterns seen on chest computed tomography (CT). METHODS: This study included 63 patients diagnosed with NTM lung infections who underwent CT at our institution. A retrospective analysis of CT images focused on the presence and distribution of nodules, presence of intrathoracic lymphadenopathy and the predominant side of infection in the lungs. The findings were classified into five groups; centrilobular (bronchogenic spread), perilymphatic (lymphangitic spread), random (hematogenous spread), combined pattern and no nodules present. The groups were then compared according to other CT findings. RESULTS: Among 51 (81%) patients identified with a nodular pattern on chest CT, 25 (39.8%) presented with centrilobular, 7 (11.1%) with perilymphatic, 6 (9.5%) with random and 13 (20.6%) with combined nodular patterns but located in different areas of the lungs. The right side of the lungs was predominant in 38 cases (60.3%). Intrathoracic lymphadenopathy was evident in 20 patients (31.7%). Significant differences in distributions of nodular patterns were seen in patients infected with Mycoplasma avium complex (MAC) associated with centrilobular pattern (p = 0.0019) and M. fortuitum associated with random pattern (p = 0.0004). Some of the findings were related to perilymphatic nodules between other isolated species of NTM (p = 0.0379). CONCLUSION: The results of this study showed a high proportion of perilymphatic nodules and right-sided predominance in the upper lobe, which, combined with intrathoracic lymphadenopathy is highly suggestive of the lymphangitic spread of lung NTM infections.

Immunotherapy for thymoma.

Thymic epithelial tumors (TETs) are rare thymic neoplasms. There are approximately 1.5 cases per million TETs per year. They are the most common anterior mediastinal tumors in adults. Due to limited activity of available treatment options novel strategies and treatment options are needed and treatment with immune checkpoint inhibitors is an attractive option. Thymic epithelial tumors have one of the lowest tumor mutational burden among all cancer in adults, but high expression of PD-L1 on tumor cells and abundant CD8+ lymphocytes provide a strong rational for implementing immune checkpoint inhibitors (ICIs) which target PD-1/PD-L1 pathway in the treatment of TETs. Few small early stage clinical trials were published so far evaluating efficacy of pembrolizumab and avelumab in thymoma and thymic carcinoma patients. Al trials showed reasonable response rates and progression-free survival. Higher PD-L1 expression was predictor of response in all trials. However, increased incidence of immune-related adverse events was seen in TET patients treated with immune checkpoint inhibitors compared to patients with other cancers. At the moment, ICIs are not standard of care for patients with TET and larger trials are needed to establish the right role of ICIs regarding efficacy and safety of these agents.

An extremely rare primary sarcoma of the lung with peritoneal and small bowel metastases: a case report.

BACKGROUND: Primary sarcoma of the lung is a very rare malignant tumor accounting for less than 0.5% of all lung tumors and presenting diagnostic and treatment challenge. We describe a case of a patient diagnosed with primary lung undifferentiated pleomorphic sarcoma developing subsequent peritoneal and small bowel metastases, which stand for highly unusual disease presentation. CASE PRESENTATION: A 57-year-old male presented with extensive partially necrotic tumor in the left upper lobe (LUL) of the lung that involved LUL bronchus and extended to the visceral pleura. There was no evidence of nodal or visceral dissemination. After initial presentation, the patient was admitted to the hospital's pulmonology department for further workup. The most likely diagnosis based on biopsy specimen was poorly differentiated sarcoma. Left pneumonectomy with mediastinal lymph node dissection was performed. The final pathohistological diagnosis (PHD) was undifferentiated pleomorphic sarcoma (UPS). Three months after lung surgery, a follow-up CT scan was done which showed a 60-mm obstructive metastatic intraabdominal lesion with small bowel infiltration and further separate peritoneal deposits. Unfortunately, an urgent surgery had to be performed as the patient developed signs of acute abdomen due to bowel perforation. Only 2 months later, the patient passed away at home. CONCLUSIONS: Treatment options of UPS are based on algorithms used in treatment of extremity lesions with well-established role of surgery. However, the role of perioperative chemotherapy remains equivocal with no strong evidence-based data due to the rarity of the disease. Small bowel is an unexpected metastatic site, but of significant clinical relevance.

Size, edge, and stage of NSCLC determine the release of CYFRA 21-1 in bloodstream.

BACKGROUND: The computed tomography (CT) is the "golden standard" for the assessment of lung cancer progression due to its ability to clearly display the radiomorphologic characteristics. As lung cancer mortality is very high, more comprehensive approaches may be needed for its earlier diagnosis. The research hypothesis was to investigate the relation between the CT morphologic characteristics (size, stage, and edges) of pulmonary lesion and the extent of release of a soluble fragment of cytokeratin 19 being a part of the cytoskeleton of lung epithelial cells. METHODS: This is a retrospective study including 246 pulmonary lesions being diagnosed and subsequently treated at the University Hospital Centre Zagreb, Croatia. The information about the relevant clinical, radiological, and laboratory facts was collected at the time of diagnosis in 164 NSCLC patients, 52 patients with pulmonary metastases, and 30 benign cysts. CYFRA 21-1 was determined by electrochemiluminescence immunoassay. The nonparametric statistical methods were applied. RESULTS: There was a positive correlation between the size and CYFRA 21-1 in NSCLC unlike metastases or cysts (p = 0.0001). The highest values of CYFRA 21-1 were seen in advanced stages of NSCLC and lesions with spiculated edges. CONCLUSIONS: The level of CYFRA 21-1 positively correlates with the greatest size of NSCLC measured by CT. The differences in CYFRA 21-1 according to TNM classification are significant (p = 0.0001): higher values were observed in advanced stages and with tumors having spiculated, lobulated, and poorly defined edges. The combination of CYFRA 21-1 and CT may help articulate the malignancy of pulmonary lesions.

Breast metastasis from lung adenocarcinoma diagnosed with fine needle aspiration cytology: a case report.

Metastases to the breast from extramammary neoplasms are very rare. Correct diagnosis of breast malignancy is important for establishing appropriate management and for avoiding unnecessary radical surgery. Metastasized breast malignancies from non-small cell lung carcinoma are extremely rare. Here we report a 55-year old female patient with breast metastasis from lung adenocarcinoma which was diagnosed with fine needle aspiration cytology and confirmed by immunocytochemistry.

Mycobacterium xenopi pulmonary disease - epidemiology and clinical features in non-immunocompromised patients.

OBJECTIVES: The genus Mycobacterium has more than 120 well-characterized species. Although the incidence of tuberculosis has decreased over the studied period, other, non-tuberculous mycobacteria (NTM) are isolated more often. Since, Mycobacterium xenopi is the most frequent NTM isolate in Croatia we studied its epidemiology and clinical relevance. METHODS: We performed a retrospective study over a 25-year period determining epidemiology, radiological findings and clinical importance of M. xenopi infection, obtaining data from archives in health care institutions from all over the country. RESULTS: We detected 40 patients with a positive isolate of M. xenopi. Twenty-four patients met American Thoracic Society criteria for pulmonary disease. Eighteen (90%) of treated patients were male, on average 61.7 years old. Nineteen (95%) patients lived in towns. Most of them had comorbid disease, 18 (90%), with chronic obstructive pulmonary disease (COPD) being the most frequent, found in 11 (55%) patients. All patients were immunocompetent. We found COPD as the most frequent comorbid disease in the group of patients with worse treatment response (n=8; 80%), while in patients with good treatment response COPD was less frequent (n=3; 30%). Differences in the proportions of patients with COPD were significant (p=0.037). CONCLUSION: In patients with M. xenopi pulmonary infection, COPD is a predisposing condition, and as a comorbid disease, is an important prognostic factor for treatment response.