A rare radiological presentation of pulmonary metastases from malignant melanoma.

Malignant melanoma is a highly aggressive cancer with metastatic potential to various locations such as the lymph nodes, lungs, liver, brain, and bone. After the lymph nodes, the lungs are the most common site of malignant melanoma metastases. Pulmonary metastases from malignant melanoma commonly presents as solitary or multiple solid nodules, sub-solid nodules or miliary opacities on CT chest. We present a case of pulmonary metastases from malignant melanoma in a 74-year-old man which presented unusually on CT chest as a combination of patterns like "crazy paving," upper lobe predominance with subpleural sparing, and centrilobular micronodules. Video-assisted thoracoscopic surgery, wedge resection and tissue analysis were performed, which confirmed the diagnosis of malignant melanoma metastases, and the patient further underwent PET-CT for staging and surveillance. Patients with pulmonary metastases from malignant melanoma can have atypical imaging findings, therefore radiologists should be aware of these unconventional presentations to avoid any misdiagnoses.

Single-institution experience of 500 pulmonary resections guided by intraoperative molecular imaging.

OBJECTIVE: Intraoperative molecular imaging (IMI) using tumor-targeted optical contrast agents can improve thoracic cancer resections. There are no large-scale studies to guide surgeons in patient selection or imaging agent choice. Here, we report our institutional experience with IMI for lung and pleural tumor resection in 500 patients over a decade. METHODS: Between December 2011 and November 2021, patients with lung or pleural nodules undergoing resection were preoperatively infused with 1 of 4 optical contrast tracers: EC17, TumorGlow, pafolacianine, or SGM-101. Then, during resection, IMI was used to identify pulmonary nodules, confirm margins, and identify synchronous lesions. We retrospectively reviewed patient demographic data, lesion diagnoses, and IMI tumor-to-background ratios (TBRs). RESULTS: Five hundred patients underwent resection of 677 lesions. We found that there were 4 types of clinical utility of IMI: detection of positive margins (n = 32, 6.4% of patients), identification of residual disease after resection (n = 37, 7.4%), detection of synchronous cancers not predicted on preoperative imaging (n = 26, 5.2%), and minimally invasive localization of nonpalpable lesions (n = 101 lesions, 14.9%). Pafolacianine was most effective for adenocarcinoma-spectrum malignancies (mean TBR, 2.84), and TumorGlow was most effective for metastatic disease and mesothelioma (TBR, 3.1). False-negative fluorescence was primarily seen in mucinous adenocarcinomas (mean TBR, 1.8), heavy smokers (>30 pack years; TBR, 1.9), and tumors greater than 2.0 cm from the pleural surface (TBR, 1.3). CONCLUSIONS: IMI may be effective in improving resection of lung and pleural tumors. The choice of IMI tracer should vary by the surgical indication and the primary clinical challenge.

Metástasis pulmonar miliar como primera manifestación de carcinoma de tiroides bien diferenciado en niños

Objetivo: Presentar el caso de una adolescente con manifestaciones de afectación pulmonar como motivo de consulta, debido a una metástasis pulmonar miliar de carcinoma (Ca) papilar de tiroides. Caso Clínico: Se trata de una adolescente femenina de 13 años de edad quien presenta tos seca, disnea de esfuerzo, palpitaciones, dolor precordial, y pérdida de peso de 15 días de evolución. Al examen clínico se evidencia aumento de volumen de la región anterior del cuello a predominio izquierdo, con adenopatía cervical palpable, acrocianosis y cianosis peribucal. Hematología completa, función tiroidea y electrocardiograma normales. La gasometría arterial demuestra una hipoxemia severa. En Rx. de tórax se observa infiltrado miliar micro y macronodular bilateral. En ultrasonido impresionan adenopatías de ubicación pretraqueal y paracarotideas. Tomografía de cuello revela imagen altamente sugestiva de malignidad en lóbulo tiroideo izquierdo y tomografía toraco-abdominal muestra infiltrado pulmonar bilateral micronodular sugestivo de lesiones metastásicas. Estudio histopatológico de ganglio latero cervical izquierdo reporta metástasis de Ca papilar tiroideo a predominio de estructuras foliculares. Se hace diagnóstico de carcinoma papilar bien diferenciado de tiroides con metástasis a región pulmonar, se realiza tiroidectomía total y control de T4L y TSH a los 30 y 60 días post cirugía, con valores normales de T4L y ligeramente aumentados de TSH (7 uU/ml), planteándose metástasis pulmonares funcionantes. Se indica terapia ablativa con I131 presentando evolución clínica estable, pero con cifras de 300 mg/dL de tiroglobulina a los seis meses, por lo que se planifica otra sesión con radioyodo. A propósito de este caso, el segundo en cinco años en la Unidad de Endocrinología del IAHULA, se lleva a cabo una revisión de la literatura sobre esta entidad nosológica. Conclusiones: En niños, el Ca papilar de tiroides puede ponerse en evidencia por las manifestaciones clínicas debidas a la afectación pulmonar, con un pronóstico reservado, sobre todo si se trata de metástasis pulmonares de tipo miliar.

Objective: To present the case of a female adolescent admitted with findings of pulmonary illness due to miliar pulmonary metastases of thyroid cancer. Clinical Case: A girl of 13 years old with non productive cough, dyspnea, palpitations, precordial pain and decrease of weigh, since fifteen days before she consulted at the pediatric emergency. She presented with a goiter, predominantly growing of the left lobe, with a cervical adenopathy, acrocyanosis and cyanosis of her lips. Complete haematology, thyroid function and electrocardiogram were normal. The arterial gasometry showed severe hypoxia. Chest radiography showed diffuse micro and macronodular lesions. Neck ecography showed definitive regional adenopaties. Neck tomography demonstrated an image suggestive of malignancy in left thyroid lobe and the thoracic tomography showed micronodular bilateral lesions, suggestive of me- tastases. Biopsy of the cervical left adenopathy concluded in metastases of papillary thyroid cancer with follicular structures. Total thyroidectomy was performed. Levels of TSH 60 days after surgery, were slightly increased (7 uU/ml), suggesting functioning pulmonary metastases. Ablative therapy with 131I was administrated, but 6 months after it, thyroglobulin levels were elevated (300 mg/dl) and the patient is waiting for another 131I therapy session. This is the second case studied in the Endocrinology Unit at the IAHULA. Conclusions: The clinical findings of pulmonary affectation could be the first manifestations of papillary thyroid cancer in children, specially if miliar pulmonary metastases are present, worsening the prognosis.