A pleural based mass in a post-partum woman.

Can you diagnose this case of a 27-year-old female who presented 1-week post-partum with an incidental finding of intrathoracic masses and probable hilar lymphadenopathy? https://bit.ly/3S3ejVK.

The urachus revisited: multimodal imaging of benign & malignant urachal pathology.

The urachus is a fibrous tube extending from the umbilicus to the anterosuperior bladder dome that usually obliterates at week 12 of gestation, becoming the median umbilical ligament. Urachal pathology occurs when there is incomplete obliteration of this channel during foetal development, resulting in the formation of a urachal cyst, patent urachus, urachal sinus or urachal diverticulum. Patients with persistent urachal remnants may be asymptomatic or present with lower abdominal or urinary tract symptoms and can develop complications. The purpose of this review is to describe imaging features of urachal remnant pathology and potential benign and malignant complications on ultrasound, CT, positron emission tomography CT and MRI.

Rapid and sustained airway control in metastatic malignant melanoma: a case report.

Endobronchial metastasis from extrapulmonary malignancies are rare and include malignant melanoma. Cases that are complicated by central airway obstruction should follow a patient-centred approach, guided by patient and tumour characteristics. http://bit.ly/32baZvo.

Diagnostic accuracy of diffusion-weighted imaging- magnetic resonance imaging compared to positron emission tomography/computed tomography in evaluating and assessing pathological response to treatment in adult patients with lymphoma: A systematic review.

The use of Positron emission tomography/computerised tomography (PET/CT) is well established in the staging and assessment of treatment response of lymphoma. Recent studies have suggested that whole body diffusion-weighted imaging -magnetic resonance imaging (WB-DW-MRI) may be an alternative to PET/CT in both staging and assessment of treatment response. A systematic review was performed to assess the ability of DW-MRI in the assessment of treatment response in lymphoma. Pubmed, Medline, Web of Science and Embase databases were queried for studies examining whole body DW-MRI compared to PET/CT in adult patients using a protocol of search terms. We carried out an extensive assessment of titles, abstracts and full texts of relevant paper as well as quality assessment with the Quality Assessment of Diagnostic Accuracy (QUADAS-2) tool. Eight studies were found to meet the criteria and were included in our review and analysis. Overall, the quality of studies was found to be moderate, with good inter-rater agreement (K = 0.74). Data analysis showed that lesion-based assessment in 5 studies with pooled results had a sensitivity and specificity of 94.7% and 99.3%. Assessment with Cohen's Kappa coefficient showed agreement to be excellent (K = 0.88). Three studies were included for qualitative analysis, two of which showed good equivalence between PET/CT and DW-MRI. WB-DWI-MRI can be considered a sensitive and specific method for assessing treatment response in Lymphoma without the use of ionising radiation or administration of F-18 Flurodeoxyglucose. Further studies are needed to evaluate the optimum b-values in assessing treatment response.

Patterns of Disease in Patients with Middle-Lobe Predominant Bronchiectasis.

BACKGROUND: Middle-lobe predominant bronchiectasis affecting the right middle-lobe and/or lingula (RMLP) is classically described in asthenic, elderly females with skeletal abnormalities or associated nontuberculous mycobacterial (NTM) infection. OBJECTIVES: We aimed to evaluate the frequency and clinical characteristics of patients with an RMLP phenotype in a cohort of newly diagnosed bronchiectasis patients and determine associations with disease severity. METHODS: A retrospective observational cross-sectional cohort study of consecutive bronchiectasis patients in our institution was performed. Data were collected on baseline variables, microbiology status, lung function, and radiology according to the modified Bhalla score. Disease severity was assessed using bronchiectasis severity index (BSI) and FACED severity scores. RESULTS: Of 81 patients (mean age [SD] 62.6 [12.4], females 55 [67.9%], BMI 26.9 [5.7%]), 20 (24.7%) had RMLP disease. These patients were significantly younger, female, and with lower BMIs than patients with the classical bronchiectasis phenotype (p = 0.03, 0.01, and p <0.01, respectively). Fewer symptoms of cough and daily sputum (p = 0.01 and <0.01), prior exacerbation frequency (p = 0.03), and higher baseline forced expiratory volume (p = 0.04) were noted. A higher incidence of NTM at diagnosis was demonstrated (p = 0.01). BSI and FACED severity scores in RMLP patients were significantly lower than their counterparts (both p < 0.001). CONCLUSIONS: The RMLP phenotype is associated with younger patients than classically described in the literature. An increased rate of NTM infection in this phenotype was noted, particularly in females, but much lower than previously described. Lung function and disease severity scores in this patient group are relatively normal, suggesting a milder phenotype in patients with this form of the disease.

Overdiagnosis of Pulmonary Embolism by Pulmonary CT Angiography.

OBJECTIVE: The purpose of this study is to evaluate the rate of overdiagnosis of pulmonary embolism (PE) by pulmonary CT angiography (CTA) in a tertiary-care university hospital. MATERIALS AND METHODS: This study is a retrospective review of all pulmonary CTA examinations performed in a tertiary-care university hospital over a 12-month period. Studies originally reported as positive for PE were retrospectively reinterpreted by three subspecialty chest radiologists with more than 10 years' experience. A pulmonary CTA was considered negative for PE when all three chest radiologists were in agreement that the pulmonary CTA study was negative for PE. The location and potential causes for PE overdiagnosis were recorded. RESULTS: A total of 937 pulmonary CTA studies were performed over the study period. PE was diagnosed in the initial report in 174 of these cases (18.6%). There was discordance between the chest radiologists and the original radiologist in 45 of 174 (25.9%) cases. Discordance occurred more often where the original reported PE was solitary (46.2% of reported solitary PEs were considered negative on retrospective review) and located in a segmental or subsegmental pulmonary artery (26.8% of segmental and 59.4% of subsegmental PE diagnoses were considered negative on retrospective review). The most common cause of diagnostic difficulty was breathing motion artifact, followed by beam-hardening artifact. CONCLUSION: In routine clinical practice, PEs diagnosed by pulmonary CTA are frequently overdiagnosed, when compared with the consensus opinion of a panel of expert chest radiologists. Improvements in the quality of pulmonary CTA examination and increased familiarity with potential diagnostic pitfalls in pulmonary CTA are recommended to minimize misdiagnosis of PE.

Hiatal hernias are correlated with increased severity of non-cystic fibrosis bronchiectasis.

BACKGROUND AND OBJECTIVE: Hiatal hernias (HH) are associated with gastro-oesophageal reflux and may contribute to lung disease severity. We aimed to evaluate the prevalence of HH among stable non-cystic fibrosis bronchiectasis (NCFB) patients and determine associations with disease severity. METHODS: A retrospective cross-sectional cohort study of 100 consecutive NCFB patients in our institution was performed. Data were collected on baseline variables, microbiology, lung function and radiology, according to the modified Bhalla score. Disease severity was assessed using the Bronchiectasis Severity Index (BSI) and FACED severity scores. RESULTS: Following expert radiological review, 81 patients were deemed suitable for study inclusion (mean age (SD) 62.6 (12.4), females 55 (67.9%), body mass index (BMI) 26.9 (5.7)); 29 (35.8%) were HH positive (HH+). HH+ patients had a trend towards higher BMI (P = 0.07), and a significantly higher proportion had reflux symptoms (HH+ 62.1% vs HH- 28.8%, P < 0.01). The presence of HH+ was associated with cystic bronchiectasis (HH+ 30.1%, HH- 11.5%; P = 0.03), increased number of lobes involved (HH+ 2.62 (1.54), HH- 2.17 (1.42); P = 0.03), increased extent of bronchiectasis, (HH+ 6.2 (4.7), HH- 4.5 (3.1); P = 0.04), decreased parenchymal attenuation (HH+ 1.0 (1.8), HH- 0.2 (0.5); P = 0.03) and reduced per cent predicted forced expiratory volume in 1 s (HH+ 75.4% (24.5), HH- 90.4% (25.5); P = 0.02). There was no lobar predilection. HH+ was associated with increased disease severity scores: BSI (HH+ 4.93 (1.65), HH- 3.25 (2.13); P < 0.001) and FACED (HH+ 2.21 (1.52), HH- 1.35 (1.43); P < 0.01). CONCLUSIONS: HH+ was associated with worse disease severity in NCFB patients, characterized by decreased lung function, increased extent and severity of radiological disease, and increased composite disease severity scores.

Update in the evaluation of the solitary pulmonary nodule.

A solitary pulmonary nodule (SPN) is defined as a round opacity that is smaller than 3 cm. It may be solid or subsolid in attenuation. Semisolid nodules may have purely ground-glass attenuation or be partly solid (mixed solid and ground-glass attenuation). The widespread use of multidetector computed tomography (CT) has increased the detection of SPNs. Although clinical assessment of patients' risk factors for malignancy--such as age, smoking history, and history of malignancy--is important to determine appropriate treatment, in the recently published Fleischner guidelines for subsolid nodules, smoking history does not factor into their recommendations for management because there is an increasing incidence of lung adenocarcinoma in younger and nonsmoking patients. At imaging evaluation, obtaining prior chest radiographs or CT images is useful to assess nodule growth. Further imaging evaluation, including CT enhancement studies and positron emission tomography (PET), helps determine the malignant potential of solid SPNs. For subsolid nodules, initial follow-up CT is performed at 3 months to determine persistence, because lesions with an infectious or inflammatory cause can resolve in the interval. CT enhancement studies are not applicable for subsolid nodules, and PET is of limited utility because of the low metabolic activity of these lesions. Because of the likelihood that persistent subsolid nodules represent adenocarcinoma with indolent growth, serial imaging reassessment for a minimum of 3 years and/or obtaining tissue samples for histologic analysis are recommended. In the follow-up of subsolid SPNs, imaging features that indicate an increased risk for malignancy include an increase in size, an increase in attenuation, and development of a solid component.

A clue in a colour? EBUS-TBNA in the analysis of isolated mediastinal lymphadenopathy.

A 52-year-old female patient with a background history of malignant melanoma was referred to the interventional pulmonology unit at Galway University Hospital for the investigation of possible intrathoracic recurrence. A CT of the thorax (CT thorax) demonstrated mediastinal lymphadenopathy at position 4R, right paratracheal region. An endobronchial ultrasound (EBUS) revealed multiple enlarged lymph nodes at station 4R. The nodes were heterogeneous with solid and cystic elements. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) obtained a black material consistent with malignant melanoma. Multiple TBNA samples were obtained and the diagnosis was confirmed pathologically by the presence of multiple epithelioid pigmented cells on cell block analysis. This case report emphasises the value of EBUS in the assessment of metastatic disease and, in particular, how the gross appearance of the sample can be suggestive of the diagnosis.

Multimodality imaging evaluation of esophageal cancer: staging, therapy assessment, and complications.

Esophageal cancer is among the leading causes of cancer-related deaths worldwide. The management of patients with esophageal cancer is determined to a large extent by patient performance status, location of the primary cancer, and stage of disease at presentation. Multimodality regimens combining neoadjuvant chemotherapy and/or radiotherapy followed by surgery have been increasingly used in suitable candidates with locally advanced cancer. There is substantial morbidity and mortality associated with this treatment strategy, which makes appropriate patient selection important. Endoscopic esophageal ultrasound is the optimal modality to evaluate the local extent of the primary tumor and diagnose locoregional nodal metastasis. Computed tomography is more useful in detecting distant nodal and systemic metastasis. Positron emission tomography/CT is increasingly being used in patient management and improves the accuracy of staging, particularly in the detection of distant nodal and systemic metastatic disease. In this article, we review the role of imaging in the staging, assessment of therapeutic response, and detection of recurrent disease, as well as the evaluation of therapeutic complications in patients with esophageal cancer.

Solid pseudopapillary neoplasm of the pancreas.

Solid pseudopapillary neoplasms (SPNs) are rare entities accounting for between 0.13 and 2.7 per cent of pancreatic tumours. This neoplasm has a predilection for females under the age of 35. The authors report this case of a SPN incidentally discovered when a 59-year-old female underwent a chest x-ray to investigate a wheeze. A subsequent CT abdomen revealed a 10 cm well-circumscribed mass adjacent to the tail of the pancreas. This mass was successfully resected. Immunohistochemical markers established the diagnosis of a SPN. The wheeze associated with the presentation of this case was unrelated to the tumour which was an incidental finding. These neoplasms are largely asymptomatic and indolent reaching a large size before detection. Diagnosis is confirmed on histology and in this case surgical resection was curative and there was no metastasis at presentation.

Unsuspected pulmonary emboli in oncology patients undergoing routine computed tomography imaging.

INTRODUCTION: Clinically unsuspected pulmonary embolism (PE) can be detected in oncology patients undergoing computed tomography (CT) imaging for reasons other than for PE diagnosis, but there is little prospective data on its true prevalence, clinical importance, or on methods to improve detection. METHODS: In consecutive oncology patients undergoing CT imaging of the chest for indications other than PE detection, CT pulmonary angiography (CTPA) was systematically included as part of the imaging protocol. Each imaging study was prospectively analyzed for the presence of PE. A 6-month follow-up was performed. Institutional review board approval was obtained. RESULTS: Four hundred seven oncology patients were included. Indications for chest CT imaging included baseline staging (31%), restaging after therapy (53%), routine surveillance (15%), or assessment of extrathoracic disease (1%). Clinically unsuspected PE were detected in 18 patients (4.4%). The prevalence of unsuspected PE was 6.4% among inpatients and 3.4% among outpatients. PE was more prevalent among patients with metastatic disease (7% versus 2%, p = 0.007) and in patients who had received recent chemotherapy (11% versus 3%, p = 0.008). In 7 (39%) of the 18 patients with clinically unsuspected PE, emboli were only identifiable on the CTPA study and not on the routine chest CT study. The diagnosis of PE led to immediate changes in patient management. CONCLUSION: Clinically unsuspected PE is present in up to 4.4% of oncology patients undergoing CT imaging for indications other than PE diagnosis. Modifying standard CT imaging protocols to include a CTPA examination optimizes their detection and leads to changes in patient management.

Clinical utility of PET/CT in lymphoma.

OBJECTIVE: The purpose of this review is to assist interpreting radiologists in becoming familiar with the role of PET/CT in baseline staging and therapeutic response assessment in the management of lymphoma, in becoming aware of imaging pitfalls, and in understanding the natural behavior of lymphoma and the therapeutic options. CONCLUSION: Therapeutic strategies for the management of lymphoma are constantly being refined to improve long-term survival with the lowest risk of toxicity to the patient. PET/CT is accurate for baseline staging and yields important prognostic information for determining the most appropriate initial treatment. Used for evaluation of treatment response, PET/CT can depict residual viable malignant lesions with greater accuracy than can other imaging techniques. The findings thereby influence decisions about the need for additional or alternative treatment.