Noninfectious pulmonary complications after hematopoietic stem cell transplantation: practical approach to imaging diagnosis.

Hematopoietic stem cell transplantation (HSCT) is a widely available treatment for a variety of malignant and nonmalignant disorders. The treatment outcome is affected by the type of transplant and is limited by complications secondary to immunosuppression and treatment-related toxicity. Pulmonary complications are very common and follow a predictable timeline that reflects the immunologic status of the patient in the peritransplant period. Until recently, pulmonary complications were largely attributed to infectious causes. However, advances in diagnosis and treatment have led to a shift, and noninfectious complications have emerged as a major cause of morbidity and mortality in this population. With the increasing number of centers that perform HSCT, knowledge of posttransplant noninfectious pulmonary complications has become increasingly relevant. The basic principles of and indications for HSCT are described, and a timeline for the clinical, radiologic, and pathologic manifestations of noninfectious pulmonary complications is presented. Emphasis is given to high-resolution computed tomographic findings and the role of imaging in management of complications. A practical approach is provided to guide imaging interpretation and diagnosis of noninfectious pulmonary complications after HSCT.

Brachial artery occlusion in a young adult with an ACTA2 thoracic aortic aneurysm.

Mutations of the ACTA2 gene, which encodes the smooth muscle cell-specific isoform of α-actin protein, have recently been found to be among the most common genetic abnormalities observed in patients with familial thoracic aortic aneurysms/dissection (TAAD). Other reported vascular manifestations caused by these mutations include premature coronary artery disease and stroke. We report a young adult who presented with an acute brachial artery occlusion and was subsequently found to have aortopathy and an ACTA2 mutation. This expands the spectrum of vascular disease associated with ACTA2 mutation to include acute limb ischemia.

Pulmonary Langerhans cell histiocytosis: a comparative study of computed tomography in children and adults.

PURPOSE: Langerhans cell histiocytosis is a rare idiopathic disorder, characterized by the infiltration of 1 or more organs by large mononuclear cells. It can develop at any age. Pulmonary Langerhans cell histiocytosis (PLCH) is found more frequently and is better described in adults than in children. The PLCH findings on computed tomography (CT) scans include nodular opacities, thin-walled cysts (often bizarre in shape), and marked parenchymal fibrosis. The purpose of this study was to compare the chest CT findings between adults and children with PLCH. MATERIALS AND METHODS: We retrospectively analyzed the chest CT findings in a series of 7 children and 12 adults. Two independent observers reviewed the CT studies of all cases, and then correlated their observations. Statistical analysis was done with the Fisher exact test. RESULTS: The mean ages were 8 years (3 mo to 16 y) for the pediatric group and 39 years (21 to 59 y) for the adults. Extrapulmonary disease was present in 3 (43%) children and 1 (8.3%) adult. All the adults reported smoking, and only 1 pediatric patient (16 y old) had a history of smoking. The CT findings were characterized by the presence of cysts, fibrosis, and nodules, with the findings being similar in size and appearance for both populations. However, the distribution was different; the subpleural parenchyma in the costophrenic recess was spared in the entire adult group, but not spared in any of the pediatric patients. CONCLUSIONS: The CT findings of PLCH were similar in the adult and the pediatric populations, with the exception that costophrenic recess subpleural parenchyma was spared in the adult group but demonstrated pathology in the pediatric group.

Recurrent cardiac constriction after complete pericardiectomy.

We present a patient with recurrent constrictive physiology resulting from exuberant post-operative fibrosis after complete pericardiectomy. The patient underwent a repeat stripping procedure. At surgery, there was an extensive fibrotic and calcified rind around the heart. The recurrence of constriction physiology after complete pericardiectomy in non-tuberculous pericarditis is a rarely reported in literature. The management supports repeat surgery and the potential value of steroid administration.

Role of MDCT coronary angiography in the evaluation of septal vs interarterial course of anomalous left coronary arteries.

BACKGROUND: Conventional coronary angiography (CCA) may be inaccurate to distinguish between interarterial and septal subtypes of anomalous left coronary arteries (CAs). OBJECTIVE: We compared the classification of anomalous left CA arising from the right sinus of Valsalva (RSV) or right CA on the basis of multidetector computed tomography coronary angiography (MDCTCA) with the classification derived from CCA. METHODS: A retrospective review of 6000 consecutive electrocardiographic-gated MDCTCAs identified 15 cases of anomalous left main or left anterior descending CA arising from the RSV or right CA coursing between the aorta and the main pulmonary artery. On the basis of MDCTCA findings, the proximal course of each vessel was classified into 3 subtypes: 1, interarterial; 2, septal; and 3, mixed. CCA was reviewed in 5 cases (33%) and classified according to traditional criteria. When CCA images were not available, 3-dimensional volume-rendered reconstructions were used to simulate CCA. RESULTS: On the basis of MDCTCA, subtypes were distributed as type 1 (n = 2), type 2 (n = 4), and type 3 (n = 8). One case could not be classified into any of these subtypes and was classified as type 4, right ventricular infundibulum (RVI). Applying CCA criteria, 2 cases would have been classified as interarterial and 14 as septal without appreciation of the mixed or RVI subtypes. CONCLUSIONS: Classification of anomalous left CAs into either septal or interarterial may be too simplistic. There is an anatomic spectrum of anomalous left CAs detected by MDCTCA that challenges the traditional classification based on CCA.

Necrotizing granuloma of the lung: imaging characteristics and imaging-guided diagnosis.

OBJECTIVE: The purpose of this study was to assess CT findings and the sensitivities of imaging-guided fine-needle aspiration (FNA) biopsy and core needle biopsy in the diagnosis of necrotizing granuloma of the lung. CONCLUSIONS: The CT characteristics of necrotizing granuloma are indistinguishable from those of malignant tumors; tissue diagnosis therefore is necessary. Core needle biopsy is a sensitive method for diagnosing necrotizing granuloma of the lung, but FNA biopsy is insufficient for diagnosis.

Surgery for chronic thromboembolic pulmonary hypertension--inclusive experience from a national referral center.

BACKGROUND: Chronic thromboembolic pulmonary hypertension represents a unique form of pulmonary hypertension amenable to curative intervention with a pulmonary thromboendarterectomy (PTE). Canada's first successful and sustainable program for PTE surgery was established at the University of Ottawa Heart Institute in 1995. Inclusive results from similarly sized programs are not readily available owing to selective reporting, therefore making it difficult to benchmark outcomes. The purpose of this report is to provide a review of the inclusive results from our moderately sized national program for all PTE, with a particular emphasize on the aspects of the learning curve in terms of patient management. METHODS: Since 1995, 180 patients have been referred for consideration of PTE, and 106 patients have undergone surgery with a perioperative 30-day mortality rate of 9.4%. RESULTS: There was a significant improvement in all hemodynamic parameters except right ventricular ejection fraction in nonsurvivors (mean pulmonary artery pressure pre 47 +/- 12 mm Hg versus post 28 +/- 9 mm Hg, p < 0.0001; pulmonary vascular resistance pre 814 +/- 429 dynes x sec(-1) x cm(-5), post 224 +/- 145 dynes x sec(-1) x cm(-5), p < 0.0001; cardiac index pre 2.0 +/- 0.7 L x min(-1) x m(-2), post 3.2 +/- 0.7 L x min(-1) x m(-2), p < 0.0001). A postoperative pulmonary vascular resistance of 500 dynes x sec(-1) x cm(-5) or more was associated with increased perioperative mortality (odds ratio, 12 +/- 8.7; p = 0.001). On average, these procedures were associated with significant resource use involving operating room time (610 +/- 243 minutes), intensive care unit and hospital days (11.2 +/- 13.7 and 19.5 +/- 15.6 days), and ventilation time (7.8 +/- 10.0 days). There was no significant change in hospital or intensive care unit length of stay, or the mortality rate during this first decade. CONCLUSIONS: PTE programs are resource-intensive surgical specialty services that demand excellence in cardiothoracic expertise. The initial decade reflected an expanding referral basis and likely parallel increases in patient complexity and expertise. The current results at a national referral center have emphasized the importance of centralization of resources to optimize patient outcome.

Pleural mesothelioma: sensitivity and incidence of needle track seeding after image-guided biopsy versus surgical biopsy.

PURPOSE: To retrospectively compare the sensitivity of image-guided core-needle biopsy, thoracoscopy, and thoracotomy in the diagnosis of malignant pleural mesothelioma and to retrospectively determine the incidence of needle track seeding after these procedures. MATERIALS AND METHODS: Institutional review board approval was obtained, and informed consent was not required. The study included 100 consecutive patients (81 men, 19 women; average age, 65.8 years) with pathologically proved malignant pleural mesothelioma who were treated between 1994 and 2002. A total of 23 core-needle biopsies were performed in 22 patients, and 11 of these biopsies were coupled with fine-needle aspiration biopsy. A coaxial technique was used, and biopsy was performed with fluoroscopic (12 biopsies), computed tomographic (10 biopsies), or ultrasonographic (one biopsy) guidance. Sixty-nine patients underwent surgical biopsy in the form of thoracoscopy (n = 51) and/or thoracotomy (n = 21). Patients were followed up clinically for any evidence of needle track seeding after image-guided or surgical procedures. The sensitivity of diagnostic procedures and the incidence of needle track seeding as a result of intervention were calculated. RESULTS: Sensitivity was 86% for image-guided core-needle biopsy, 94% for thoracoscopy, and 100% for thoracotomy. The incidence of needle track seeding was 4% for image-guided core-needle biopsy and 22% for surgical biopsy. CONCLUSION: Image-guided core-needle biopsy in patients with malignant pleural mesothelioma has a lower incidence of needle track seeding than surgical biopsy and has a high sensitivity for diagnosis.

Chronic thromboembolic pulmonary arterial hypertension: correlation of postoperative results of thromboendarterectomy with preoperative helical contrast-enhanced computed tomography.

INTRODUCTION: Pulmonary thromboendarterectomy is the treatment of choice for patients with chronic thromboembolic pulmonary arterial hypertension (CTEPH). Some patients do poorly after this procedure and may be better candidates for heart-lung transplant. The purpose of this study was to correlate preoperative findings on helical contrast-enhanced computed tomography (CT) with surgical outcome. METHODS: Thirty-seven patients (mean age 52.9, range 22-71) who underwent pulmonary thromboendarterectomy and had preoperative helical contrast-enhanced CT followed by High Resolution CT (HRCT) scans were included in the study. The CTs were evaluated for the presence of central and segmental disease and for the presence of mosaic perfusion pattern. RESULTS: The presence of central disease, as well as the presence of segmental disease, correlated negatively with the postoperative mean pulmonary arterial pressure [r(c) = -0.401, P = 0.015, r(s) = -0.38, P = 0.024)] and the pulmonary vascular resistance [(r(c) = -0.37, P = 0.027, r(s) = -0.39, P = 0.019]. No correlation was found between the clinical variables and the presence of mosaic perfusion pattern. CONCLUSION: Patients with CTEPH and evidence of chronic PE in the central or segmental pulmonary arteries have a better clinical outcome after pulmonary thromboendarterectomy than patients without these findings. The presence of mosaic perfusion pattern is not helpful in predicting postoperative outcome.

Ultrathin needle (25 G) aspiration lung biopsy: diagnostic accuracy and complication rates.

The aim of this study was to evaluate the diagnostic accuracy and complication rate of 25-G fine-needle aspiration biopsy (FNAB) of the lung in patients with suspected malignant focal lesions and abnormal lung function. The 25-G FNAB was performed in 123 patients who underwent prebiopsy CT and pulmonary function tests. Retrospective evaluation included pulmonary function, cytology, size of the lesion, depth of location, presence of emphysema on CT, needle passes, pneumothorax and drainage. The final diagnosis (gold standard) was based on histopathology after surgical resection or follow-up and response to treatment. Sixty-one patients had normal lung function or mild impairment (group 1) and 62 had moderate or severe impairment (group 2). Pneumothorax occurred in 26 of 126 procedures (20.6%) with drainage needed in 11 (8.7%). In group 2 pneumothorax occurred in 19 of 63 procedures (30.15%) with drainage needed in 11 (17.5%). The sensitivity, specificity and diagnostic accuracy of cytology results were 93.6, 100 and 94.4%, respectively. FEV1 ( p=0.014), FEV1/FVC ( p=0.005), FEF25-75 ( p=0.001), DLCO ( p=0.013) and presence of emphysema on CT ( p<0.001) correlated with pneumothorax (Student's t test). The 25-G lung FNAB is accurate and safe in diagnosing malignancy in patients with severe lung functional abnormality. Patients with moderate to severe airway obstruction have a higher prevalence of pneumothorax than patients with mild or no functional impairment.