[ ISSN : 2573-3680 ]
Incidentaloma; Incidental findings; Thoracic computer tomography
Background: CT scanning remains one of the most routinely used diagnostic tools in a setting of Interstitial Lung Disease (ILD). New and improved technologies, such as High Resolution Computer Tomography (HRCT) have revolutionized the quality of imaging, leading to a prominent increase in number of incidental findings that may or may not be of any clinical significance. The aim of this study was to evaluate the prevalence of incidental findings on thoracic CT and their clinical significance.
Methods: Retrospective analysis was conducted on a cohort of 84 patients referred to our academic center as cases of ILD. Patients were referred for further evaluation between January 2000 and January 2014 and were followed over the disease course. CT scans were done annually as part of clinical management and patients were screened for any incidental findings. All incidental findings were reviewed, recorded in a clinical database and followed up on subsequent visits.
Results: 25 (30%) patients were found to have incidental findings. Liver abnormalities were found in 12 (14.29 %) patients. 11(13.10 %) patients were reported to have coronary artery calcifications. 5 (5.95 %) and 3 (3.57%) patients had thyroid abnormalities and renal cysts, respectively. A malignant lesion was found in 1 patient each in liver and thyroid abnormality subgroup.
Conclusion: Incidental findings are common on thoracic CT scans providing valuable and unexpected findings which warrant investigation by health care providers to exclude malignant processes.
Incidentalomas are tumors or nodules that are found by coincidence without any symptoms or clinical suspicion. They are often found on routine radiological imaging for other primary reasons. A small percentage of these Incidental Findings (IFs), eventually through clinical investigation turn out to be malignant processes. Though some recent studies dispute reporting or searching for IFs [1] finding them to be an unnecessary financial burden on our health system [2], we firmly believe that radiological IFs should be fully investigated in the proper clinical setting.
Thoracic Computer Tomography (CT scans) remains one of the most commonly used radiological tools. However improved technologies such as High Resolution Computer Tomography (HRCT) have revolutionized image quality, leading to an increase in number of IFs. IFs have been reported on up to 54.8% thoracic CTs [3]. With this perspective we conducted a study to evaluate the prevalence and clinical outcome of incidentalomas on thoracic CT scans consistently done as part of clinical management in patients with Interstitial Lung Disease (ILD).
We conducted a retrospective review of data collected on 84 patients with a diagnosis of ILD. Patients were seen at the outpatient pulmonary department of the North Shore — Long Island Jewish Health System. For the purposes of the study ILD was defined in accordance with the guidelines set forth by the American Thoracic Society [4]. All patients who underwent complete physical exam, pulmonary function testing as well as CT scans of the chest were considered for the study. CT scan of the chest results were read and noted for any thyroid abnormalities, splenomegaly, liver abnormalities, coronary artery calcifications, renal cysts or any other incidental findings. If any clinical worsening was observed, a more frequent CT scanning was performed. Institutional Review Board approval was obtained for this study (IRB# 14-202a).
There were a total of 84 patients (25 males, 59 females mean age 60.7 years) who were found to have ILD between January 2000 and January 2014 who were followed over the disease course. Of these 84 patients, 25 (29.8%) were found to have IFs, some of them with more than one. Out of our 84 ILD patients, liver abnormalities were seen in 12 (14.3 %) patients and were the most frequently noted IF. 11 (13.1%) ILD patients were found to have coronary artery calcifications. 5 (5.95 %) and 3 (3.57%) out of the 84 ILD patients respectively had thyroid abnormalities and renal cysts (Table 1). IFs were followed if clinically indicated. From our cohort 2 patients, whose IFs were further investigated were found to have malignancy, one with adenocarcinoma of the common bile duct and one renal cell carcinoma. Both of these patients were referred to specialty specific oncologist and were managed expectantly.
Table 1: Incidental Finding Frequency in ILD Patients.
In general, incidental findings have increased as non-invasive medical imaging technology has improved. Traditional ILD diagnosis methods of roentgram and open biopsy fail to provide a holistic and detailed image as compared to computer tomography of the lungs. Our results indicate when correlating clinical details with radiological findings, IFs uncovered 2 (2.38%) potentially life threatening processes. In a study by Swensen et al. non-pulmonary CT IFs have been observed in up to 14% of patients. In the same study 15/210 patients (7.14%) were found to have newly discovered Table 1: Incidental Finding Frequency in ILD Patients N (% of ILD Patients) Total cohort of ILD patients 84 (100) Incidental Finding Patients with at least one IF 25 (29.8) Liver Abnormalities 12 (14.3) Coronary Artery Calcifications 11 (13.1) Thyroid Abnormalities 5 (6.0) Renal Cysts 3 (3.6) Splenomegaly 0 (0) IF – incidental finding malignancy [5]. Additionally in studies which utilized chest computer tomography as the primary mode of imaging it was found that prevalence of patients with at least one incidental imaging abnormality varied from 3% to 41.5% [6]. Another study focusing on lung cancer screening discovered IFs in 3% which led to 12 invasive procedures; however, only 8 of these were clinically relevant [7]. With such data we can say that the fiscal burden of additional testing is worth it as we can’t put a price on life. Use of HRCT will inevitably produce false positive findings of incidentalomas as compared to traditional diagnostic methods. Incidentalomas may lead to a clinical “dead end” but as physicians our duty is to investigate findings which we deem necessary to preserve our patients’ health. In the end it is the responsibility of the physician to clinically correlate radiological findings and act appropriately in the investigation of IFs.
Sahni S, Verma S, Thomas RS, Capozzi B and Talwar A. Clinical Relevance of the Incidentaloma: A Clinician’s Viewpoint. SM J Clin Med. 2015; 1(2): 1006
The purpose of this statement is none other than to highlight the importance of ethical standards and quality required in basic and applied research currently being done so we can subsequently inform health care professionals of new developments that are taking place in this area.
Ma. Esperanza Rodríguez-van Lier*
Chemotherapy is commonly used in cancer treatment. So far, chemotherapy agents can be categorized into three types: classical chemotherapeutic drugs, molecular target agents and cellular machineries target drugs.
Ziyou Wang1,2 and Zunnan Huang1,2*
Blood transfusion can cause some transfusion adverse reactions. In order to understand the incidence of adverse transfusion reactions, we performed a meta-analysis in Chinese hospitals. Of 809 literatures, seven studies involving a total of 211, 050 patients with blood transfusion treatment were included in this meta-analysis. Meta-analysis showed that the total incidence of adverse reactions was 0.4% [95% CI (0.2, 0.9), P < 0.0001]. Further subgroup analysis showed that the incidence of febrile and allergic reactions was 0.2% [95% CI (0.1, 0.5), P < 0.0001] and 0.2% [95% CI (0.1, 0.3), P < 0.0001], respectively. The common blood components caused adverse reactions were red blood cell, plasama, and platelet in clinical practice.
Yulu Gao1 , Qinyun Li2 , Zongshuai Gao2 , Yunxia Zhu4 , Yanqiu Liao5 , Changtai Zhu2 *# , Yongning Sun3 *#
Hepatitis C Virus infection (HCV) is an increasing public health concern with an estimated 184 million people infected worldwide and approximately 350.000 yearly deaths from HCV-related complications.
Nesrine Gamal and Pietro Andreone*
We report a case of large cell undifferentiated lung carcinoma in a middle aged patient with previously treated tuberculosis and scarring. 20 pack years of smoking history was noted. He presented with metastasis at multiple sites including trochanter, liver and acute bilateral lateral rectus palsy. Chest radiography showed fibrosis of right upper zone with homogenous opacity. Sputum examination for AFB was negative. Computerized tomography of the thorax showed an irregular heterogeneously enhancing mass involving right upper lobe with cavitation, necrosis along with lymph node involvement and the erosion of the 4th rib with liver metastasis. Radiography of hip joint was suggestive of lesser trochanteric metastasis. MRI brain was suggestive of mass at base of brain in parasellar area. Fine needle aspiration cytology and CT guided biopsy confirmed undifferentiated large cell carcinoma of lung. Tuberculosis and smoking may increase the risk of lung scarring and malignancy and pulmonary scarring may be associated with increased lung carcinoma in ipsilateral lung. Clinician needs to be more sensitive to look for malignancy association particularly in patient with or previously treated for tuberculosis and even more emphasis to be laid if scarring of lung is observed.
Sreenivasa Rao Sudulagunta1 *, Shyamala Krishnaswamy Kothandapani2 , Mahesh Babu Sodalagunta3 , Hadi Khorram2 , Mona Sepehrar4 and Zahra Noroozpour1
Systemic Sclerosis (SSc) is a connective tissue disease characterized by fibrosis of the skin and internal organs, pronounced alterations in the microvasculature and frequent cellular and humoral immunity abnormalities. The rheumatic involvement of SSc is polymorphic and can reveal the disease or may appear during the course of its progression. Musculoskeletal involvement is dominated by non specific arthralgia, polyarthritis, and bony resorption especially acro-osteolysis. The diagnosis of these rheumatic manifestations is generally based on x rays examination. Musculoskeletal involvement in SSc is generally relieved with Non Steroidal Anti-Inflammatory Drugs (NSAID) or low dose of corticotherapy. The immunosuppressive therapy is used in corticoid-resistant or corticoid-dependent forms such us méthotrexate. The aim of our review is to presents an overview of the different osteoarticular and muscular involvement in SSc, their diagnosis and management.
Nessrine Akasbi*, Fatima Ezzahra Abourazzak and Taoufik Harzy
Sedigheh Mirhashemi1 , Mohammad Hosein Kalantar Motamedi1 *, Amir Hossein Mirhashemi2 and Hamid Reza Rasouli1
We encountered two autopsy cases of huge cardiomegaly with over 1000g in weight. Histochemical characteristics were examined using conventional staining including HE and Azan stains and immunohistochemical staining using antibodies against Complement Component 9 (CC9), RNA Binding Protein Motif 3(RBM3), Endothelial Type NO Synthase (eNOS) and Hypoxic Inducible Factor1α (HIF1). The reactive area with anti CC9 antibody, which presumed to be a marker of hypoxic change of myocardium, overlapped with eosinophilic area by HE and basophilic one by Azan. Although the reactive area with anti CC9 antibody showed relatively weak in the cytoplasm by anti eNOS antibody and no in the nucleus of cardiocytes with anti RBM3 antibody, outside of the reactive area with anti CC9 antibody there were intensive reactivity with anti eNOS antibody in cytoplasm and in a nucleus with anti RBM3 antibody. Anti HIF1 antibody showed weak reactivity with cytoplasm of endocardial cardiocytes and no with cytoplasm of cardiocytes in another area. The results obtained from the present cases revealed that the hypoxic change was equivalent even though the cause of cardiomegaly was deferred between two cases, and conventional staining such as HE and Azan utilized to detect hypoxic change in the heart and immunohistochemical studies seemed to be a useful tool for clarifying the cascade of hypoxic changes in the myocardium.
Satoshi Furukawa1,2*, Mayumi Kataoka1 , Satomu Morita1,2, Akari Uno2 , Masahito Hitosugi2 , Hiroshi Matsumoto1,3 and Katsuji Nishi1,2
A 45-year-old woman with multiple sclerosis was admitted to our hospital after out of hospital cardio-pulmonary resuscitation. The first ECG showed ventricular fibrillation. Following direct current defibrillation and mechanical reanimation, spontaneous circulation was restored and the ECG unremarkable without any signs of ischemia. Coronary angiography showed unobstructed coronary arteries Figure 1, (Panel A). Left ventriculography revealed apical wall obstruction, suggestive of apical aneurysm (Panel B, supplementary videos). Transthoracic echocardiography and Cardiac Magnetic Resonance Imaging (CMR) eventually lead to the diagnosis of a rare case of Apical Hypertrophic Cardiomyopathy (AHC) with ace of spades-form (Panel C,D). The patient underwent Cardioverter-Defibrillator Implantation (ICD) and amiodarone medical therapy for secondary prophylaxis. Patient’s family history and screening for HCM were unsuspicious.
Wiedemann S# *, Heidrich FM# , Speiser U and Strasser RH
We present the case of a 23-year-old female who was 23 weeks pregnant and presented to the emergency room of our Obstetric Department in nausea and vomiting that had been worsening over the course of 2 months with loss of eight kilograms in clinical presentation compatible with hyperemesis.
Elisa Picardo1*, Marco Mitidieri1, Marco Bozzaro2, Roberto Altieri2, Carlo Carmazzi1 and Saverio Danese1