January 2016 Imaging Case of the Month

Michael B. Gotway, MD 

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Imaging Case of the Month CME Information  

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive  0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives:
As a result of this activity I will be better able to:    

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None.

Clinical History: A 44 year-old man presented with refractory heart failure following the relatively asymptomatic detection of severe aortic regurgitation at auscultation 11 years earlier. When the valvular disease was discovered, the patient’s left ventricular ejection fraction was 25%. He underwent open aortic valvular replacement and his systolic function stabilized on medication in the years that followed, but eventually his cardiac function deteriorated further and he was listed for cardiac transplant.

As part of the pre – transplant evaluation frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography. 

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of six panels)

1. The frontal chest radiograph shows a relatively circumscribed opacity at the left base
2. The frontal chest radiograph shows abnormal mediastinal contours
3. The frontal chest radiograph shows basal predominant fibrotic abnormalities
4. The frontal chest radiograph shows large lung volumes with a cystic appearance
5. The frontal chest radiograph shows no abnormal findings

Cite as: Gotway MB. January 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016;12(1):13-9. doi: http://dx.doi.org/10.13175/swjpcc001-16 PDF

Medical Image of the Week: Solitary Fibrous Tumor

 

 

      

 Figure 1. Pleural based Right Lung mass shown on CXR (A), CT scan (B), and MRI (C).  MRI confirms lack of significant invasion to surrounding structures.

Figure 2.  Bisection of specimen (A) reveals a pale, tan-brown 9.5 x 10.2 x 4.5 cm mass suspended from surrounding normal lung by two pedicles, without gross evidence of invasion of surrounding lung tissue. H & E staining of a representative section of lung mass (B) reveals a dense infiltrate of spindly, fibroblast-like mesenchymal cells with bland nuclear features in the background of a dense collagenous stroma. When labeled with anti-CD34 antibody (C), a marker of fibroblasts and endothelial cells, diffuse cytoplasmic and membranous positivity is seen. Though not shown, staining for Bcl-2 and pankeratin were also performed, and were diffusely positive and negative, respectively. These immunohistochemical findings and a storiform or “pattern-less” pattern is characteristic of typical benign solitary fibrous tumors.

A 68 year old female with a history of resected lung cancer and new onset joint pain and swelling presented for evaluation.  Imaging revealed a right intrapleural mass and resection confirmed solitary fibrous tumor (SFT) of the pleura (benign).  The patient experienced resolution of her joint pain, which was due to pulmonary hypertrophic osteoarthropathy, shortly after resection.  Although not present in our patient, tumor induced hypoglycemia (Doege-Potter syndrome) can also be seen in SFTs.  Solitary fibrous tumors are uncommon neoplasms of mesenchymal tissue, and can originate from either visceral or parietal pleural surfaces.  Though they can grow to large size before clinical detection, the majority are benign, and can be treated with en bloc surgical resection.

Jessica Baumann, MD¹; James L Knepler, MD²; Richard Sobonya, MD¹ and Samuel Kim, MD³

Departments of Pathology¹, Medicine², and Surgery³

University of Arizona Thoracic Oncology Program

Tucson, Arizona

Reference

Cardillo G, Lococo F, Carleo F, Martelli M. Solitary fibrous tumors of the pleura. Curr Opin Pulm Med. 2012;18(4):339-46. [CrossRef] [PubMed]

Reference as: Baumann J, Knepler JL, Sobonya R, Kim S. Medical image of the week: solitary fibrous tumor. Southwest J Pulm Crit Care. 2013;7(3):179-80. doi: http://dx.doi.org/10.13175/swjpcc120-13 PDF