Medical Image of the Week: Evolution of Low Grade Adenocarcinoma

Figure 1. Coned down chest CT images. Panels a-d: small ground glass focus in the right upper lobe demonstrating slow growth over a period of 10 years (yellow arrows) and gradual development of a soft tissue component (red arrows).

Ground glass lesions above 5 mm in greatest diameter found on chest computed tomography (CT) require initial followed up in 3 months according to the Fleischner Society Guidelines, to exclude a transient inflammatory focus (1). If persistent, surveillance for at least 24 months to confirm stability is recommended. Any change in size or density should warrant further action, ideally surgical consultation, given the suboptimal yield of percutaneous biopsy and risk of inappropriate staging if the whole lesion is not examined. This may result in the inability to recognize the transition from in-situ adenocarcinoma into minimally invasive or invasive lesions, which in turn results in inaccurate staging and prognosis.

Diana Palacio MD, Berndt Schmit MD, and Veronica Arteaga MD

Department of Medical Imaging

Banner-University Medical Center Tucson

Tucson, AZ USA

Reference

1. MacMahon H, Austin JH, Gamsu G, Herold CJ, Jett JR, Naidich DP, Patz EF Jr, Swensen SJ; Fleischner Society. Guidelines for management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society. Radiology. 2005 Nov;237(2):395-400. [CrossRef] [PubMed]

Cite as: Palacio D, Schmit B, Arteaga V. Medical image of the week: evolution of low grade adenocarcinoma. Southwest J Pulm Crit Care. 2017;14(3):103. doi: https://doi.org/10.13175/swjpcc026-17 PDF 

December 2016 Imaging Case of the Month

Eric A. Jensen, MD

Michael B. Gotway, MD 

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

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): Eric A. Jensen, 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

Clinical History: A 47-year-old woman presented for medical evaluation prior to trans-sphenoid hypophysectomy for pituitary adenoma for Cushing syndrome. The patient had an extensive past medical history, including kidney minimal change disease treated with corticosteroids between 5-7 years previously (no longer on corticosteroid therapy), type II diabetes mellitus, focal segmental glomeruloscleroosis on renal biopsy, morbid obesity, gout, obstructive sleep apnea on continuous positive airway pressure (CPAP) supplemented with oxygen for the previous 8 years, hypertension, and recent-onset atrial fibrillation, as well as a history of several pneumonias, perhaps related to chronic immunosuppression. Her past surgical history included bilateral partial knee replacement, lower extremity vein ablation, and breast reduction. Her medication list was extensive, including allopurinol, anti-hypertensives, anti-depressants, colchicine, oxygen, and Tacrolimus, among others, including over-the-counter medications.

Laboratory data, include white blood cell count, coagulation profile, and serum chemistries were within normal limits. Oxygen saturation on room air was 95%.

Frontal and lateral chest radiographs (Figure 1) were performed. A previous chest radiograph performed 2 years earlier is presented for comparison (Figure 2).

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

Figure 2.  Frontal chest radiography performed 2 years prior to presentation.

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

1. Frontal and lateral chest radiography appears normal
2. Frontal and lateral chest radiography shows a mass projected over the right paratracheal region
3. Frontal and lateral chest radiography shows asymmetric hyperlucency affecting the right thorax
4. Frontal and lateral chest radiography shows basal reticulation suggesting possible fibrotic disease
5. Frontal and lateral chest radiography shows cardiomegaly only, but is unchanged from prior

Cite as: Jensen EA, Gotway MB. December 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016;13(6):290-301. doi: https://doi.org/10.13175/swjpcc135-16 PDF 

Medical Image of the Week: Atherosclerotic Aneurysm of Aortic Arch and Descending Thoracic Aorta

Figure 1.  Chest radiograph displays mild CHF, prominent vascular markings, and a large thoracic aneurysm.

Figure 2. Panel A: Computerized tomography angiography (CTA) with contrast displays an aneurysm of the aortic measuring 6.8 cm with eccentric thrombi. Panel B: CTA also shows an aneurysm of the descending aorta measuring 6 cm across with eccentric thrombi. Panel C: CTA demonstrates a tortuous descending aorta displayed by the curving of the descending aorta as it transitions to the abdominal aorta.

A 94-year-old Spanish-speaking woman presented to the hospital with intermittent episodes of dyspnea and abdominal pain for one week. Her past medical history was notable for 30 pack-year smoking history and hypertension, which was reportedly controlled with medical therapy.  Physical exam showed trace peripheral edema bilaterally, intact peripheral pulses, and a mild abdominal bruit. Work up at the emergency department revealed a non-ST elevation myocardial infarction with troponin T of 0.34 ng/mL but no ST-wave abnormality on electrocardiography. Chest x-ray displayed an incidental thoracic aneurysm (Figure 1). Chest computed tomography with contrast demonstrated a continuous aneurysm of the aortic arch and descending thoracic aorta with diameters measuring 6.8 cm and 6 cm, respectively (Figure 2A and 2B). Eccentric thrombi are noted in the aortic arch and the descending aorta. Interestingly, the distal descending thoracic aorta curves as it transitions to the abdominal aorta, which is evidence of a tortuous descending aorta (Figure 2C). The patient declined both invasive and non-invasive treatment and left the hospital against medical advice one day after admission.     

Melvin Parasram MS¹, Lea McKinnon MD², Iwan Nyotowidjojo MD³, and Kareem Ahmad MD⁴

¹Midwestern University: Arizona College of Osteopathic Medicine, Glendale, AZ USA

²Departments of Radiology, ³Internal Medicine and ⁴Pulmonary and Critical Care, Banner University Medical Center - Tucson, Tucson, AZ USA

Cite as: Parasram M, McKinnon L, Nyotowidjojo I, Ahmad K. Medical image of the week: atherosclerotic aneurysm of aortic arch and descending thoracic aorta. Southwest J Pulm Crit Care. 2016;12(2):46-7. doi: http://dx.doi.org/10.13175/swjpcc155-15 PDF