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A 50-year-old Caucasian man was presented to the emergency department with cough and progressive dyspnoea. Plain chest x-ray showed multiple pseudo-nodular parenchymal opacities, partly confluent and calcified, prominent in the middle-basal lung fields (figure 1A). Figure 1 (A) Plain chest x-ray showing multiple pseudo-nodular parenchymal opacities, partly confluent and calcified, prominent in the middle-lower lung fields. (B) Trans-axial HRCT slice …

Solitary fibrous tumor (SFT) of the pleura usually presents as a peripheral mass, in contact with the surface of the pleura. However, on occasion, it can occur separately from the pleura, in the lung parenchyma. We describe the radiological and imaging features of three SFTs of the lung, diagnosed in our department, with relevant clinical data. The diagnosis of SFT of the lung, although rare, should be considered in a slow-growing solitary lung parenchymal nodule.

Malignant fibrous histiocytoma (MFH) is a pleomorphic sarcoma, occurring most frequently in the deep soft tissues of the extremities, and it is most frequently seen in elderly patients. A primary MFH of the diaphragm is very rare, and to the best of our knowledge, a multi-phased spiral CT appearance of this tumour has not been previously reported. In this report, we describe the clinical and multi-phase CT features of a primary MFH of the diaphragm.

This review discusses the usefulness of bedside lung ultrasound in the diagnostic distinction between the various causes of acute dyspnoea in the emergency department, with special attention to the differential diagnosis of pulmonary oedema and exacerbation of chronic obstructive pulmonary disease (COPD). This is made possible by using mid- to low-end scanners and simple acquisition techniques accessible to both radiologists and clinicians. Major advantages include ready availability at the bedside, the absence of ionising radiation, high reproducibility and cost efficiency. The technique is based on the recognition and analysis of sonographic artefacts rather than direct visualisation of the pulmonary structures. These artefacts are caused by the interaction of water-rich structures and air, called comet tails or B-lines. When such artefacts are widely detected on anterolateral transthoracic lung scans, diffuse alveolar-interstitial syndrome can be diagnosed, which is often a sign of acute pulmonary oedema. This condition rules out exacerbation of COPD as the main cause of acute dyspnoea.

Diffuse comet-tail B-line artifacts in lung ultrasound are a sign of alveolar-interstitial syndrome, but isolated transthoracic scans positive for B-lines (multiple B lines or B+) could be detected in other conditions. The aim was to assess the prevalence and distribution of this sonographic sign in patients with normal lung or isolated alveolar consolidation in chest radiography.Two hundred seventeen patients consecutively admitted to this emergency medicine unit with any diagnosis and without radiographic or clinical evidence of diffuse interstitial syndrome were analyzed. Each patient underwent chest radiography and lung sonographic examination with four anterolateral chest scans per side.Of the 1736 sonographic scans performed, 13.2% were positive for the B+ pattern. Positive scans significantly corresponded to laterobasal areas or radiographic opacities due to lung alveolar consolidations (p0.005). Twenty percent of the laterobasal scans of 145 patients with radiologically normal lung were positive. The negative predictive value of B+ was 83.9% (95% confidence interval: 78.2-89.7%), with a specificity of 90.3% (95%CI: 85.5-95.1%) for predicting any localized radiographic pulmonary opacity.B+ scans can be detected in the chest areas surrounding an isolated alveolar consolidation and in the laterobasal scans of a radiographic normal lung. These features should always be considered when lung ultrasound is performed to rule out the alveolar-interstitial syndrome in an emergency setting. Moreover, B+ patterns have a satisfactory negative predictive value for radiographic lung opacities, which could have added diagnostic value in the ED evaluation of dyspneic patients.

L’imaging delle malattie della pleura nell’anziano e sostanzialmente costituito dalle manifestazioni delle neoplasie, primitive o secondarie, da quelle delle forme flogistiche, infettive aspecifiche o tubercolari e dagli ispessimenti diffusi di tipo fibrotico che rappresentano l’evoluzione di fatti antichi esitati in fibrotorace. Un elemento che spesso concomita e talvolta si sovrappone in maniera preponderante ai processi sopra riportati e il versamento che puo dominare la scena sia nelle alterazioni flogistiche che in quelle neoplastiche.

Il torace dell’anziano senza patologia evidente e caratterizzato da reperti che occupano una sorta di “terra di nessuno” tra il normale e il patologico. L’invecchiamento comporta fisiologicamente delle modificazioni che devono essere riconosciute per non essere interpretate erroneamente come patologiche. D’altra parte, l’anziano tende ad ammalarsi di piu e sono piu frequenti le pluripatologie, per cui la diagnostica per immagini e un elemento chiave di chiarimento di quadri clinici spesso sfumati e non di rado puo consentire anticipazione della diagnosi, a tutto vantaggio della tempestivita dell’intervento terapeutico.

The purpose of this study was to identify the typical computed tomography (CT) features of solitary fibrous tumours of the pleura (SFTP) and determine which findings would allow confirmation of the pleural origin or benign behaviour of the tumour.Twenty-six preoperative CT studies of the chest (23 enhanced and 14 unenhanced) were retrospectively reviewed.Up to 50% of SFTP were larger than 10 cm. At unenhanced CT, they showed homogeneous attenuation in 5 cases (35.7%) and inhomogeneous attenuation in 9 (64.3%). At contrast-enhanced CT, they were inhomogeneous in 21 cases (91.3%), with geographic pattern (61.9% of cases), serpiginous linear areas of enhancement (intralesional vessels) (23.8%), rounded (52.4%) or linear (33.3%) areas of low attenuation (necrosis).Depending on location, size and histological features, SFTP may produce a large spectrum of findings. Typical CT features of small SFTP were well-defined margins and smooth contours, homogeneous attenuation and right or obtuse angles with the pleura. Larger lesions were characterised by well-defined margins and lobulated contours, geographic pattern in enhanced CT scans, acute angles or smooth tapering margins with the pleura.

Objectives: To assess the potential of bedside lung ultrasound to diagnose the radiologic alveolarinterstitial syndrome (AIS) in patients admitted to an emergency medicine unit and to estimate the occurrence of ultrasound pattern of diffuse and multiple comet tail artifacts in diseases involving lung interstitium. Methods: The ultrasonic feature of multiple and diffuse comet tail artifacts B line was investigated in each of 300 consecutive patients within 48 hours after admission to our emergency medicine unit. Sonographic examination was performed at bedside in a supine position. Eight anterolateral ultrasound chest intercostal scans were obtained for each patient. Results: The artifact showed a sensitivity of 85.7% and a specificity of 97.7% in recognition of radiologic AIS. Corresponding figures in the identification of a disease involving lung interstitium were 85.3% and 96.8%. Conclusion: Comet tail artifact B line is a lung ultrasound sign reasonably accurate for diagnosing AIS at bedside.

Mediastinal tumours are frequently asymptomatic and first noted on routine chest radiograph. In most cases, evaluation should proceed to spiral computed tomography (sCT) of the chest with iodinated contrast material. The specific location and appearance of tumours on sCT is instrumental in planning further diagnostic and treatment strategies. Primary tumours in the anterior mediastinum account for half of all mediastinal masses. They comprise various benign and malignant neoplasms, but a wide variety of nonneoplastic lesions (developmental, inflammatory) can present as a localised mass in this compartment. The most common primary anterior mediastinal tumours are thymoma, teratoma and lymphoma; all other lesions are rare. Nonneoplastic conditions include thymic cysts, lymphangioma and intrathoracic goitre. Understanding the pathology, clinical presentation, imaging and diagnosis of the major tumour types is instrumental in the safe and efficient work-up of a mediastinal mass. Patients with primary mediastinal masses and cysts will usually undergo surgical resection; radiological and clinical features should prompt limited biopsy specimens followed by oncologic consultation, and chemotherapy or radiotherapy when appropriate. The objective of this review was to examine the role of diagnostic imaging in the management of masses of the anterior mediastinum.

Acute intramural aortic hematoma may result from ruptured vasa vasorum without intimal disruption (IMH hereafter) but can also be found in association with processes in which an intimal lesion is present, such as aortic dissections (AD), where the hematoma represents the acute thrombosis of the false lumen, or in penetrating atherosclerotic ulcers (PAU), where blood collects beyond the disrupted internal elastic lamina. As the clinical presentation of these conditions is very similar, imaging techniques should aim both to diagnose the hematoma and to characterize the underlying pathology. This review critically analyzes the diagnostic potential of several imaging methods based on personal experience and literature reports. Although intramural hematoma can be easily diagnosed unrespective of the tomographic imaging modality, it is usually difficult to distinguish between IMH and hematomas associated either to AD or to PAU. Indeed, only PAU related hematomas can be consistently diagnosed due to the high probability of unveiling the causative wall ulceration; conversely, the differential diagnosis between IMH and AD - associated hematomas is still matter of controversy. According to the literature, the two conditions cannot be differentiated by transesophageal echocardiography, though some reports state that a distinction might be made by MR imaging. As regards CT, only a small percentage of AD - associated hematomas exhibit clear evidence of a typical intimal flap, allowing for a safe diagnosis to be made: often, unfortunately, the intimal lesion subsequently found at surgery cannot be detected, yielding a picture of IMH. Therefore, the radiological report should give the same diagnostic probability to both conditions.

First described by Klemperer and Rabin in 1931, solitary fibrous tumour of the pleura (SFTP) is a mesenchymal tumour that tends to involve the pleura, although it has also been described in other thoracic areas (mediastinum, pericardium and pulmonary parenchyma) and in extrathoracic sites (meninges, epiglottis, salivary glands, thyroid, kidneys and breast). SFTP usually presents as a peripheral mass abutting the pleural surface, to which it is attached by a broad base or, more frequently, by a pedicle that allows it to be mobile within the pleural cavity. A precise preoperative diagnosis can be arrived at with a cutting-needle biopsy, although most cases are diagnosed with postoperative histology and immunohistochemical analysis of the dissected sample. SFTP, owing to its large size or unusual locations (paraspinal, para-mediastinal, intra-fissural and intraparenchymal), can pose interpretation problems or, indeed, point towards a diagnosis of diseases of a totally different nature. We present some unusual radiographic and computed tomography (CT) images of large SFTP or SFTP located in atypical thoracic locations in patients who underwent surgical resection.

A 65-year-old female presented in our Emergency Department complaining of cough and progressive dyspnea. Plain chest radiography showed long-segment narrowing of the trachea. Multislice computed tomography confirmed the tracheal narrowing and demonstrated multiple nodular calcifications protruding into the visceral lumen, involving also the main and segmental bronchi but sparing the pars membranacea trachealis (Fig. A).

7206 Background: In 2001 a feasibility study testing low-dose sCT as an early diagnosis tool in asymptomatic volunteers at high risk for lung cancer was planned and initiated at our institution with an evaluation at baseline and then annually for 5 years. Subjects & Methods: We enrolled 520 asymptomatic volunteers, 73% males, aged 55 years or older (median age 60 yrs), with at least 20 pack-years of cigarette smoking and no previous cancer. Results: At baseline, one hundred forty-four extra-pulmonary findings (28%) were detected. The more common findings were: radiologically-detected adrenal enlargements (19%); thyroid struma (8%); hepatic abnormalities, like angiomas, cysts, calcifications, steatosis (29%); renal alterations, like cysts, lithiasis, vascular calcifications and one case of stage I renal carcinoma (21%); spleen abnormalities, like cysts, calcifications, accessory spleen (5%); cholelithiasis (4%); pancreatic alterations (1%); thymic nodules (1%); axillary adenopathy (5%); aortic ectasia or aneurysm (5%) and one breast nodule. In 2 cases (renal carcinoma and breast nodule) a surgical resection was performed. All these findings were followed up through a letter to the general practitioner. In 62 subjects the initial findings were considered worth of further imaging investigations or were suggestive for a clinically definite disease (e.g. renal carcinoma). In the remaining 82, mainly based on personal history data, the abnormalities were already known and previously diagnosed. Globally, the cumulative number of extrapulmonary findings from 2nd to 5th year was 275 and the more common findings were: cysts (hepatic 9%, renal 13%), lithiasis (renal 1%, hepatic 5%), thyroid struma 4%, adrenal adenomas 3%, vascular calcifications 37%, aneurysm 3%, vertebral artropathy 2%. Conclusions: Even if early detection of lung cancer will result in a survival benefit, in the cost-effectiveness analyses the additional costs from the detection of extra-pulmonary findings should also be carefully considered because in many cases they may request substantial outpatient clinic admissions and further diagnostic investigations. No significant financial relationships to disclose.

It is unclear whether (and, to what extent) radiologists look at and report cardiovascular abnormalities on non-cardio-synchronized standard chest computed tomography (CT). In this study, the frequency and the reporting rate of cardiovascular findings in chest CT examinations were retrospectively assessed. This study was approved by the institutional review board of each participating center. Four academic centers provided data on 447 subjects who underwent non-ECG-synchronized chest CT examinations for evaluating pulmonary fibrosis (161/447, 36 %), suspected pulmonary embolism (140/447, 31.3 %), or lung cancer staging (146/447, 32.7 %). A total of 220/447 (53.7 %) and 227/447 CT (46.3 %) examinations were evaluated and reported by junior and senior chest radiologists, respectively. Two radiologists with training in cardiac imaging reviewed the same chest CT images looking for the presence of incidental cardiovascular abnormalities using a preformatted score sheet. Inter-observer agreement was assessed using the kappa coefficient of agreement (k). Inter-observer agreement between the study reviewers was moderate to good (0.4–0.73) for most of the incidental cardiovascular findings. At least one incidental cardiovascular finding not documented in the original report was identified by the study reviewers in 225/409 (55 %) of chest CT examinations. A total of 168/266 (63.2 %) potentially clinically significant cardiovascular findings were unreported in the original reports of 177/447 (39.6 %) subjects (p

Solitary fibrous tumor of the pleura (SFTP) is a mesenchymal tumor that tends to involve the pleura, and is also described in other thoracic and extrathoracic sites. SFTP usually presents as a peripheral mass abutting the pleural surface, to which it is attached by a broad base or by a pedicle that allows it to be mobile. SFTPs exist in benign and malignant forms. A precise pre-operative diagnosis can be arrived at with a cutting-needle biopsy, although most cases are diagnosed with postoperative histology and immunohistochemical analysis. In this pictorial essay, we review a large series of cases, with emphasis on the radiographic appearance of these lesions and their findings from computed tomography, magnetic resonance imaging, ultrasonography and positron emission tomography.

A 60-year-old woman presented to the emergency department (ED) of a suburban hospital with complaints of cough, fever, and dyspnea. She had a history of chronic obstructive pulmonary disease (COPD) and chronic steroid therapy. At presentation, she was in severe respiratory distress. Orotracheal intubation was decided due to persistence of severe hypoxia and hypercapnia with deterioration of consciousness despite a first attempt at noninvasive ventilation. The intubation was performed in rapid sequence using a 7.5-mm diameter single lumen tube without stylet. The patient had a regular and anatomically intact airway. The maneuver itself was reported to be an easy procedure and was considered successful after the first attempt. After about an hour of invasive ventilation, a subcutaneous emphysema appeared on the neck and anterior chest wall, respiratory failure worsened, and a slight hemoptysis occurred. The chest radiograph showed subcutaneous emphysema and protrusion of the cuff outside the tracheal lumen (Fig. 1). A computed tomography (CT) scan visualized the injury of the posterior tracheal wall due to the rupture of the pars membranacea (Fig. 2). The patient was then referred to our hospital to undergo a bronchoscopy, which revealed a longitudinal hole with sharp margins at the posterior part of the membranous portion, extending up to 2 cm from the carina with a total length of 5 cm. The lesion was surgically repaired via right thoracotomy. Fig. 1 a Chest radiograph in the anteroposterior view of the patient with tracheal rupture, showing subcutaneous and mediastinal emphysema. b Detailed view shows the protrusion of the cuff of the tube outside the tracheal lumen (white arrows) Fig. 2 a–c Corresponding CT axial scans corroborating the diagnosis of subcutaneous and mediastinal emphysema. d The lumen of the tracheal tube appears enlarged and deformed after the herniation of the cuff Mechanisms that may determine tracheal laceration are mechanical and anatomical [1]. An over-distended balloon cuff coupled with fragility of the tracheal wall due to chronic lung diseases and steroid therapy may be crucial [2]. The appearance of specific symptoms after intubation, like subcutaneous emphysema, hemoptysis, and persistence of hypoxia despite adequate ventilation, are consistent with a possible tracheal rupture [1–4]. Radiology may confirm the clinical suspicion.