Ground-glass opacity of the lung in a patient with melanoma: “The radiological seed of doubt”

Dalpiaz, G.; Kawamukai, K.; Parisi, A.M.; La Torre, L.; Forcella, D.; Leuzzi, G.

doi:10.1016/j.remnie.2015.10.004

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(a) Plain film of KUB region shows no radio-opaque calculus. After intravenous bolus injection of water soluble contrast, sequential plain films were acquired at 7, 15, 60 and 120min. Plain images (b–e) revealed normally located both kidneys with prompt extraction of contrast in adequate concentration. Right PCS is compact with sharp fornicial angles and maintained papillary impression. Right ureter is normal in course, caliber and outline. Left PCS is dilated with blunting of fornicial angles and ballooning of calices. Left ureter is not visualized. Plain image (f) acquired 5min after intravenous injection of lasix which revealed complete excretion of contrast from right PCS while persistence of contrast in left PCS (s/o left sided grade IV hydronephrosis with pelviureteric junction obstruction). Intraop micturating cysto-urethrogram (MCU) image (g) No e/o evidence of vesicoureteric reflux (VUR)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "T.K. Jain, R.K. Basher, B.R. Mittal, A. Bhatia, K.L.N. Rao" "autores" => array:5 [ 0 => array:2 [ "nombre" => "T.K." "apellidos" => "Jain" ] 1 => array:2 [ "nombre" => "R.K." "apellidos" => "Basher" ] 2 => array:2 [ "nombre" => "B.R." "apellidos" => "Mittal" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Bhatia" ] 4 => array:2 [ "nombre" => "K.L.N." "apellidos" => "Rao" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808915001019?idApp=UINPBA00004N" "url" => "/22538089/0000003400000006/v1_201510310036/S2253808915001019/v1_201510310036/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "Interesting images" "titulo" => "Ground-glass opacity of the lung in a patient with melanoma: “The radiological seed of doubt”" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "390" "paginaFinal" => "392" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "G. Dalpiaz, K. Kawamukai, A.M. Parisi, L. La Torre, D. Forcella, G. Leuzzi" "autores" => array:6 [ 0 => array:3 [ "nombre" => "G." "apellidos" => "Dalpiaz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "K." "apellidos" => "Kawamukai" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A.M." "apellidos" => "Parisi" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "La Torre" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "D." "apellidos" => "Forcella" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 5 => array:4 [ "nombre" => "G." "apellidos" => "Leuzzi" "email" => array:1 [ 0 => "gio.leuzzi@yahoo.it" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Department of Radiology, Bellaria Hospital, Bologna, Italy" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Thoracic Surgery, Maggiore and Bellaria Hospitals, Bologna, Italy" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Oncology, Imola, Italy" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Surgical Oncology, Thoracic Surgery Unit, Regina Elena National Cancer Institute – IFO, Rome, Italy" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Opacidad pulmonar en vidrio esmerilado en un paciente con antecedente de melanoma: “la semilla radiológica de la duda”" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 600 "Ancho" => 1620 "Tamanyo" => 238442 ] ] "descripcion" => array:1 [ "en" => "(A) Microscopic findings (Haematoxylin and Eosin, original magnification ×5): tumor cells spreading along the alveolar walls and organized in lepidic pattern. No necrotic foci were evidenced. (B) The tumor cells were diffusely stained for antibody anti-S100. Based on these findings, the final pathology was consistent with lung metastasis from melanoma." ] ] ] "textoCompleto" => "A 51-year-old Caucasian woman referred to our Department for radiological evidence of ground-glass opacity (GGO) of the left lung. She was an active smoker; her medical history was unremarkable with the exception of the surgical excision 2 years before of a malignant melanoma localized in the left hand and with metastases of axillary nodes (staged as pT3bN0M1b). A contrast-enhanced computed tomography scan (CT) revealed a non-solid nodule (measuring 2cm) of the left upper lobe (LUL) along with some subcentimetric GGOs bilaterally (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). After the admission, an 18FDG PET-CT (PET-CT) highlighted an increase of its solid component associated to a slight uptake (SUVmax 2.1) of the LUL lesion (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). No signs of pathologic mediastinal nodes or extra-thoracic disease were disclosed. Given the subsolid nature of the nodule, bronchoscopy or CT-guided biopsy were not performed, thus, after a multidisciplinary meeting, the patient underwent a thoracoscopic LUL wedge resection. Frozen section disclosed atypical cells with lepidic growth only, making a proper pathological diagnosis unfeasible: hence, an uneventful left upper lobectomy plus systematic lymphadectomy was performed. Interestingly, final pathology evidenced intra-pulmonary metastasis from melanoma expressing c-kit mutation (B-Raf wild-type) without nodal involvement (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), so the patient started chemo and immuno-therapy. One year after surgery, oncological follow-up evidenced a stable disease.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia>So far, the management of nonsolid/subsolid pulmonary nodules is an extremely challenging issue. As advocated by the Fleischner Society, persistent nonsolid/subsolid nodules usually represent part of the pathologic spectrum of lung adenocarcinoma.<a class="elsevierStyleCrossRef" href="#bib0020">1</a> Moreover, lung metastasis from adenocarcinoma of thoracic or extra-thoracic origin (gastrointestinal tract, pancreas, kidney) and atypical adenomatous hyperplasia may present with such radiological features and lepidic growth. On the other hand, benign lesions arising from lymphoproliferative disorders, organizing pneumonia and focal interstitial fibrosis may mimic sometimes lung neoplasms given the high rate of GGOs related to these diseases.Pulmonary metastases from melanoma commonly present as one or multiple solid nodules at standard imaging while GGOs are very rarely reported in literature.<a class="elsevierStyleCrossRef" href="#bib0025">2</a> In this setting, PET-CT may play a role in the case of subsolid metastasis.<a class="elsevierStyleCrossRef" href="#bib0030">3</a> In fact, in our patient nuclear images (along with CT) were useful: (i) to evaluate the increase of nodule density; (ii) to assess the 18FDG uptake of the solid component (as reported for nodules exhibiting a solid part measuring more than 10mm); (iii) to exclude nodal or extra-thoracic disease. Unfortunately, this uncommon radiological behavior reflects the pathological one related to lepidic growth (resulting from cancer spreading along alveolar walls), thus leading in difficult pathological diagnosis and, sometimes, overtreatment. In fact, due to the adenocarcinoma-like pathologic pattern, the patient underwent lobectomy rather than lung-sparing surgery.In conclusion, in case of radiological evidence of GGOs after surgery for melanoma, follow-up through CT scan and growth rate evaluation are well-recognized options to further analyze such nodules.<a class="elsevierStyleCrossRef" href="#bib0020">1</a> When non-solid nodules acquire partially solid pattern, PET-CT may be useful to better characterize the solid component and to accurately stage the disease. Furthermore, in the suspect of primary or secondary lesions, surgery is usually indicated in order to obtain final diagnosis and oncological treatment simultaneously.Conflicts of interestNone declared." "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 740 "Ancho" => 975 "Tamanyo" => 142239 ] ] "descripcion" => array:1 [ "en" => "CT scan performed before admission (axial slice): CT images demonstrate a non-solid nodule (measuring 2cm in the major axis) of the left upper lobe along with some subcentimetric ground-glass opacities bilaterally." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1800 "Ancho" => 1865 "Tamanyo" => 220244 ] ] "descripcion" => array:1 [ "en" => "Whole body PET/CT performed 1h after the administration of 296 MBq of 118FDG (axial and oblique slices): the images evidenced an increase of the solid component of the lung nodule associated with a slight 18FDG uptake (SUVmax 2.1). No signs of pathologic mediastinal nodes or extra-thoracic disease were disclosed." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 600 "Ancho" => 1620 "Tamanyo" => 238442 ] ] "descripcion" => array:1 [ "en" => "(A) Microscopic findings (Haematoxylin and Eosin, original magnification ×5): tumor cells spreading along the alveolar walls and organized in lepidic pattern. No necrotic foci were evidenced. (B) The tumor cells were diffusely stained for antibody anti-S100. Based on these findings, the final pathology was consistent with lung metastasis from melanoma." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recommendations for the management of subsolid pulmonary nodules detected at CT: a statement from the Fleischner Society" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.P. Naidich" 1 => "A.A. Bankier" 2 => "H. MacMahon" 3 => "C.M. Schaefer-Prokop" 4 => "M. Pistolesi" 5 => "J.M. Goo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/radiol.12120628" "Revista" => array:6 [ "tituloSerie" => "Radiology" "fecha" => "2013" "volumen" => "266" "paginaInicial" => "304" "paginaFinal" => "317" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23070270" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0025" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ground-glass nodules found in two patients with malignant melanomas: different growth rate and different histology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M.J. Kang" 1 => "M.A. Kim" 2 => "C.M. Park" 3 => "C.H. Lee" 4 => "J.M. Goo" 5 => "H.J. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.clinimag.2009.10.036" "Revista" => array:6 [ "tituloSerie" => "Clin Imaging" "fecha" => "2010" "volumen" => "34" "paginaInicial" => "396" "paginaFinal" => "399" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20813308" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0030" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "High-risk melanoma: accuracy of FDG PET/CT with added CT morphologic information for detection of metastases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K. Strobel" 1 => "R. Dummer" 2 => "D.B. Husarik" 3 => "M. Pérez Lago" 4 => "T.F. Hany" 5 => "H.C. Steinert" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/radiol.2442061099" "Revista" => array:6 [ "tituloSerie" => "Radiology" "fecha" => "2007" "volumen" => "244" "paginaInicial" => "566" "paginaFinal" => "574" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17641374" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/22538089/0000003400000006/v1_201510310036/S2253808915001007/v1_201510310036/en/main.assets" "Apartado" => array:4 [ "identificador" => "7927" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Interesting images" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22538089/0000003400000006/v1_201510310036/S2253808915001007/v1_201510310036/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808915001007?idApp=UINPBA00004N"]

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The Revista Española de Medicina Nuclear e Imagen Molecular (Spanish Journal of Nuclear Medicine and Molecular Imaging), was founded in 1982, and is the official journal of the Spanish Society of Nuclear Medicine and Molecular Imaging, which has more than 700 members. The Journal, which publishes 6 regular issues per year, has the promotion of research and continuing education in all fields of Nuclear Medicine as its main aim. For this, its principal sections are Originals, Clinical Notes, Images of Interest, and Special Collaboration articles. The works may be submitted in Spanish or English and are subjected to a peer review process. In 2009, it became the leading Spanish journal in the field of Medical Imaging on having an Impact Factor , awarded by the Journal Citation Reports.

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Vol. 34. Issue 6.

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