ISSN: 2165-3259 JAOCR Official Journal of the American Osteopathic College of Radiology CHEST IMAGING Guest Editors: Les Folio, D.O., MPH, FAOCR Bernard F. Laya, D.O. Editor-in Chief: William T. O’Brien, Sr., D.O. April 2014, Vol. 3, Issue 2 JAOCR About the Journal Aims and Scope The Journal of the American Osteopathic College of Radiology (JAOCR) is designed to provide practical up-to- date reviews of critical topics in radiology for practicing radiologists and radiology trainees. Each quarterly issue covers a particular radiology subspecialty and is composed of high quality review articles and case reports that highlight differential diagnoses and important teaching points. Access to Articles All articles published in the JAOCR are open access online. Subscriptions to the journal are not required to view or download articles. Reprints are not available. Copyrights Materials published in the JAOCR are protected by copyright. No part of this publication may be reproduced without written permission from the AOCR. Guide for Authors Submissions for the JAOCR are by invitation only. If you were invited to submit an article and have questions regarding the content or format, please contact the appropriate Guest Editor for that particular issue. Although contributions are invited, they are subject to peer review and final acceptance. Editor-in-Chief William T. O’Brien, Sr., D.O. San Antonio, TX Design Editor Jessica Roberts Communications Director, AOCR Managing Editor Tammam Beydoun, D.O. Farmington Hills, MI Editorial Board Susann Schetter, D.O. Daniel J. Abbis, D.O. Les R. Folio, D.O. Michael W. Keleher, D.O. Rocky Saenz, D.O. Kipp A. Van Camp, D.O. John Wherthey, D.O. J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2 Page i Table of Contents Chest Imaging Guest Editors: Les Folio, D.O., MPH, FAOCR Bernard F. Laya, D.O. Title/Author(s) Page No. From the Editor 1 Review Articles Does This Chest Radiograph Belong to a Survivor of Childhood Cancer? Radiographic Findings Suggesting Previous Treatment for Childhood Cancer – A Review 2 Aswin V. Kumar, OMS3, Sue C. Kaste, D.O. Interpretive Approach and Reporting the Intensive Care Bedside Chest X-Ray 12 Les Folio, D.O., MPH, FAOCR Case Reports Cavitary Lung Mass in a Febrile Child 21 Rachel Pevsner Crum, D.O., Ricardo Restrepo, M.D., Nolan Altman, M.D. Pulmonary Vascular Anomaly 25 David P. Concepcion, M.D., Bernard F. Laya, D.O., Ana Maria Saulog, M.D. Interstitial Lung Disease 28 Shereef Takla, B.S., Aaron M. Betts, M.D. Posterior Mediastinal Mass 32 Anagha Joshi, M.D., DMRE, Chintan Trivedi, M.D., DNB, Ashank Bansal, MBBS JAOCR at the Viewbox Pulmonary Lymphangioleiomyomatosis 35 Bernard F. Laya, D.O., Regina C. Nava, M.D. Hydatid Cyst of the Lung 36 Ali Yikilmaz, M.D. Page ii J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2 From the Guest Editor In This Issue Les Folio, D.O., MPH, FAOCR Lead Radiologist for CT, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD When Lt Col (Dr.) O’Brien asked me congenital bronchopulmonary foregut to serve as guest editor for the first anomalies while highlighting a chest edition of JAOCR, I quickly particular case. involved our friend and AOCR Shereef Takla, BS, and Aaron M. colleague, Bernard Laya, DO. With his Betts, MD, tackled the challenge of expertise in chest imaging and as a interstitial lung disease, something world expert on tuberculosis in that I thought to be impossible in a children, combined with Bill O’Brien’s case report. Yet, they met and tireless dedication to make this exceeded their goal with great Journal a success, I felt as though we images, differentials, and discussion. were in great hands to develop a chest imaging edition worth keeping Ali Yikilmaz, MD, presents an interesting case that although on your bookshelf for reference. seemingly uncommon, could show up I am confident you will find the at our viewbox at any time. Knowing included topics informative, practical the water-lily sign associated with to your practice, and up-to-date. For hydatid cysts will help us make the example, “The Posterior Mediastinal diagnosis. Mass” case report by Anagha Joshi, Although I see cases of MD, DMRE, Chintan Trivedi, MD, DNB, lymphangioleiomyomatosis (LAM) and Ashank Bansal, MBBS, has a nearly every day, Bernard Laya, DO, representative biopsy proven mass with differentials and great and Regina C. Nava, MD, put LAM into "We choose to go the the needed perspective with discussion. moon in this decade representative lung and Similarly, Dr. Rachel Crum’s extrapulmonary findings. and do the other skillful description of a pediatric I sought Bill and Bernie’s advice cavitary lung mass is supported with things, not because on making my ICU chest x-ray article great images and differentials that useful to the majority of radiologists they are easy, but allow radiologists to approach this in this audience. I included the basics scenario more confidently. because they are of line and tube placement, hard..." Aswin V. Kumar, OMS3, and Sue pulmonary pathology, newer imaging C. Kaste, DO, provide a thrilling techniques, and tips on reporting. review of chest x-ray findings that Lastly, I would like to recognize -President John F. Kennedy should make one consider that the patient might be a childhood cancer Lt Col William T. O'Brien, Sr., USAF, survivor. Knowing these clues will MC, for pioneering and bringing the help radiologists identify the effects JAOCR to its current status. Having served with the Air Force myself for of both the cancer and its therapies. 20 years and the AOCR for nearly the Nathan David P. Concepcion, same amount of time on various MD, Bernard F. Laya, DO, and Ana committees, taking on the JAOCR is a Maria Saulog, MD, orchestrated an major undertaking and is the epitome astounding yet concise summary on of the quote I selected. J Am Osteopath Coll Radiol 2014; Vol. 3, Issue 2 Page 1 Childhood Cancer, Kumar et al. Does This Chest Radiograph Belong to a Survivor of Childhood Cancer? Radiographic Findings Suggesting Previous Treatment for Childhood Cancer – A Review a,b b-d Aswin V. Kumar, OMS3 , Sue C. Kaste, D.O. aLincoln Memorial University, Harrogate, TN bDepartment of Radiological Sciences, Division of Diagnostic Imaging, Memphis TN cOncology, St. Jude Children’s Research Hospital, Memphis TN dDepartment of Radiology, University of Tennessee School of Health Sciences, Memphis, TN Introduction The aim of this article is to provide an overview of selected radiographic manifestations of thoracic Advances in the detection, treatment, and findings that may be associated with previous supportive care of pediatric malignancies has allowed treatment for pediatric cancers and their late effects for improved long-term survival among childhood by providing an image-based approach to identifying cancer survivors. At present, the 5-year survival for unique radiographic characteristics that may be seen those diagnosed with a pediatric malignancy exceeds on chest radiographs obtained for reasons unrelated 1 80% with a 10-year survival rate of 75%. The to a history of previous childhood cancer. The risk increasing number of adult survivors of childhood factors for and prevalence of tumor recurrence and malignancies now approaches an estimated 360,000 secondary malignant neoplasms are well-described in individuals, allowing for more extensive studies of the the literature and will not be included in this pictorial delayed manifestations of adverse effects related to review. cancer treatment.1, 2 Medical conditions that persist or present in 5 or more years following treatment are referred to as late effects. Studies that investigate the Residual Mediastinal Mass After Treatment For late effects of pediatric cancer treatment have shown that 73.4% of survivors will experience a chronic Lymphoma medical condition, with over 40% experiencing a 3 The presence of residual abnormality of the serious or life-threatening problem. mediastinum or hila after completion of therapy for The manifestations of late effects are wide ranging lymphoma can induce anxiety in patients, parents, and and involve all organ systems, with differential healthcare providers. Approximately two-thirds of presentation largely dependent on both the primary patients with Hodgkin lymphoma and one-third of malignancy and the treatment received. Some of the patients with non-Hodgkin lymphoma have been most common late effects observed in childhood reported to have residual mediastinal masses after cancer survivors are pulmonary and cardiac completion of therapy,6 which can be apparent on complications, with skeletal complications and chest radiographs (Fig. 1). These residual masses more secondary malignancies being less common.4 The often occur in patients presenting with bulky increased survivorship and incidence of morbidity mediastinal disease7 or those with nodular sclerosing amongst those treated for childhood malignancies subtype of Hodgkin disease.8 The residual soft tissue necessitates increased vigilance on the part of the masses are usually composed of benign fibrotic or adult survivors’ health-care providers to both detect inflammatory tissue and may be seen in up to 41% of and treat the anticipatory late effects in this chest radiographs and 46% of chest CTs in pediatric population. The manifestations of tissue injury from patients treated for Hodgkin disease9; these masses therapy administered during childhood may not may calcify (Fig. 2).9 Typically, residual fibrotic masses become apparent until the patient enters a phase of continue to regress over time.7,8 rapid growth, such as adolescence. At such times, the Particularly in pediatric patients, thymic rebound, treatment insult on normal tissues may result in 5 developing after completion of therapy, may mimic a impaired growth. Diagnostic imaging can provide a residual mass.8 Comparison with prior chest imaging robust means through which many late effects can be can resolve whether or not the original mass has detected.