The Value of a Negative Pleural Fluid Cytology and Biopsy in Diagnosing Malignant Pulmonary Lesions
Necrotizing Sarcoid Granulomatosis (NSG)
Figure
Left figure: Computed tomography of the chest with contrast medium. Coronal plane. Pulmonary nodules, some with an inflammatory halo. The granulomatous lesions are shown by the arrow and asterisk. Right figure: Histological image of lung tissue. Signs of necrotizing granuloma: epithelioid cells, giant cells, and necrosis.
A 37-year-old female high-school teacher with a 3-week history of increasing dyspnea on exertion, arthralgia in virtually all joints, subfebrile temperature, and fatigue was admitted as an inpatient. No other abnormalities were striking from a clinical perspective, and only C-reactive protein (CRP) was elevated in laboratory tests. Computed tomography (CT) revealed multiple pulmonary nodules, some with an inflammatory halo between 1 cm (arrow) and 4 cm in diameter (asterisk). CT-guided biopsy 9 days later demonstrated significant progression of the granulomatous lesions. Histopathological analysis revealed extensive necrotizing epithelioid cell granulomatosis. Mycobacterial infection and Epstein-Barr virus-related lymphoproliferation could be excluded. Immunosuppressive therapy with prednisolone and azathioprine was performed. On CT at 3 months, the rapid clinical improvement was accompanied by only residual pulmonary nodules. Necrotizing sarcoid granulomatosis (NSG) is a rare differential diagnosis of granulomatous lung diseases. The histopathological analysis of tissue samples as well as the exclusion of infectious/malignant causes are essential. Multiple pulmonary nodules on computed tomography, the absence of extrapulmonary involvement, typical histopathological findings, and nonspecific clinical symptoms all contribute to the confirmation of the diagnosis.
Dr. Med. Pia Maria Plank, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Plank.Pia@mh-hannover.De
Prof. Dr. Jens Vogel-Claussen, Institut für Diagnostische und Inverventionelle Radiologie, Medizinische Hochschule Hannover,
Dr. Med. Benjamin-Alexander Bollmann, Klinik für Pneumologie, Medizinische Hochschule Hannover
Conflict of interest statement: The authors declare that no conflict of interest exists.
Translated from the original German by Christine Rye.
Cite this as: Plank PM, Vogel-Claussen J, Bollmann BA: Necrotizing sarcoid granulomatosis (NSG). Dtsch Arztebl Int 2023; 120: 220. DOI: 10.3238/arztebl.M2023.0021
What Is Ground Glass Opacity?
Ground glass opacity (GGO) refers to the hazy gray areas that can show up in CT scans of the lungs. These areas show increased density inside the lungs which could indicate pneumonia or other respiratory disorders.
The term comes from a technique in glassmaking during which the surface of the glass is blasted by sand. This technique gives the glass a hazy white or frosted appearance.
This article will look at what GGO is, some of its causes, and its treatment options.
GGO refers to gray areas that can show up in lung CT scans.
Normally, the lungs appear black in X-ray and CT scans. This indicates that they are free of any visible blockages.
However, gray areas indicate increased density, meaning that something is partially filling the air spaces inside the lungs. This could be due to:
GGO can be due to many conditions. Sometimes, the cause is benign. Other times, it may be the temporary result of a short-term illness. However, it can also indicate a more serious or long-term condition.
There are several types of GGO. These include:
The shape, size, quantity, and location of opacities will vary depending on the cause. Some conditions cause only one type, but others may cause a mixture.
The sections below will look at some potential causes in more detail.
Infections are common causes of GGO. Such infections include:
PneumoniaPneumonia is a serious infection in the lungs. It can result from viruses, bacteria, or fungi.
Common causes of viral pneumonia include influenza viruses, SARS-CoV-2, or and respiratory syncytial virus. Bacterial causes include Streptococcus pneumoniae and Mycoplasma pneumoniae.
The symptoms can vary depending on the cause, but they typically include:
A doctor may prescribe antiviral medications to treat viral pneumonia. Doctors also treat bacterial and fungal pneumonia with medications. However, sometimes symptom management and rest is enough.
COVID-19A 2020 systematic review and meta-analysis found that just over 83% of people with COVID-19-related pneumonia had GGO.
Another 2020 study in 54 participants found that GGO most commonly showed up in the lower lobes of the lungs as round opacities, but that as the disease progressed, it became more patchy and affected all lobes.
The symptoms of COVID-19 can include any of the following:
Learn more about COVID-19 symptoms and what to do if they occur here.
Pneumonitis, or inflammation in the lungs, can occur if a person inhales:
Certain drugs can also cause pneumonitis and accompanying GGO. Typically, this type of pneumonitis occurs shortly after a person begins taking a new drug.
Hypersensitivity pneumonitisThe symptoms of hypersensitivity pneumonitis can include:
Other names for this condition include farmer's lung and hot tub lung.
In the short term, doctors treat this condition by trying to identify and remove the trigger of a person's symptoms. The person may also require medications and oxygen therapy.
In the long term, the condition may cause chronic fatigue, weight loss, and irreversible scarring.
EVALIE-cigarettes and vaping devices contain nicotine concentrates, solvents, and other chemicals. These products can cause EVALI.
EVALI may cause numerous types of GGO, including crazy paving and reversed halo sign, to show up on a scan.
Vaping can also cause alveolar hemorrhage. There is more detail on this condition below.
Interstitial lung disease is an umbrella term that includes many different conditions. They all cause inflammation and scarring around the alveoli, lining of the lungs, and blood vessels.
These conditions could be due to an autoimmune disease, a connective tissue disorder, or toxin exposure.
The progression of interstitial lung disease varies from person to person depending on what caused it.
Symptoms vary from mild to severe. They may include:
Treatment aims to slow the progression of the condition. Doctors may use supplemental oxygen, anti-inflammatory drugs, or immunosuppressant drugs.
Pulmonary edema is the result of fluid collecting in the air spaces of the lungs. It can be due to several conditions, including heart failure and altitude sickness.
Symptoms include:
People with these symptoms should seek medical attention immediately, as sudden pulmonary edema can be an emergency.
Alveolar hemorrhage occurs when the blood vessels in the lungs become damaged, leading to bleeding.
It is a medical emergency that can result from numerous conditions, including autoimmune diseases, vasculitis, and bleeding disorders.
The symptoms can vary widely and may include:
Doctors treat most cases of alveolar hemorrhage with steroids to reduce inflammation and immunosuppressants to stop the immune system from damaging the blood vessels further.
Sometimes, GGO nodules in the lung can indicate cancer.
Lung cancer may not have pronounced symptoms in the early stages of the condition. However, a person should speak with their doctor if they experience:
Treatment varies according to the severity and type of cancer a person has. It may include chemotherapy, surgery, and radiation therapy.
After a doctor finds GGO in a CT scan, they will take note of the size, shape, location, and distribution of the opacities to determine the likely cause.
They may also order more tests, such as:
They may also order electrocardiography and echocardiography to see if a person's lung problems could be the result of a heart condition.
Receiving test results can be worrying. Here are some questions that a person may wish to ask their doctor:
The following are commonly asked questions about GGO.
How serious is GGO?GGO develops due to many conditions, meaning that there are varying degrees of severity. Some causes are benign, and other causes can be more serious, such as lung cancer.
Is GGO a tumor?GGO nodules are an important indicator of lung cancer. However, it is important to remember that there are many causes of GGO, which can be present in benign conditions.
GGO can show up on a CT scan of the lungs. It appears as hazy gray areas that can indicate a range of conditions.
Some causes of GGO may be benign and resolve on their own, while others may be chronic.
Read this article in Spanish.
Study Demonstrates Benefits Of Lung Nodule Program In Expanding Access To Early Diagnosis
Adopting a lung nodule program (LNP) may increase the detection of early lung cancer for patients who are not eligible for lung cancer screening under existing age eligibility criteria, according to a study published in the Journal of Thoracic Oncology, an official journal of the International Association for the Study of Lung Cancer.
LNPs are established to follow up on lung nodules that are frequently identified during routine imaging for reasons other than suspected lung cancer or lung cancer screening.
The research was conducted by a team led by Dr. Raymond U. Osarogiagbon, MBBS, FACP, chief scientist for Baptist Memorial Health Care and director of the multidisciplinary thoracic oncology program and the thoracic oncology research group for Baptist Cancer Center, Memphis, Tennessee, USA. The prospective observational study compared the two-year cumulative lung cancer diagnosis risk, lung cancer characteristics, and overall survival (OS) among participants undergoing low-dose CT (LDCT) screening aged 50-80 years, and LNP participants aged 35 to 50 years and over 80 years of age.
The United States Preventive Services Task Force recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years.
Low-dose computed tomographic (LDCT) screening for lung cancer has been shown to reduce mortality by up to 20 percent. However, even after lowering the age of eligibility from 55 to 50 years, most persons diagnosed with lung cancer in the US are ineligible for lung cancer screening. LNPs, which typically use Fleischner Society lung nodule management guidelines, expand access to early lung cancer detection to a more diverse population.
Persons aged 50 to 80 years enrolled in a LNP were at greater risk of lung cancer diagnosis within two years compared to an LDCT cohort. The demographic, socio-economic characteristics, and risk factor profile of patients diagnosed with lung cancer through the LNP differed strikingly from that of the screened cohort. The lung cancer risk in persons too young or too old for screening, but who have an incidentally detected lung lesion, had not previously been rigorously estimated. According to Dr. Osarogiagbon, the study compared the cumulative lung cancer diagnosis risk, lesion characteristics, lung cancer characteristics, treatment and outcomes of screening age-ineligible persons in a LNP to an LDCT screening cohort.
The study period spanning from 2015 to 2022 revealed that lung cancer was diagnosed in 329 (3.43%) LDCT, 39 (1.07%) young, and 172 (6.87%) elderly LNP patients. Strikingly, the two-year cumulative incidence rates were 3.0% (95% CI: 2.6%–3.4%) for LDCT, 0.79% (CI: 0.54%–1.1%) for young LNP, and 6.5% (CI: 5.5%–7.6%) for elderly LNP. Despite age differences, the lung cancer diagnosis risk was found to be similar between young LNP and Lung-RADS 1 (aHR 0.88 [CI: 0.50–1.56]) and 2 (aHR 1.0 [0.58–1.72]). In contrast, elderly LNP risk exceeded that of Lung-RADS 3 (aHR 2.34 [CI: 1.50–3.65]) but was less than 4 (aHR 0.28 [CI: 0.22–0.35]).
Moreover, the study revealed significant differences in stage at the time of cancer diagnosis, with 62.92% of LDCT cases diagnosed at stage I/II compared to 33.33% for young (p=0.0003) and 48.26% for elderly (p=0.0004) LNP cohorts. Notably, 16.72%, 41.03%, and 29.65% of LDCT, young, and elderly LNP cases respectively, were diagnosed at stage IV. The 5-year OS rates were 57% (CI: 48–67), 55% (CI: 39–79), and 24% (CI: 15–40) respectively, with statistically significant differences (Log-rank p<0.0001), persisting even after excluding persons with any prior history of cancer.
Our findings indicate that our Lung Nodule Program modestly benefitted individuals deemed too young or too old for traditional screening. The observed differences in clinical characteristics and outcomes strongly suggest variations in the biological characteristics of lung cancer in these distinct patient cohorts."
Dr. Raymond U. Osarogiagbon, MBBS, FACP, chief scientist for Baptist Memorial Health Care
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