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| PICTORIAL QUIZ |
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| Year : 2021 | Volume
: 38
| Issue : 2 | Page : 193-194 |
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A patient with gastroesophageal junction carcinoma and cough
Priyanka S Makkar, Vishisht Mehta, Miranda Tan
Department of Medicine, Pulmonary Service, Memorial Sloan Kettering Cancer Center, Manhattan, New York, USA
| Date of Submission | 25-Nov-2019 |
| Date of Acceptance | 09-Dec-2019 |
| Date of Web Publication | 02-Mar-2021 |
Correspondence Address:
Dr. Priyanka S Makkar
504 East 63rd Street, Apt 9M, NY, NY 10065
USA
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/lungindia.lungindia_520_19
How to cite this article:
Makkar PS, Mehta V, Tan M. A patient with gastroesophageal junction carcinoma and cough. Lung India 2021;38:193-4 |
A 40-year-old male never-smoker with gastroesophageal junction carcinoma was evaluated for fevers, dyspnea, and productive cough after recent treatment for community-acquired pneumonia. He had recently received pembrolizumab and radiation therapy to his spine (C4 – T1). Vital signs were normal, and laboratory tests were unremarkable except for chronic anemia related to prior chemotherapy. Computed tomography of the chest was performed [Figure 1] and based on the findings, bronchoscopy with bronchoalveolar lavage and transbronchial lung biopsies were performed. | Figure 1: High-resolution computed tomography of the chest in coronal view demonstrating areas of ground-glass opacities surrounded by rim of consolidation
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Question 1: What is the computed tomography (CT) sign known as, and what is the diagnosis?
| Answer | | |
Answer 1: The sign shown on the CT scan is known as the “Atoll” or the “Reverse Halo” sign.
The diagnosis is pembrolizumab-induced organizing pneumonia (OP), a form of checkpoint inhibitor pneumonitis (CIP).
This sign is classically seen in OP. The central area relates to alveolar septal inflammation and cellular debris in alveolar spaces while the ring-shaped peripheral consolidation corresponds to granulomatous tissue within distal airspaces.[1] This sign has relatively high specificity for OP but can also be seen in inflammatory, neoplastic, or infectious diseases. By integrating the patient's history and clinical findings, the differential diagnosis can be narrowed further and sometimes, a biopsy may not be needed. This is especially helpful in the immunocompromised host.[2]
In our case, pembrolizumab-induced OP (a form of CIP) was diagnosed through transbronchial biopsy. CIP is rare but may be severe and potentially fatal. It is a diagnosis of exclusion with multiple patterns of injury reported, including nonspecific ground-glass opacities, OP, interstitial patterns, and hypersensitivity pneumonitis.[3] Treatment depends on the severity of CIP, and drug discontinuation may be necessary as in our case. The prognosis is favorable because there is a good response to steroid therapy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that his names and initials will not be published and due efforts will be made to conceal their identity.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Voloudaki AE, Bouros DE, Froudarakis ME, Datseris GE, Apostolaki EG, Gourtsoyiannis NC. Crescentic and ring-shaped opacities. CT features in two cases of Bronchiolitis Obliterans Organizing Pneumonia (BOOP). Acta Radiol 1996;37:889-92.  |
| 2. | Marchiori E, Zanetti G, Meirelles GS, Escuissato DL, Souza AS Jr., Hochhegger B. The reversed halo sign on high-resolution CT in infectious and noninfectious pulmonary diseases. AJR Am J Roentgenol 2011;197:W69-75. |
| 3. | Nishino M, Sholl LM, Hodi FS, Hatabu H, Ramaiya NH. Anti-PD-1-Related Pneumonitis during Cancer Immunotherapy. N Engl J Med 2015;373:288-90. |
[Figure 1]
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