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PICTORIAL QUIZ
Year : 2021  |  Volume : 38  |  Issue : 2  |  Page : 193-194  

A patient with gastroesophageal junction carcinoma and cough


Department of Medicine, Pulmonary Service, Memorial Sloan Kettering Cancer Center, Manhattan, New York, USA

Date of Submission25-Nov-2019
Date of Acceptance09-Dec-2019
Date of Web Publication02-Mar-2021

Correspondence Address:
Dr. Priyanka S Makkar
504 East 63rd Street, Apt 9M, NY, NY 10065
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/lungindia.lungindia_520_19

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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

How to cite this URL:
Makkar PS, Mehta V, Tan M. A patient with gastroesophageal junction carcinoma and cough. Lung India [serial online] 2021 [cited 2021 Apr 12];38:193-4. Available from: https://www.lungindia.com/text.asp?2021/38/2/193/310553



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 Top
!

Question 1: What is the computed tomography (CT) sign known as, and what is the diagnosis?


   Answer Top


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 Top

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.  Back to cited text no. 1
    
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.  Back to cited text no. 2
    
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.  Back to cited text no. 3
    


    Figures

  [Figure 1]



 

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