Are Lung Imaging Reporting and Data System Categories Clear to Radiologists? A Survey of the Korean Society of Thoracic Radiology Members on Ten Difficult-to-Classify Scenarios

OBJECTIVE: To evaluate possible variability in chest radiologists' interpretations of the Lung Imaging Reporting and Data System (Lung-RADS) on difficult-to-classify scenarios. MATERIALS AND METHODS: Ten scenarios of difficult-to-classify imaginary lung nodules were prepared as an online survey that targeted Korean Society of Thoracic Radiology members. In each question, a description was provided of the size, consistency, and interval change (new or growing) of a lung nodule observed using annual repeat computed tomography, and the respondent was instructed to choose one answer from five choices: category 2, 3, 4A, or 4B, or “un-categorizable.” Consensus answers were established by members of the Korean Imaging Study Group for Lung Cancer. RESULTS: Of the 420 answers from 42 respondents (excluding multiple submissions), 310 (73.8%) agreed with the consensus answers; eleven (26.2%) respondents agreed with the consensus answers to six or fewer questions. Assigning the imaginary nodules to categories higher than the consensus answer was more frequent (16.0%) than assigning them to lower categories (5.5%), and the agreement rate was below 50% for two scenarios. CONCLUSION: When given difficult-to-classify scenarios, chest radiologists showed large variability in their interpretations of the Lung-RADS categories, with high frequencies of disagreement in some specific scenarios.

Solitary Fibrous Tumor of the Pleura Manifesting as an Air-Containing Cystic Mass: Radiologic and Histopathologic Correlation

Solitary fibrous tumor (SFT) is a rare mesenchymal neoplasm that typically presents as a well-defined lobular soft tissue mass commonly arising from the pleura. We report an extremely rare case of an SFT containing air arising from the right major fissure in a 58-year-old woman. Chest CT showed an ovoid air-containing cystic mass with an internal, homogeneously enhancing solid nodule. To our knowledge, this is the first case in the literature. The histopathologic findings were correlated with the radiologic findings, and the mechanism of air retention within the tumor is discussed.

Histopathologic Findings Related to the Indeterminate or Inadequate Results of Fine-Needle Aspiration Biopsy and Correlation with Ultrasonographic Findings in Papillary Thyroid Carcinomas

OBJECTIVE: To determine histopathologic findings related to the indeterminate or inadequate result of fine-needle aspiration biopsy (FNAB) in papillary thyroid carcinomas (PTCs) and to correlate histopathological findings with ultrasonographic features of tumors. Materials and METHODS: We retrospectively reviewed the medical records of FNAB, histopathologic characteristics, and sonographic findings of the solid portion of 95 PTCs in 95 patients. All cases were pathologically confirmed by surgery. Histopathologic characteristics were analyzed for tumor distribution, microcystic changes, fibrosis, and tumor component. We assumed several histopathologic conditions to be the cause of indeterminate or inadequate results of FNAB, including: 1) an uneven tumor distribution, 2) > 30% microcystic changes, 3) > 30% fibrosis, and 4) < 30% tumor component. Ultrasonographic findings of each PTC were evaluated for echotexture (homogeneous or heterogeneous), echogenicity (markedly hypoechoic, hypoechoic, isoechoic, or hyperechoic), and volume of the nodule. We correlated histopathologic characteristics of the PTC with results of the FNAB and ultrasonographic findings. RESULTS: From 95 FNABs, 71 cases (74%) were confirmed with malignancy or suspicious malignancy (PTCs), 21 (22%) had indeterminate results (atypical cells), and three (4%) were negative for malignancy. None of the assumed variables influenced the diagnostic accuracy of FNAB. Tumor distribution and fibrosis were statistically correlated with ultrasonographic findings of the PTCs (p < 0.05). Uneven tumor distribution was related with small tumor volume, and fibrosis over 30% was correlated with homogeneous echotexture, markedly hypoechoic and hypoechoic echogenicity, and small tumor volume (p < 0.05). CONCLUSION: No histopathologic component was found to correlate with improper results of FNAB in PTCs. In contrast, two histopathologic characteristics, uneven distribution and fibrosis, were correlated with ultrasonographic findings.

High-Resolution CT Findings of Re-Expansion Pulmonary Edema

OBJECTIVE: To describe the high-resolution CT (HRCT) findings of re-expansion pulmonary edema (REPE) following a thoracentesis for a spontaneous pneumothorax. MATERIALS AND METHODS: HRCT scans from 43 patients who developed REPE immediately after a thoracentesis for treatment of pneumothorax were retrospectively analyzed. The study group consisted of 41 men and two women with a mean age of 34 years. The average time interval between insertion of the drainage tube and HRCT was 8.5 hours (range, 1-24 hours). The patterns and distribution of the lung lesions were analyzed and were assigned one of the following classifications: consolidation, ground-glass opacity (GGO), intralobular interstitial thickening, interlobular septal thickening, thickening of bronchovascular bundles, and nodules. The presence of pleural effusion and contralateral lung involvement was also assessed. RESULTS: Patchy areas of GGO were observed in all 43 patients examined. Consolidation was noted in 22 patients (51%). The geographic distribution of GGO and consolidation was noted in 25 patients (58%). Interlobular septal thickening and intralobular interstitial thickening was noted in 28 patients (65%), respectively. Bronchovascular bundle thickening was seen in 13 patients (30%), whereas ill-defined centrilobular GGO nodules were observed in five patients (12%). The lesions were predominantly peripheral in 38 patients (88%). Of these lesions, gravity-dependent distribution was noted in 23 cases (53%). Bilateral lung involvement was noted in four patients (9%), and a small amount of pleural effusion was seen in seven patients (16%). CONCLUSION: The HRCT findings of REPE were peripheral patchy areas of GGO that were frequently combined with consolidation as well as interlobular septal and intralobular interstitial thickening.

A Case of Sarcoidosis That Was Initially Misdiagnosed as Nontuberculous Mycobacteria Pulmonary Disease / 결핵및호흡기질환

There are several respiratory diseases that show chronic granulomatous inflammation for the histologic finding. Among them, sarcoidosis and tuberculosis are not easy to differentiate when the clinical and radiological features present similar patterns. The increasing incidence of nontuberculous mycobacteria pulmonary disease is making it more difficult for clinicians to arrive at a proper diagnosis. A 69 year old male patient visited our hospital with chronic cough as his chief compliant. His radiologic findings were multiple enlarged mediastinal lymphadenpathies with innumerable micronodules and multiple patch infiltrations. The spleen biopsy finding showed chronic granulomatous inflammation, and Mycobacterium avium was identified on the bronchoscopic culture. Because of these findings, we treated him with drugs for nontuberculous mycobacteria disease other than sarcoidosis. However, during the treatment, his symptoms and radiological features became aggravated. Thus, we reviewed the radiologic and pathologic findings and decided to treat him with steroid, which relieved his symptoms and improved the radiologic findings. We report here on a case of sarcoidosis that was initially misdiagnosed as nontuberculous mycobacteria pulmonary disease.

Protein Expression and Gene Amplification of Epidermal Growth Factor Receptor in Non-Small Cell Lung Cancer: Correlation with the Response to Gefitinib Therapy

BACKGROUND: Gefitinib is an EGFR tyrosine kinase inhibitor that has shown dramatic effectiveness in a subset of non-small cell lung cancer (NSCLC) patients. We evaluated the response rate to gefitinib, and the significance of the EGFR and HER2/neu status as predictive markers of the tumor response. METHODS: The EGFR and HER2/neu protein expressions, as determined by immunohistochemistry (IHC) and gene amplification via chromogenic in situ hybridization (CISH), were analyzed in biopsy specimens from 46 patients with advanced NSCLC. After their failure with the first-line treatment, all the patients had received gefitinib treatment. RESULTS: A partial response (PR) was achieved in 8 patients (17.4%). An EGFR overexpression was detected in 80.4% (37/46) of the tumors, and this was observed exclusively in patients with a PR (100% vs 75.3%, respectively; p=0.076). EGFR gene amplification was present in 47.8% of the tumors (22/46). HER2/neu was overexpressed in 13%(6/46) and it was amplified in 17% (7/46). The overall survival was prolonged in the female patients (p=0.007), and in patients with T1 and T2 disease (p=0.039), adenocarcinoma (p=0.010), a PR (p=0.022), an EGFR IHC+ status (p=0.033), an EGFR IHC+/CISH+ status (p=0.010), or an EGFR+/HER2/neu+ status (p=0.030). On multivariate analysis, gender, T disease and EGFR IHC/CISH remained the significant predictors of survival. CONCLUSIONS: Gefitinib showed a modest effect for the patients with chemotherapy-refractory advanced NSCLC. A combination of EGFR IHC and CISH might be important for identifying those patients who are most likely to benefit from gefitinib therapy.

The Caspase-3 and c-myc Expressions in Completely Resected Non-small Cell Lung Cancer and Its Prognostic Significance / 대한흉부외과학회지

BACKGROUND: Caspase-3 is a cysteine protease that plays a major role in the process of apoptotic cell death. The dysregulated expression of c-myc contributes to the tumorigenesis in a variety of human cancers. The aim of this study was to investigate the expressions of caspase-3 and c-myc and their significances as prognosis markers in patients with completely resected non-small cell lung cancer (NSCLC). MATERIAL AND METHOD: A total 130 consecutive patients who had undergone complete resection without pre-operative radio-therapy or chemotherapy between May 1996 and December 2003 for NSCLC were retrospectively reviewed. The median follow-up period of the patients was 50 months (range: 3~128 months). The expressions of caspase-3 and c-myc were immunohistochemically examined, and these were correlated with the clinico-pathologic data. RESULT: The prevalence of caspase-3 and c-myc expressions in the patients was 68% (88/130) and 59% (77/130), respectively. Significant association was found between the frequency of the expressions of caspase-3 and c-myc (p=0.025). The caspase-3 and c-myc expressions were not significantly associated with the prognosis in all the patients. However, according to stages, a positive caspase-3 expression was significantly correlated with a favorable prognosis for patients with stage IIIa disease (median survival period: 35 months vs. 10 months, p=0.021). Multivariate analysis showed the pathologic stage to be significantly correlated with a good prognosis in all the patients (p=0.024), and with a positive caspase-3 expression, well differentiated tumor and negative neuronal invasion in the patients with stage IIIa disease (p=0.005, p=0.003, p=0.004, respectively). CONCLUSION: Caspase-3 and c-myc were frequently expressed in NSCLC, suggesting its possible involvement in tumor development. The caspase-3 expression, as determined with performing immunohistochemical staining, may be a favorable prognostic indicator in patients with completely resected NSCLC of an advanced stage (IIIa).

Adenocarcinoma Arising in Type 1 Congenital Cystic Adenomatoid Malformation: A Case Report and Review of the Literature

Malignancies in congenital cystic adenomatoid malformations (CCAMs) of the lung are rare. We report a 41-year-old male patient with a pulmonary cystic lesion suspicious for CCAM, unrecognized until the patient was 40 years of age, and which subsequently became more consolidated during the interval between initial presentation and surgery. Microscopic examination of the resected specimen revealed features of type 1 CCAM with a mucinous adenocarcinoma, metastatic to the mediastinal lymph nodes. This case illustrates the importance of prompt surgical resection for all suspected CCAMs, especially those discovered in adulthood.

Immunohistochemical Analysis of Non-Small Cell Lung Cancer: Correlation with Clinical Parameters and Prognosis

Non-small cell lung cancers (NSCLC) vary in their biologic behavior. Recurrence and tumor-related mortality may be attributable to molecular abnormalities in primary tumors. This study evaluated such immunophenotypes with regard to cell cycle regulation and proliferation, apoptosis, and angiogenesis, to determine their significance for patient outcome. Core biopsies from 219 patients with NSCLC were assembled on tissue microarrays, and the expressions of p16, p21, p27, cyclin B1, cyclin E, Ki-67, caspase-3, survivin, bcl-2, VEGF, and endostatin were evaluated by immunohistochemistry. Despite previously described prognostic relevance of some of the investigated molecules, many of those markers were not directly associated with recurrence or survival. However, there was a trend for p16 immunoreactivity to be associated with a good prognosis (57% vs. 42% in 5-yr survival) (p=0.071). bcl-2 expression was strongly correlated with a better outcome (65% vs. 45% in 5-yr survival) (p=0.029), and the hazard of death for bcl-2 positive patients was 0.42 times of that for bcl-2 negative patients (p=0.047). A multivariate analysis with Cox proportional hazards model confirmed that the lymph node status (p=0.043) and stage (p=0.003) were other independent prognostic factors. Our results suggest that p16 and bcl-2 provide prognostic information independent of the TNM stage in NSCLC.

Sequential Responses of Adenocarcinoma of the Lung to Erlotinib after Gefitinib in Never Smoker Korean Woman / Journal of the Korean Cancer Association, 대한암학회지

A patient with adenocarcinoma of the lung was treated sequentially using two kinds of EGFR tyrosine kinase inhibitors, gefitinib and erlotinib. The patient was a 73-year-old female who received gefitinib as a second line treatment, which resulted in a partial response with response duration of 6 months. After progression of the disease, the patient received erlotinib, which resulted in partial response again with response duration of 11.5 months. This observation suggests that treatment with erlotinib may be effective in patients who develop progressive disease after a primary treatment with gefitinib following an initial response.

Two Cases of Fatal Hypoxemia after Talc Pleurodesis for Recurrent Malignant Pleural Effusion / 결핵및호흡기질환

Talc pleurodesis is a safe and effective treatment for a recurrent malignant pleural effusion. However, acute hypoxemia, pulmonary edema or acute respiratory failure can develop in a small number of patients. We report 2 patients who developed fatal hypoxemia after talc pleurodesis which was necessary the control recurrent pleural effusion. The first case was an 18-year old male diagnosed with Ewing's sarcoma with bilateral lung metastases and pleural effusion. The performance status was ECOG (Eastern Cooperative Foncology Group) grade 3. Fever along with hypoxemia and leukocytosis developed 10 hours after the second talc pleurodesis on the right side for an uncontrolled pleural effusion, The patient died from respiratory failure after 13 days. The second case was a 66-year old female diagnosed with non-small cell lung cancer with a bone metastasis. Two weeks after systemic chemotherapy, she complained of dyspnea, and a pleural effusion was observed on the right side. Her performance status was ECOG grade 3. Talc pleurodesis was performed for recurrent pleural effusion, but hypoxemia developed 6 days after pleurodesis and she died from respiratory failure 10 days after pleurodesis. In conclusion, talc pleurodesis should be performed very carefully in patients with a poor performance status, in cases with repeated pleurodesis, bilateral pleural effusion, recent chemotherapy, radiotherapy and when there are parenchymal metastatic lesions present.

The Vascular Pedicle Width seen on Chest PA in Normal Korean Adults

PURPOSE: We wanted to measure the vascular pedicle width (VPW) in normal Korean adults and correlate the VPW with the body physique and we also wanted to establish the index for normal VPWs, which could be utilized in reading chest PAs. MATERIALS AND METHODS: The VPW was measured on the posteroanterior (PA) chest radiographs of 262 normal Korean adults (134 men and 128 women, age range: 22-88 years, mean age: 45.2 years), who visited the hospital for a general health examination. The relationship between the VPW and the height and the Body Mass Index (BMI) was evaluated. Correlations between height and the thoracic spine length (TSL) and between the BMI and the lateral chest wall thickness (CWT) were analyzed as well. RESULTS: The mean VPW was 47.4 (+/-6.4) mm. The VPW was positively correlated with the height (p<0.01) and the BMI (p<0.01) of the subject. The patient's height was well correlated with the TSL, and the BMI was correlated with the CWT (r=0.75, r=0.76). The table for the normal VPWs according to patient's TSL and CWT was established. CONCLUSION: By measuring the TSL and the CWT on chest PA, which reflect the height and BMI, respectively, and by utilizing the provided table for the normal VPW, we can determine the normality of a patient's VPW.

Citation Trend and Suggestions for Improvement of Impact Factor of Journal of Korean Therapeutic Radiology and Oncology / 대한방사선종양학회지

PURPOSE: To analyze the recent citation trend and to find a way to improve impact factor (IF) of the Journal of Korean Therapeutic Radiology and Oncology (JKSTRO) by analysis of Korean Medical Citation Index (KoMCI) citation data of JKSTRO and comparison with that of mean citation data of all journals enlisted on KoMCI (KoMCI journals) during 2000-2005. MATERIALS AND METHODS: All citation data of entire journals enlisted on KoMCI and JKSTRO from 2000 to 2005 were obtained from KoMCI. The trend of total and annual number of published articles and reference citations, total citations and self-citations per paper, IF and impact factor excluding self-citations (ZIF) were described and compared on both KoMCI journals and JKSTRO. RESULTS: Annual number of published articles was decreased for 6 years on both KoMCI journals and JKSTRO (32% and 38% reduction rate). The number of Korean journal references per article is 1.6 papers on JKSTRO comparing to 2.0 papers on KoMCI journals. The percentage of Korean references/total references increased from 5.0% in 2000 to 7.7% in 2005 on JKSTRO and from 8.5% in 2000 to 10.1% on KoMCI journals. The number of total citations received/paper on JKSTRO (average 1.333) is smaller than that of KoMCI journals (average 1.694), there was an increased rate of 67% in 2005 comparing to 2000. The percentage of self-citations/total citations (average 72%) on JKSTRO is slightly higher than that of KoMCI journals (average 61%). IF of JKSTRO was gradually improved and 0.144, 0.125, 0.088, 0.107, 0.187, and 0.203 in 2000-2005 respectively. However, ZIF of JKSTRO is steadily decreased from 0.038 in 2000 to 0.013 in 2005 except 0.044 in 2004. CONCLUSION: IF of JKSTRO was slightly improved but had some innate problem of smaller number of citations received. To make JKSTRO as a highly cited journal, the awareness of academic status of JKSTRO and active participation of every member of JKSTRO including encouraging self-citations of papers published recent 2 years and submission of English written papers, and active academic cooperation with related academic societies.

Lung Cancer Screening with Low-Dose Chest CT: Current Issues / Journal of the Korean Cancer Association, 대한암학회지

Computed tomography offers many advantages over routine radiographs in screening for lung cancer, and it is clear that low-dose spiral CT screening can more frequently find considerably smaller lung cancers than previous detection tools. Recently, investigators have performed low-dose spiral CT scanning for screening of lung cancer, and have suggested that CT screening can depict lung cancers at smaller sizes and at earlier stages. With technological advances in spiral CT scanners, the detection rate of small noncalcified pulmonary nodules has markedly increased, with higher rates noted with thinner collimation of CT scanning. Unfortunately, the majority of these have proved to be benign, i.e. false positive results. If, even in part, CT features could be found to predict benign nodules without follow-up, the false-positive rate would be reduced, and consequently, the cost, emotional stress, radiation dose, morbidity and mortality associated with interventional procedures would also be reduced. There have been several studies trying to establish reliable CT features for benign lesions in small pulmonary nodules and to determine their outcome. Although these efforts have not completely resolved the issue of false positive results, it is expected that lessons will be learnt on how to manage these small nodules through experience with screening in the near future. Because pulmonary nodules on CT are much more common in Korea than in western countries, the management algorithm for screening CT-detected nodules should be modified according to different circumstances, with consensus among related physicians and radiologists. In addition, to enhance patient care and avoid misunderstanding of inherent limitation of CT screening by the screening subjects, physicians, hospital managers as well as radiologists should provide proper information regarding CT screening to the screenees.

Endobronchial Lipoma Diagnosed by Chest CT: A Case Report / 대한흉부외과학회지

Endobronchial lipomas are rare benign tumors that arise from the lung. They partially or totally obstruct the bronchial lumen, producing a variable degree of collapse, irreversible bronchiectasis, and pulmonary damage. Although bronchoscope, CT and MR are reported to be helpful in establishing the diagnosis, CT is highly specific and sensitive in detecting fatty tumor. They may be removed by endoscope or thoracotomy or lobectomy. We present a case of endobronchial lipoma completely obstructing the right middle lobe and postobstructive irreversible pulmonary change with review of literatures.

Lung Cancer Screening with Low-Dose Spiral CT / Journal of the Korean Cancer Association, 대한암학회지

No abstract available.

Radiologic Reports: Attitudes, Preferred Type, and Opinion of Referring Physicians

PURPOSE: To determine referring physicians 'general attitudes, preferred reporting types, and opinions on radiologic reports. MATERIALS AND METHODS: A survey questionnaire was distributed to the 315 staff and residents of four university hospitals with 400 to 800 beds, and a total of 228 physicians responded. The questionnaire aimed to determine of the general attitude of referring physicians to radiologic reports, the type of report they preferred, and other opinions and suggestions. The responses elicited, as well as discrepancies among residents, staff, internist, and surgeons, were analyzed. RESULTS: Most referring physicians replied that they read an entire report regardless of its length, and the second majority read the conclusion first and then the remainder of the report only if clarification was required. With regard to report length, physicians answered that reports describing the findings of conventional radiography were often too short, while those dealing with MRI were verbose. The majority experienced occasional confusion when reading a report, the major cause being grammatical errors and incomprehensible sentence structure. When confused, most physicians consulted the radiologist; staff showed a greater inclination than residents to pursue this option. Most physicians preferred brief phrases or telegraphic-style sentences to a style which stressed completeness and detail, a preference which was statistically higher among residents than staff. Whereas physicians favored a brief radiologic report in cases of normal radiologic findings, conventional radiologic studies or no clinical findings, they wished to see a more detailed report in cases of abnormal radiologic findings, specific radiologic studies (special radiographs, US, CT, or MRI), or positive clinical findings. This need for more detail was expressed more frequently by internists than by surgeons. CONCLUSION: If implemented, the results of this study can be expected to enhance the quality and comprehensibility of radiologic reports, and may also lead to more efficient communication between radiologists and physicians.

Primary Pulmonary Hodgkin's Lymphoma: A case report

Primary pulmonary Hodgkin's lymphoma is a rare but distinct entity to be distinguished from nodal Hodgkin's lymphoma and from lymphomas involving lung secondarily. This lymphoma affects women more frequently than men, and typically involves superior portions of the lung. This case is reported to illustrate the clinical, radiographic and anatomic characteristics of the primary pulmonary Hodgkin's lymphoma. A 34-year-old woman presented for the evaluation of hemoptysis. A chest CT revealed a large poorly defined mass in the medial aspect of the right upper lobe, extending to the right mediastinum and trachea. The microscopic examination of the biopsied lesion revealed fibroblastic stroma infiltrated by a mixture of lymphocytes, histiocytes, and eosinophils. The clinical impression was inflammatory pseudotumor, presumably due to slightly favorable response to corticosteroid therapy. Two months later the patient's symptoms worsened despite the steroid therapy and a lobectomy was done. The specimen showed a soft to firm, pale yellow, ill defined mass, 10.0 8.0 cm, involving the visceral pleura. A few satellite nodules around the main mass were noted. The histologic findings were consistent with Hodgkin's lymphoma, nodular sclerosis type.

Inflammatory Pseudotumor of the Anal Sphincter Complex: A Case Report

We describe a case of inflammatory pseudotumor involving the anal sphincter complex, and its ultrasonographyand MR imaging features. Transperineal ultrasonography showed a well-marginated ovoid low echoic lesionintermingled with sparse echogenic foci within the right anal sphincter complex. The lesion was of intermediatesignal intensity on T1-weighted images and of heterogeneous hyperintensity on T2-weighted, compared tosurrounding muscle. After the infusion of gadolinium, the le-sion showed heterogeneous enhancement, with amultifocal non-enhanced center. T 2 - weighted endorectal MR images were more accurate in depicting the lesion andanal sphincter complex, and the patient underwent surgical resection. The final histo-logic diagnosis wasinflammatory myofibroblastic tumor.

Primary Amyloidosis Involving Mediastinal and Hilar Lymph Nodes: A Case Report

Amyloidosis is a rare systemic disease caused by extracellular accumulation of insolubel fibrillar material invarious tissues. The radiographic findings of amyloidosis involving the lymph nodes have not been previously reported in Korea, and we report a rare case of primary amyloidosis involving the mediastinal and hilar lymphnodes, with CT and radiographic appearances.