Clinical investigation of Q. Flex for improvement of PET/CT image quality and quantitative accuracy of pulmonary nodules / 中华核医学与分子影像杂志

Objective:To compare the imaging quality and metabolic quantitative parameters of pulmonary nodules between Q. Flex whole information five-dimensional (5D) and conventional three-dimensional (3D) PET/CT imaging for clinical evaluation.Methods:Fifty-four patients (30 males, 24 females, age: 60(42, 75) years; 78 solid pulmonary nodules (maximum diameter≤3 cm) with abnormal uptake of 18F-FDG) from Tianjin Cancer Hospital Airport Hospital between June 2022 and August 2022 were enrolled in this retrospective study. All patients underwent 5D scanning and 3D, 5D reconstruction. Image quality scores, signal-to-noise ratio (SNR), SUV max, SUV mean and metabolic tumor volume (MTV) of pulmonary nodules of 5D group and 3D group were evaluated and compared with χ2 test and Wilcoxon signed rank test. Correlation of quantitative parameters between 2 groups were analyzed by using Spearman rank correlation analysis. Results:Thirty-five of 78(45%) pulmonary nodules with image quality score≥4 were found in 5D group, which were more than those in 3D group (22/78(28%); χ2=4.67, P=0.031). Meanwhile, SNR, SUV max, SUV mean, and MTV were significantly positively correlated between the 2 groups ( rs values: 0.86, 0.86, 0.85, and 0.95, all P<0.001). SNR, SUV max and SUV mean of pulmonary nodules in 5D group were significantly higher than those in 3D group, which were 37.46(18.42, 62.00) vs 32.72(16.97, 54.76) ( z=-4.07, P<0.001), 9.71(5.48, 13.82) vs 8.96(4.82, 12.63) ( z=-3.05, P<0.001) and 6.30(3.39, 8.94) vs 5.61(2.99, 7.63)( z=-4.07, P<0.001) respectively. MTV of pulmonary nodules in 5D group was significantly lower than that in 3D group, which was 1.72(0.66, 2.74) cm 3vs 1.98(1.06, 4.63) cm 3 ( z=-7.13, P<0.001). Quantitative parameters of lower lung field and nodules with maximum diameters of >10 mm and ≤20 mm based on 5D scanning changed most significantly compared with those based on 3D scanning ( z values: from -5.23 to -2.48, all P<0.05). Conclusion:Q. Flex 5D PET significantly improves the quantitative accuracy of SUV and MTV of pulmonary nodules, and the improvement of image quality is substantial without increasing the radiation dose, which has clinical practical value.

Short-term efficacy of surgical treatment for multiple pulmonary nodules: A retrospective study in a single center / 中国胸心血管外科临床杂志

@#Objective To summarize and analyze the clinical diagnosis, surgical treatment and prognosis of multiple pulmonary nodules (MPNs). Methods The clinical data of lung cancer patients who received surgical treatment in our hospital from 2018 to 2020 were collected. The short-term efficacy of surgical treatment for MPNs was analyzed. Results A total of 97 patients were enrolled, including 30 males and 67 females with an average age of 56.1±10.0 years at onset ill. There were 62 patients with double lesions, 22 patients with three lesions, 4 patients with four lesions, and 9 patients with more than four lesions. A total of 213 lesions were surgically treated, including 88 pure ground-glass nodules, 81 partially solid nodules, and 7 solid nodules. There were 87 simultaneous surgeries and 10 staged surgeries, with an average operation interval of 5.2 months. The pathological combination type included adenocarcinoma-adenocarcinoma in 96 (99.0%) patients, squamous cell carcinoma-squamous cell carcinoma in 1 (1.0%) patient, and no lymph node metastasis was found. The 2-year disease-free survival (DFS) rate was 92.1%, and the overall survival (OS) rate was 100.0%. Univariate analysis showed that high-risk lesion size>2 cm (P=0.316), residual lesions (P=0.782) and pathological combination type (P=0.913) had statistical effect on the 2-year DFS rate. Conclusion MPNs are mainly diagnosed with multiple primary lung cancers, and the pathological combination is mostly adenocarcinoma-adenocarcinoma combination. Imaging examination is of great help to the surgical approach selection, diagnosis and differential diagnosis of MPNs. During the operation, maximal preservation of lung function and complete resection of high-risk nodules should be taken as the principle, and the prognosis is satisfactory.

Augmented reality navigation system for assisting CT-guided puncture of pulmonary nodules in dog models / 中国介入影像与治疗学

Objective To observe the value of augmented reality(AR)navigation system for assisting CT-guided puncture of pulmonary nodules in dog models.Methods Five healthy dogs were selected,and 4 target lung rings were implanted in each dog to build pulmonary nodule models.Deferring to crossover design,CT-guided punctures were performed with or without AR navigation 2 and 4 weeks after successful modeling,respectively,while punctures with AR navigation were regarded as AR group and the others as conventional group,respectively.The time duration of puncturing,the times of CT scanning,of needle adjustment,and the deviation distance between needle pinpoint to the center of pulmonary nodule shown on three-dimensional reconstruction were compared between groups.Results The duration time of puncture in AR group and conventional group was(13.62±5.11)min and(20.16±4.76)min,respectively.In AR group,the times of CT scanning,of needle adjustment,and the deviation distance was 2.40±0.50,2.75±0.44 and(2.94±1.92)mm,respectively,while in conventional group was 3.10±0.64,3.70±0.57 and(4.90±3.38)mm,respectively.The introduction of AR navigation was helpful to shortening the duration of puncture,reducing times of CT scanning and needle adjustment,also decreasing positioning error of needle pinpoint(all P＜0.05).In contrast,the variance of puncture sequences and dogs had no obvious effect on the results(both P＞0.05).Conclusion AR navigation system could improve accuracy and efficiency in CT-guided puncture of pulmonary nodules in dog models.

Clinical diagnosis and treatment of multiple pulmonary nodules / 中华肿瘤杂志

CT screening has markedly reduced the lung cancer mortality in high-risk population and increased the detection of early-stage pulmonary neoplasms, including multiple pulmonary nodules, especially those with a ground-glass appearance on CT. Multiple primary lung cancer (MPLC) constitutes a specific subtype of lung cancer with indolent biological behaviors, which is predominantly early-stage adenocarcinoma. Although MPLC progresses slowly with rare lymphatic metastasis, existence of synchronous lesions and distributed location of these nodules still pose difficulty for the management of such patients. One single operation is usually insufficient to eradicate all neoplastic lesions, whereas repeated surgical procedures bring about another dilemma: whether clinical benefits of surgical treatment outweigh loss of pulmonary function following multiple operations. Therefore, despite the anxiety for treatment among MPLC patients, whether and how to treat the patient should be assessed meticulously. Currently there is a heated discussion upon the timing of clinical intervention, operation mode and the application of local therapy in MPLC. Based on clinical experience of our multiple disciplinary team, we have summarized and commented on the evaluation, surgical treatment, non-surgical local treatment, targeted therapy and immunotherapy of MPLC in this article to provide further insight into this field.

Feasibility and safety of one-stage bilateral video-assisted thoracic surgery for resection of bilateral multiple pulmonary nodules / 南方医科大学学报

OBJECTIVE@#To evaluate the feasibility and safety of one- stage bilateral video-assisted thoracic surgery (VATS) for resection of bilateral multiple pulmonary nodules (BMPNs).@*METHODS@#We analyzed the clinical characteristics, pathological features, perioperative outcomes and follow-up data of 41 patients with BMPNs undergoing one-stage bilateral VATS from July, 2011 to August, 2021.@*RESULTS@#One-stage bilateral VATS was performed uneventfully in 40 of the patients, and conversion to open surgery occurred in 1 case. The surgical approaches included bilateral lobectomy (4.9%), lobar-sublobar resection (36.6%) and sublobar-sublobar resection (58.5%) with a mean operative time of 196.3±54.5 min, a mean blood loss of 224.6±139.5 mL, a mean thoracic drainage duration of 4.7±1.1 days and a mean hospital stay of 14±3.8 days. Pathological examination revealed bilateral primary lung cancer in 15 cases, unilateral primary lung cancer in 21 cases and bilateral benign lesions in 5 cases. A total of 112 pulmonary nodules were resected, including 67 malignant and 45 benign lesions. Postoperative complications included pulmonary infection (5 cases), respiratory failure (2 cases), asthma attack (2 cases), atrial fibrillation (2 cases), and drug-induced liver injury (1 case). No perioperative death occurred in these patients, who had a 1-year survival rate of 97.6%.@*CONCLUSION@#With appropriate preoperative screening and perioperative management, one-stage bilateral VATS is feasible and safe for resection of BMPNs.

Clinical outcome and prognosis of indeterminate pulmonary nodules in patients with osteosarcoma / 中华骨科杂志

Objective:To explore the incidence, clinical characteristics, imaging features, clinical outcome and prognosis of indeterminate pulmonary nodules (IPN) in patients with osteosarcoma.Methods:A total of 69 patients of osteosarcoma with IPN in lung treated in the Bone tumor Center of Eastern Theater General Hospital from January 2011 to January 2021 were collected retrospectively, there were 47 males and 22 females, with a median age of 19 years old (range 7-60 years old). The clinical characteristics including disease-free interval, the chemotherapy response, with recurrence/non-pulmonary, IPN presence before / during / after chemotherapy and imaging features of IPN including number of IPN, location of IPN, density of IPN, boundary clarity of IPN and outcome. The patients were divided into the metastasis pulmonary nodules group and the benign nodules group according to the final outcome of IPN. Further, χ 2 test was performed for comparison of the clinical and imaging characteristics between the two groups. The survival of patients was counted and the correlation between single factor and survival was compared by Kaplan-Meier test, and multivariate survival analyses were performed using Cox proportional hazards regression models. Results:Sixty-nine cases occurred IPN in 211 patients with osteosarcoma, with an incidence of 32.7%. Of the 69 patients, 45 patients (65.2%) with IPN were diagnosed as metastases, and 24 patients (34.8%) with IPN were diagnosed as benign nodules. Follow-up length ranged from 1 to 124 months, with the median follow up time 43 months. To the end of follow-up, 41 patients (59.4%) remained alive and 28 patients (40.6%) had died. The median survival time was 41.0 (20.0, 65.0) months and the median survival time after diagnosis of IPN was 25.0 (10.0, 43.0) months. There were significant differences in lung nodule density ( P<0.001), boundary ( P=0.002), history of recurrence/extra-pulmonary metastasis ( P=0.023) and chemotherapeutic effect ( P<0.001) between the metastasis pulmonary nodules group and the benign nodules group. Multivariate survival analysis showed that chemotherapeutic effect was an independent factor affecting the overall survival of patients [ HR=0.048, 95% CI (0.01, 0.26)]. Boundary definition [ HR=0.12, 95% CI (0.02, 0.93)] and chemotherapeutic effect [ HR=0.06, 95% CI (0.01, 0.29)] were independent factors influencing survival after diagnosis of IPN. Conclusion:Osteosarcoma patients with IPN have a poor prognosis. The poor effect of chemotherapy is an independent risk factor for the overall survival time of those patients and the survival time after diagnosis of IPN. The boundary definition of IPN is an independent risk factor for the survival time after diagnosis of IPN.

Low-dose CT-guided Hookwire puncture for localization of lung nodules in patients with body mass index≤22 kg/m2 / 中国介入影像与治疗学

Objective To explore the feasibility of low-dose CT-guided Hookwire localization of lung nodules in patients with body mass index(BMI)≤22 kg/m2.Methods Totally 53 BMI≤22 kg/m2 patients with 66 lung nodules were prospectively enrolled,CT-guided Hookwire localization of lung nodules were performed.According to the dose of CT scanning,the patients were divided into conventional dose group(group A,25 patients with 32 lung nodules)or low dose group(group B,28 patients with 34 lung nodules),while previous conventional dose CT scanning data of patients in group B were taken as control(group C).The image quality of group A and group B were scored using a 5-point scale,and the displaying of lung nodules in group B and group C were scored using a 3-point scale.The basic information of patients,lung nodules location,type,CT value,the maximum diameter,image quality score,puncture times,complications,as well as volume CT dose index(CTDIvol),dose-length product(DLP)and effective dose(ED)were compared between group A and B,so were score of lung nodules display,the maximum diameter and CT value of nodules between group B and C.Results No significant difference of basic information,the location,type,CT value,the maximum diameter,puncture times of lung nodules nor complications was found between group A and B(all P＞0.05).The quality score of group B(4[3,4])was lower than that of group A(5[4,5])(P＜0.05)but all greater than 3 and met the needs of puncturing.CTDIvol,DLP and ED of group B were lower than those of group A(all P＜0.05).There was no significant difference of the maximum diameter,CT value nor score of lung nodules display between group B and C(all P＞0.05).Conclusion Low-dose CT-guided Hookwire localization of lung nodules was feasible in patients with BMI≤22 kg/m2.

Minimally invasive interventions for biopsy of malignancy-suspected pulmonary nodules: a systematic review and meta-analysis

ABSTRACT BACKGROUND: Imaging tests are important for diagnosis during the management of pulmonary nodules; however, biopsy is required to confirm the malignancy. OBJECTIVES: To compare the effects of different techniques used for the biopsy of a pulmonary nodule. DESIGN AND SETTING: Systematic review and meta-analysis were conducted using Cochrane methodology in São Paulo, São Paulo, Brazil. METHODS: We conducted a systematic review of randomized controlled trials (RCTs) on minimally invasive techniques, including tomography-guided percutaneous biopsy (PERCUT), transbronchial biopsies with fluoroscopy (FLUOR), endobronchial ultrasound (EBUSR), and electromagnetic navigation (NAVIG). The primary outcomes were diagnostic yield, major adverse events, and need for another approach. RESULTS: Seven RCTs were included (913 participants; 39.2% female, mean age: 59.28 years). Little to no increase was observed in PERCUT over FLUOR (P = 0.84), PERCUT over EBUSR (P = 0.32), and EBUSR over NAVIG (P = 0.17), whereas a slight increase was observed in NAVIG over FLUOR (P = 0.17); however, the evidence was uncertain. EBUSR may increase the diagnostic yield over FLUOR (P = 0.34). PERCUT showed little to no increase in all bronchoscopic techniques, with uncertain evidence (P = 0.02). CONCLUSION: No biopsy method is definitively superior to others. The preferred approach must consider availability, accessibility, and cost, as safety and diagnostic yield do not differ. Further RCTs planned, conducted, and reported with methodological rigor and transparency are needed, and additional studies should assess cost and the correlation between nodule size and location, as well as their association with biopsy results. SYSTEMATIC REVIEW REGISTRATION: PROSPERO database, CRD42018092367 -https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=92367.

Detection of subsolid nodules on chest CT scans during the COVID-19 pandemic / Detecção de nódulos subsólidos na TC de tórax durante a pandemia de COVID-19

ABSTRACT Objective: To investigate the detection of subsolid nodules (SSNs) on chest CT scans of outpatients before and during the COVID-19 pandemic, as well as to correlate the imaging findings with epidemiological data. We hypothesized that (pre)malignant nonsolid nodules were underdiagnosed during the COVID-19 pandemic because of an overlap of imaging findings between SSNs and COVID-19 pneumonia. Methods: This was a retrospective study including all chest CT scans performed in adult outpatients (> 18 years of age) in September of 2019 (i.e., before the COVID-19 pandemic) and in September of 2020 (i.e., during the COVID-19 pandemic). The images were reviewed by a thoracic radiologist, and epidemiological data were collected from patient-filled questionnaires and clinical referrals. Regression models were used in order to control for confounding factors. Results: A total of 650 and 760 chest CT scans were reviewed for the 2019 and 2020 samples, respectively. SSNs were found in 10.6% of the patients in the 2019 sample and in 7.9% of those in the 2020 sample (p = 0.10). Multiple SSNs were found in 23 and 11 of the patients in the 2019 and 2020 samples, respectively. Women constituted the majority of the study population. The mean age was 62.8 ± 14.8 years in the 2019 sample and 59.5 ± 15.1 years in the 2020 sample (p < 0.01). COVID-19 accounted for 24% of all referrals for CT examination in 2020. Conclusions: Fewer SSNs were detected on chest CT scans of outpatients during the COVID-19 pandemic than before the pandemic, although the difference was not significant. In addition to COVID-19, the major difference between the 2019 and 2020 samples was the younger age in the 2020 sample. We can assume that fewer SSNs will be detected in a population with a higher proportion of COVID-19 suspicion or diagnosis.

RESUMO Objetivo: Investigar a detecção de nódulos subsólidos na TC de tórax de pacientes ambulatoriais antes e durante a pandemia de COVID-19, bem como correlacionar os achados de imagem com dados epidemiológicos. Nossa hipótese foi a de que nódulos não sólidos (pré) malignos foram subdiagnosticados durante a pandemia de COVID-19 em virtude da sobreposição de achados de imagem de nódulos subsólidos e pneumonia por COVID-19. Métodos: Estudo retrospectivo no qual foram incluídas todas as imagens de TC de tórax realizadas em pacientes ambulatoriais adultos (com idade > 18 anos) em setembro de 2019 (antes da pandemia de COVID-19) e em setembro de 2020 (durante a pandemia de COVID-19). As imagens foram reavaliadas por um radiologista torácico, e os dados epidemiológicos foram extraídos de questionários preenchidos pelos pacientes e de encaminhamentos clínicos. Modelos de regressão foram usados para controlar fatores de confusão. Resultados: Foram reavaliadas 650 e 760 imagens de TC de tórax nas amostras de 2019 e 2020, respectivamente. Foram encontrados nódulos subsólidos em 10,6% dos pacientes que compuseram a amostra de 2019 e em 7,9% daqueles que compuseram a amostra de 2020 (p = 0,10). Nódulos subsólidos múltiplos foram encontrados em 23 e 11 dos pacientes que compuseram as amostras de 2019 e 2020, respectivamente. As mulheres constituíram a maioria da população do estudo. A média de idade foi de 62,8 ± 14,8 anos na amostra de 2019 e de 59,5 ± 15,1 anos na amostra de 2020 (p < 0,01). A COVID-19 foi responsável por 24% de todos os encaminhamentos para a realização de TC em 2020. Conclusões: Foram detectados menos nódulos subsólidos na TC de tórax de pacientes ambulatoriais durante a pandemia de COVID-19 do que antes da pandemia, embora a diferença não tenha sido significativa. Além da COVID-19, a principal diferença entre as amostras de 2019 e 2020 foi o fato de que a amostra de 2020 era mais jovem. Podemos supor que menos nódulos subsólidos serão detectados numa população com maior proporção de suspeita ou diagnóstico de COVID-19.

Evaluation of respiratory bronchiolitis nodules with maximum intensity projection images

SUMMARY OBJECTIVE: Respiratory bronchiolitis is a disease associated with heavy smoking. Computed tomography in this disease often shows symmetrical and bilaterally ill-defined circumscribed centriacinar micronodular involvement in the upper-middle lobes. The maximum intensity projection method is a kind of image processing method and provides a better evaluation of nodules and vascular structures. Our study aimed to show whether maximum intensity projection images increase the diagnostic accuracy in the detection of micronodules in respiratory bronchiolitis. METHODS: Two radiologists with different experiences (first reader: 10-year radiologist with cardiothoracic radiology experience and second reader: nonspecific radiologist with 2 years of experience) reviewed images of patients whose respiratory bronchiolitis diagnosis was supported by clinical findings. The evaluation was done independently of each other. Both conventional computed tomography images and maximum intensity projection images of the same patients were examined. The detection rates on conventional computed tomography and maximum intensity projection images were then compared. RESULTS: A total of 53 patients were evaluated, of whom 48 were men and 5 were women. The first reader detected centriacinar nodules in 42 (79.2%) patients on conventional computed tomography and centriacinar nodules in all 53 (100%) patients on maximum intensity projection images. The second reader detected centriacinar nodules in 12 (22.6%) patients on conventional computed tomography images and in 48 (90.6%) patients on maximum intensity projection images. For the less experienced reader, the detection rate of micronodules in respiratory bronchiolitis in maximum intensity projection images increased statistically significantly (p<0.001). CONCLUSION: Maximum intensity projection images in respiratory bronchiolitis increase the detectability of micronodules independently of the experience of the radiologist.

Application of CT-guided Localization with Medical Glue for Single and Two or More Small Pulmonary Nodules before Video-assisted Thoracic Surgery / 中国肺癌杂志

BACKGROUND@#The localization of pulmonary nodules is related to whether the lesions can be found and removed accurately and quickly. It is an important link for the success of minimally invasive video-assisted thoracic surgery (VATS). This study investigated the feasibility of medical glue localization under VATS video-assisted thoracoscopic computed tomography (CT) guidance for single pulmonary nodule and more than two pulmonary nodules, and compared with the accuracy and safety of single nodule localization.@*METHODS@#A retrospective analysis of the clinical data of patients who underwent unilateral CT-guided medical glue localization before VATS from November 2018 to March 2021 were performed, the patients was divided into multiple pulmonary nodules group (localized nodules ≥2) and single pulmonary nodule group according to the number of localized nodules. The localization time, success rate and complication rate of the two groups were compared.@*RESULTS@#There were 126 nodules in the two groups, including 62 in single pulmonary nodule group and 64 in multiple pulmonary nodules group. The average single nodule localization time was (13.23±4.5) min in single pulmonary nodule group and (10.52±2.8) min in multiple pulmonary nodules group, the difference between the two groups is statistically significant (P<0.05). The localization success rate of single pulmonary nodule group and multiple pulmonary nodules group were 100% and 98.4% separately, the difference between the two groups was not statistically significant (P>0.05). All VATS were successfully completed after localization. The incidence of pneumothorax was higher in multiple pulmonary nodules group than in single pulmonary nodule group (P=0.07).@*CONCLUSIONS@#Compared with localization of single lung nodule, unilateral CT-guided medical glue localization for multiple pulmonary nodules before VATS is also feasible and accuracy, it is worthy of clinical application. But the higher rate of pneumothorax should be paid attention to.

Evaluation on the feasibility of total-body PET/CT imaging with short acquisition time in lungs and parenchymal organs / 中华核医学与分子影像杂志

Objective:To investigate the effects of total-body PET/CT imaging with short acquisition time on image quality and lesion detectability in lungs and parenchymal organs.Methods:Sixty patients (31 males, 29 females, age (61.1±11.8) years) with pulmonary nodules (PN) and 53 patients (29 males, 24 females, age (56.7±17.2) years) with parenchymal organ lesions (POL) who underwent total-body PET/CT imaging in the First Affiliated Hospital of Shandong First Medical University between October 2021 and April 2022 were retrospectively analyzed. The acquisition time with PET was 600 s, and the reconstructed images were divided into 6 groups based on different duration (30, 60, 120, 180, 300 and 600 s), namely G30, G60, G120, G180, G300 and G600 groups. The subjective analysis was carried out with the 5-point Likert scale in 3 aspects: the overall impression of image quality, noise, and lesion conspicuity. The objective analysis indicators included the SUV mean of the mediastinal blood pool (MBP); the SUV mean, standard deviation (SD) and signal-to-noise ratio (SNR) of the liver; SUV max and target-to-background ratio (TBR) of the lesions. Differences of the indicators among 6 groups were analyzed by Friedman test with Bonferroni correction. G600 served as the reference for the other 5 groups to test their lesion detectability. Results:The subjective image quality of different groups for PN and that of G120, G180, G300 groups for POL could meet the needs of clinical diagnosis in terms of the overall image quality, noise, and lesion conspicuity (all scores>3). There was no significant difference in the SUV mean of MBP among different time groups (median for PN: 1.52-1.56, median for POL: 1.35-1.47; χ2 values: 10.23, 11.02, both P>0.05). Difference was not found in SUV mean of the liver either (median for PN: 2.51-2.56, median for POL: 2.33-2.40; χ2 values: 8.35, 8.93, both P>0.05). The liver SD significantly increased along with the shortened acquisition time ( χ2 values: 400.99, 400.00, both P<0.001; z values: from -16.90 to -3.15, all P<0.003). The SNR significantly decreased along with the shortened acquisition time ( χ2 values: 397.32, 400.00, both P<0.001; z values: 2.98-16.90, all P<0.003). The SUV max (median for PN: 3.55-4.01, median for POL: 5.77-6.08; χ2 values: 8.58, 3.02, both P>0.05) and TBR (median for PN: 2.42-2.81, median for POL: 2.36-2.45; χ2 values: 9.83, 3.69, both P>0.05) of lesion were not significantly different among 6 groups. Taking G600 group as a reference, the lesion detection rates were 100% in G30 group and other 4 groups for PN (81/81) and in G120, G180, G300 groups for POL (80/80). Conclusion:Total-body PET/CT imaging with acquisition time of 30 s for lungs and that with acquisition time of 120 s for parenchymal organs are feasible for clinical use, with the PET image quality and lesion detectability maintained.

Cytomegalovirus pneumonia presenting as pulmonary nodules

Abstract Cytomegalovirus (CMV) pneumonia is a well-known cause of morbidity and mortality in patients with a history of allogenic hematopoietic stem cell transplant. Radiographically, CMV pneumonia most commonly presents as bilateral ground glass opacities; however, the presentation is non-specific and can be variable, including presenting as areas of air-space consolidation or pulmonary nodules. We report a case of a 70-year-old man who presented with rapidly progressive bilateral pulmonary nodules approximately two months after receiving a bone marrow transplant. No infectious etiology was identified for the pulmonary nodules, and a bronchoscopy was unable to be performed due to a rapid decline in the patient's overall condition and respiratory status. The patient died shortly after the decision was made to transition to palliative care and a limited autopsy was performed to explore the pulmonary findings. Corresponding to premortem imaging were the postmortem gross findings of numerous bilateral pulmonary nodules and a large mass-like area of consolidation in the right upper lobe. Microscopic examination of the nodules demonstrated a necrotizing pneumonia with few foci of viral cytopathologic change consistent with CMV, which was confirmed by immunohistochemistry. While CMV is a common infectious agent in the immunocompromised population, CMV pneumonia continues to be a challenging entity due to difficulty in diagnosis and treatment. Rapidly enlarging pulmonary nodules in an immunosuppressed patient is highly suggestive of an infectious process and careful histologic examination for viral cytopathologic change is essential.

Resección por videotoracoscopía de nódulos pulmonares marcados con lipiodol: experiencia en dos centros universitarios / Videotoracoscopy resection of pulmonary nodules marked with lipiodol: experience in two university centers

INTRODUCCIÓN: Para facilitar la localización intraoperatoria de los nódulos pulmonares existe la alternativa de marcarlos previamente con lipiodol. OBJETIVO: Describir los resultados quirúrgicos de los pacientes sometidos a resección por videotoracoscopía de nódulos pulmonares marcados previamente con lipiodol. MATERIAL Y MÉTODOS: Estudio descriptivo. Se incluyeron los pacientes que fueron sometidos a resección por videotoracoscopía de nódulos pulmonares marcados con lipiodol, en Clínica Las Condes e Instituto Nacional del Tórax, entre junio de 2012 y junio de 2019. Se consideraron variables demográficas, radiológicas, quirúrgicas e histológicas. RESULTADOS: Se estudió un total de 93 pacientes. La edad promedio fue 63,5 (± 11,9) años. El tamaño promedio de los nódulos fue de 10,7 (± 5,8) mm. Se identificó y extrajo el 100% de los nódulos marcados. Los días de hospitalización promedio fueron 4,7 (± 6,9). Solo se registró un fallecimiento de causa no quirúrgica. CONCLUSIONES: La resección videotoracoscópica de nódulos pulmonares marcados previamente con lipiodol, es una técnica segura y eficaz.

BACKGROUND: To facilitate the intraoperative location of lung nodules there is the alternative of pre-marking them with lipiodol. OBJECTIVE: To describe the surgical results of patients undergoing videotoracoscopy resection of pulmonary nodules previously marked with lipiodol. MATERIAL AND METHODS: Descriptive study. Patients who underwent videotorcoscopy resection of pulmonary nodules marked with lipiodol were included at Clínica Las Condes and Instituto Nacional del Tórax between June 2012 and June 2019. Demographic, radiological, surgical and histological variables were considered. RESULTS: A total of 93 patients were studied. The average age was 63,5 (± 11.9) years. The average size of the nodules was 10.7 (± 5.8) mm. 100% of the marked nodules were identified and extracted. The average hospitalization days were 4.7 (± 6.9). Only one death of non-surgical cause was recorded. CONCLUSIONS: Videotoracoscopic resection of pulmonary nodules previously marked with lipiodol is a safe and effective technique.

Current status and advancement of medical imaging management for multiple pulmonary nodules / 中国胸心血管外科临床杂志

@#The widespread use of low-dose computed tomography (LDCT) in lung cancer screening has enabled more and more lung nodules to get identified of which more than 20% are multiple pulmonary nodules. At present, there is no guideline or consensus for multiple pulmonary nodules whose management is based primarily on the pulmonary imaging characteristics and associated risk factors. Herein, this review covers the imaging methods, CT appearances and management of multiple pulmonary nodules.

Etiología de nódulos pulmonares en pacientes con cáncer mamario / Etiology of pulmonary nodules in patients with breast cancer

Resumen Objetivo: Describir los diagnósticos histopatológicos a partir de los casos de las pacientes con cáncer de mama que fueron llevadas a resección de nódulos pulmonares en el Instituto Nacional de Cancerología (INC). Materiales y métodos: Se desarrolló un estudio tipo serie de casos donde se describen las características clínicas, histológicas y anatomopatológicas de un grupo de pacientes con diagnóstico confirmado de cáncer de mama de novo o que durante su enfermedad presentaron nódulos pulmonares que requirieron resección quirúrgica mediante cuña pulmonar o lobectomía en el INC, entre el 1 de enero de 2015 y el 30 de abril de 2018. Resultados: En el periodo de estudio se realizaron 225 resecciones en cuña pulmonar y lobectomías, 55 de estos pacientes tenían diagnóstico de cáncer de mama, de los cuales el 69,1% fueron de origen neoplásico, 26 pacientes fueron metástasis de cáncer mama (47,3%), 9 pacientes tenían segundo primario pulmonar (16,4%) y un paciente tenía concomitantemente cáncer primario pulmonar y una metástasis de mama (1,8%). Otras 2 pacientes tenían metástasis de otros órganos, uno de recto y uno de tiroides (3,6%), mientras que las 17 pacientes restantes presentaron reporte de lesiones pulmonares benignas en la anatomía patológica (30,9%). Conclusión: La presencia de nódulos pulmonares en pacientes con cáncer de mama no siempre son secundarias a enfermedad metastásica en pulmón; pueden existir otras etiologías como cáncer primario pulmonar, metástasis de otros órganos, tumores benignos o infecciones. Conocer la etiología de los nódulos pulmonares en pacientes con cáncer de mama es determinante para evaluar las opciones terapéuticas que pueden variar desde el manejo quirúrgico hasta el manejo sistémico.

Abstract Objectives: To describe the histopathological diagnoses of patients with breast cancer who underwent resection of pulmonary nodules at the National Cancer Institute (INC) of Bogotá. Materials and methods: A case-series study was developed to describe the clinical, histological and anatomopathological characteristics of a sample of patients with a diagnosis of de novo metastatic breast cancer or whom presented with pulmonary nodules during their disease that required surgical resection by wedge pulmonary or lobectomy in the INC, between January 1, 2015 and April 30, 2018. Results: During the study period, 225 resections were performed in lung wedge and lobectomies, 55 of these patients had a diagnosis of breast cancer, of which 69.1% were of neoplastic origin, 26 (47.3%) were metastatic of breast cancer, 9 (16.4%) second primary pulmonary and 1 (1.8%) patient had concomitantly primary lung cancer and a breast metastasis. Another 2 (3.6%) patients had metastases from other organs, one from the rectum and one from the thyroid, while the remaining 17 (30.9%) patients presented a report of benign lung lesions in the pathology. Conclusion: The presence of pulmonary nodules in patients with breast cancer are not always secondary to metastatic disease. Other etiologies may exist, such as primary pulmonary cancer, metastasis from other cancers, benign lung tumors or infections. Knowing the etiology of pulmonary nodules in patients with breast cancer is crucial to evaluate the therapeutic options that can vary from surgical management to systemic management.

Cordeiro em pele de lobo: um caso clínico / Sheep in wolf's clothing: a case report / Cordero con piel de lobo: un caso clínico

Introdução: Quando um utente recorre a uma consulta médica, este já tem uma ideia pré-definida do seu problema de saúde. Esta advém da sua experiência anterior, da cultura local e da sua estrutura de apoio. Apresentação do Caso: Mulher de 48 anos, ex-fumadora. Antecedentes pessoais de excisão de leiomioma uterino há 18 anos. Recorreu à médica de família por tosse há quatro meses. Fez uma tomografia computadorizada tórax, onde se individualizavam formações nodulares dispersas, sugestivas de metastização. Referenciou-se de urgência para consulta de pneumologia, onde lhe foi pedida biópsia, a qual a doente recusou. Após breve avaliação familiar, a própria utente compreendeu que o seu medo era gerado pela sua experiência prévia de vida. A utente acabou por realizar biópsia que revelou padrão de leiomioma. Admitiu-se leiomiomatose benigna metastizante secundária à excisão de miomas uterinos. Conclusão: A "dolência" compreendida pelos utentes vai influenciar o modo como vão gerir a sua doença e a sua dolência. Na consulta existe a gestão entre os medos do doente e as incertezas diagnósticas por parte do médico. Nestes casos, o médico de família não deve assumir uma posição paternalista de decisão, mas sim capacitar os utentes para uma escolha consciente e informada.

Introduction: When a patient has a medical appointment, they already have a pre-defined idea of their health problem. This idea is influenced by their previous experience, local culture and family support. Case Description: 48-year-old female, former smoker. She reveals a personal history of uterine leiomyoma excision 18 years ago. She turns to her doctor complaining of cough for the last four months. A chest computed tomography was ordered, in which nodular formations were identified, suggestive of metastasis. An urgent referral was made to a pulmonology consultation, where a biopsy was requested, which the patient refused to perform. After a family assessment, the patient realized that her previous life experience generated her fear. The patient ended up performing the biopsy that revealed a leiomyoma pattern. The diagnosis of benign metastatic leiomyomatosis secondary to uterine fibroid excision was made. Conclusion: The "illness" understood by patients will influence how they will manage their disease and their malaise. In the consultation there is a confrontation between the patient's fears and the diagnostic uncertainties of the physician. In such cases, the family doctor should not assume a paternalistic position of decision, but should empower patients to make a conscious and informed choice

Introducción: Cuando un paciente tiene una cita médica, ya tiene una idea predefinida de su problema de salud. Esta idea está influenciada por su experiencia previa, cultura local y apoyo familiar. Presentación del caso: Mujer de 48 años, exfumadora. Ella revela una historia personal de escisión de leiomioma uterino hace 18 años. Ella recurre a su médico quejándose de tos durante los últimos cuatro meses. Se ordenó una Tomografía computarizada de tórax, en la que se identificaron formaciones nodulares, sugestivas de metástasis. Se hizo una referencia urgente a una consulta de neumología, donde se solicitó una biopsia, que el paciente se negó a realizar. Después de una evaluación familiar, la paciente se dio cuenta de que su experiencia de vida anterior generaba miedo. Se realizó el diagnóstico de leiomiomatosis benigna metastatizante secundaria a escisión de fibromas uterinos. Conclusión: La "enfermedad" entendida por los pacientes influirá en cómo manejarán su enfermedad y su malestar. En la consulta existe una confrontación entre los temores del paciente y las incertidumbres diagnósticas del médico. En tales casos, el médico de familia no debe asumir una posición paternalista de decisión, sino que debe capacitar a los pacientes para que tomen una decisión consciente e informada.

Delftia acidovorans pneumonia with lung cavities formation / Neumonia con formación de cavidades pulmonares causada por Delftia acidovorans

Abstract Case Description: A 52-year-old female patient was admitted to our clinic with complaints of cough, sputum, fever and fatigue. The patient has been receiving immunosuppressive therapy for thrombocytopenic purpura for 5 years. Clinical Finding: Inspiratory crackles were heard on both hemithorax. Oxygen saturation measured with the pulse oximeter was 97%. Chest X-ray showed diffuse reticular opacities that were more prominent in the upper zones of both lungs. WBC counts were 17,600 mm3 and Platelet counts were 29,000 mm3. Thorax CT showed that there were many thin-walled cavities and millimetric nodules accompanied by ground-glass infiltrates in the upper and middle lobes. Gram staining of bronchial fluid, taken by bronchoscopy, revealed Gram-negative bacilli and intense polymorphonuclear leukocytes. The bacteria were defined as Delftia acidovorans by BD Phoenix automated system. Treatment and outcomes: The patient was hospitalized with suspicion of opportunistic pulmonary infections and cavitary lung disease. After the empirical treatment of intravenous piperacillin-tazobactam and oral clarithromycin, her clinical and radiological findings significantly regressed, and she was discharged with outpatient follow-up. Clinical Relevance: This is the first example of cavitary pneumonia due to Delftia acidovorans in an immunocompromised patient. We would like to emphasize that Delftia pneumonia should be considered in the differential diagnosis of pulmonary cavitary involvement in such patients.

Resumen Descripción del caso: Una mujer de 52 años llegó a la clínica con tos, esputo, fiebre y fatiga. El paciente estuvo recibiendo terapia inmunosupresora durante 5 años para el tratamiento de la púrpura trombocitopénica. Hallazgo clínico: se escucharon crepitaciones inspiratorias en ambos hemitórax. La saturación de oxígeno fue del 97%. La radiografía de tórax mostró opacidades reticulares difusas que eran más prominentes en las zonas superiores de ambos pulmones. Los recuentos de leucocitos fueron de 17,600 mm3 y los recuentos de plaquetas fueron de 29,000 mm3. La TC de tórax mostró muchas cavidades de pared delgada y nódulos milimétricos acompañados de infiltrados vitrales en los lóbulos superior y medio. La tinción de Gram del líquido bronquial reveló bacilos gramnegativos y leucocitos polimorfonucleares. Las bacterias fueron identificadas como Delftia acidovorans. Tratamiento y resultados: La paciente fue hospitalizado con una sospecha de infección oportunista pulmonar y enfermedad pulmonar cavitaria. Después del tratamiento empírico de piperacilina-tazobactam intravenosa y claritromicina oral, los síntomas y signos retrocedieron significativamente, y fue dada de alta con seguimiento ambulatorio. Relevancia clínica: este es el primer registro de neumonía cavitaria causado por Delftia acidovorans en una paciente inmunocomprometida. Enfatizamos que la neumonía por Delftia debe considerarse en el diagnóstico diferencial de la afectación de la cavidad pulmonar en tales pacientes.

Effect of detection algorithm based on deep learning for pulmonary nodules in different lung lobes / 中国医学影像技术

Objective: To explore the effect of pulmonary nodules in different lung lobes detection algorithm based on deep learning (DL). Methods: Totally 493 eligible patients with pulmonary nodules on chest CT were included, and pulmonary nodules were labeled. The results of pulmonary nodules detection algorithm based on DL were compared with those of radiologist's labelling, and the match ratios in every lung lobe were counted, respectively. The radiologist finally re-evaluated the nodules that might be detected by algorithm but were missed during the initial inspection. Results: The match ratio of 4.1 -30.0 mm nodules of DL algorithm was 96.05% (73/76), 96.91% (94/97), 96.94% (95/98), 98.59% (70/71), 95.95% (71/74) and 96.30% (26/27) for pulmonary nodules in left upper lobe, left lower lobe, right upper lobe, right middle lobe, right lower lobe and interlobar pleura, respectively (all P>0.05). After re-evaluation, 50.92% (747/1467) of the no matched nodules detected by algorithm were reassigned as true positives. There were statistical differences among the missed nodules on different lobes (all P<0.05). Conclusion: The performance of pulmonary nodule detection algorithm based DL is not affected by nodule locations in terms of pulmonary lobes. The distribution of missed nodules meets the general consensus of medical profession.

Clinicopathological features of diffuse pulmonary meningotheliomatosis / 中华病理学杂志

Objective@#To study the clinicopathological characteristics, immunophenotype, pathologic diagnosis and differential diagnosis of diffuse pulmonary meningotheliomatosis (DPM).@*Methods@#The clinical data, histological features and immunohistochemical results of three cases of DPM collected from January 2016 to May 2018 at Guangdong Provincial People′s Hospital were analyzed, and the relevant literature reviewed.@*Results@#The three DPM patients age was 53, 69 and 74 years. The lesions consisted of multiple minute pulmonary meningothelial-like nodules profusely involving the lungs. Microscopically, they showed typical morphology, characterized by medium-sized elongated tumor cells resembling meningothelial cells with whorled/nested clusters. The cells were uniform and had abundant eosinophilic cytoplasm with oval nuclei with delicate chromatin. Immunohistochemical staining showed tumor cells were diffusely and strongly positive for EMA, vimentin and PR, but were negative for CAM5.2, CgA, Syn, CK7 and TTF1.@*Conclusions@#DPM is extremely rare, and may be confused with primary interstitial pulmonary processes and metastatic malignant tumors of lung. Recognition of this entity is essential for pathologists to avoid misdiagnosis and unnecessary treatment.