[The subclinical involvement of the lung in rheumatoid arthritis: evaluation by high-resolution computed tomography] / L'interessamento polmonare subclinico nell'artrite reumatoide: studio mediante tomografia ad alta risoluzione.

Pulmonary involvement is one of the most frequent extra-articular manifestations of rheumatoid arthritis (RA) and represents a serious complication, being the second cause of death after infection. High-resolution computed tomography (HRCT), owing to its increased sensitivity and diagnostic accuracy respect to the conventional chest radiograph (CXR), allows to detect pulmonary abnormalities in RA patients more frequently than CXR. The aim of this study was to assess pulmonary involvement by HRCT in lifelong non-smoking RA patients without symptoms and clinical signs of pulmonary disease. Seventy-two patients (54 women and 18 men) with a mean age of 56.8+/-10.4 years (range, 40-77 years) and mean duration of disease of 6.9+/-4.7 years (range, 2-12 years) entered the study. 52/72 (72%) were positive for rheumatoid factor (> 20 UI/ml). Standard CXR and HRCT were carried out in each patient. CXR showed a mild interstitial fibrosis in 7 patients (9.7%), whereas HRCT demonstrated pulmonary abnormalities in an higher number of them (22/72 = 30.5%). The most frequent abnormal findings on HRCT were irregular pleural margins (13.8%) and septal/subpleural lines (18%), both compatible with pulmonary fibrosis. Ground-glass opacities were found in 8.3% of the patients. Pulmonary nodules (diameter, range 0,5-2 cm) predominantly located in the subpleural portions of the lung, were demonstrated in the same percentage (8.3%) of patients. Small airway involvement, represented by bronchiectasis/bronchioloectasis, was shown in 15.2% of patients. Subpleural cysts were present in two cases (2.8%). No patient had evidence of honeycombing on HRCT. In conclusion, HRCT is an accurate, non-invasive and safe method of diagnosing lung abnormalities in RA patients without signs and clinical symptoms of pulmonary disease.

Clinical applications of 2D and 3D CT imaging of the airways--a review.

Hardware and software evolution has broadened the possibilities of 2D and 3D reformatting of spiral CT and MR data set. In the study of the thorax, intrinsic benefits of volumetric CT scanning and better quality of reconstructed images offer us the possibility to apply additional rendering techniques to everyday clinical practice. Considering the large number and redundancy of possible post-processing imaging techniques that we can apply to raw CT sections data, it is necessary to precisely set a well-defined number of clinical applications of each of them, by careful evaluation of their benefits and possible pitfalls in each clinical setting. In diagnostic evaluation of pathological processes affecting the airways, a huge number of thin sections is necessary for detailed appraisal and has to be evaluated, and information must then be transferred to referring clinicians. By additional rendering it is possible to make image evaluation and data transfer easier, faster, and more effective. In the study of central airways, additional rendering can be of interest for precise evaluation of the length, morphology, and degree of stenoses. It may help in depicting exactly the locoregional extent of central tumours by better display of relations with bronchovascular interfaces and can increase CT/bronchoscopy sinergy. It may allow closer radiotherapy planning and better depiction of air collections, and, finally, it could ease panoramic evaluation of the results of dynamic or functional studies, that are made possible by increased speed of spiral scanning. When applied to the evaluation of peripheral airways, as a completion to conventional HRCT scans, High-Resolution Volumetric CT, by projection slabs applied to target areas of interest, can better depict the profusion and extension of affected bronchial segments in bronchiectasis, influence the choice of different approaches for tissue sampling by better evaluation of the relations of lung nodules with the airways, or help to detect otherwise overlooked slight pathological findings. In the exploration of the air-spaces of the head and neck, targeted multiplanar study can now be performed without additional scanning by retro-reconstructed sections from original transverse CT slices. Additional rendering can help in surgical planning, by simulation of surgical approaches, and allows better integration with functional paranasal sinuses endoscopic surgery, by endoscopic perspective rendering. Whichever application we perform, the clinical value of 2D and 3D rendering techniques lies in the possibility of overcoming perceptual difficulties and 'slice pollution', by easing more efficient data transfer without loss of information. 3D imaging should not be considered, in the large majority of cases, as a diagnostic tool: looking at reformatted images may increase diagnostic accuracy in only very few cases, but an increase in diagnostic confidence could be not negligible. The purpose of the radiologist skilled in post-processing techniques should be that of modifying patient management, by more confident diagnostic evaluation, in a small number of patients, and, in a larger number of cases, by simplifying communication with referring physicians and surgeons. We will display in detail possible clinical applications of the different 2D and 3D imaging techniques, in the study of the tracheobronchial tree, larynx, nasal cavities and paranasal sinuses by Helical CT, review relating bibliography, and briefly discuss pitfalls and perspectives of CT rendering techniques for each field.

[Subclinical interstitial lung involvement in rheumatic diseases. Correlation of high resolution computerized tomography and functional and cytologic findings]. / L'interessamento polmonare interstiziale subclinico nelle malattie reumatiche. Correlazione fra Tomografia computerizzata con alta risoluzione e i reperti funzionali e citologici.

INTRODUCTION: Rheumatic diseases are frequently associated with interstitial lung disease. Since interstitial fibrosis is an irreversible process, understanding the mechanisms leading to fibrosis is necessary for the development of treatment strategies to prevent irreversible pulmonary damage. High-resolution Computed Tomography (HRCT) is superior to chest radiography in assessing the presence and extent of parenchymal abnormalities in diffuse infiltrative lung diseases and provides a sensitive and noninvasive method of quantifying global disease extent. PURPOSE: The aims of this study were to quantify the severity and extent of subclinical interstitial lung disease as depicted on HRCT and to study the relationship between the patterns of lung disease quantified by HRCT and the functional parameters and bronchoalveolar lavage findings in patients with rheumatic diseases. PATIENTS: Eighty nonsmoking patients (24 patients with systemic sclerosis, 24 with primary Sjögren's syndrome, 20 with rheumatoid arthritis and 7 with dermatopolymyositis) were examined. No patient had any signs or symptoms of pulmonary disease. RESULTS: Thirty-three of 80 patients (41.2%) had abnormal HRCT findings, namely isolated septal/subpleural lines, irregular pleural margins and ground-glass appearance. Chest X-ray showed parenchymal abnormalities in only 15 patients (18.7%) who had evidence of fibrosis on HRCT. Abnormal differential cell counts (alveolitis) at bronchoalveolar lavage were found in 46 of 80 patients (57.5%). Three types of alveolitis were observed: pure lymphocyte alveolitis, pure neutrophil alveolitis, and neutrophil alveolitis associated with lymphocytosis (mixed alveolitis). The patients with neutrophil alveolitis had more extensive disease on HRCT than those with lymphocyte alveolitis or with normal cellular patterns at bronchoalveolar lavage. The extent of a reticular pattern on HRCT correlated with the neutrophil rate (p = 0.001) and total count (p = 0.003) on bronchoalveolar lavage. Eosinophil and lymphocyte rate and total count correlated (p < 0.05) with the extent of the ground-glass pattern on HRCT. Lung volumes were not significantly different among patients with ground-glass pattern and those with reticular patterns on HRCT, while the diffusing capacity for carbon monoxide was significantly lower (p < 0.05) in the latter. CONCLUSIONS: HRCT is a sensitive tool in detecting interstitial lung disease in patients with rheumatic diseases with no signs and symptoms of pulmonary involvement. The relationship between the different HRCT patterns and bronchoalveolar lavage cell profiles can identify patients at higher risk of developing irreversible lung fibrosis. A long-term, prospective follow-up study is needed to determine whether these patients will develop over pulmonary disease.

Integration of TBNA and TCNA in the diagnosis of peripheral lung nodules. Influence on staging.

Although transbronchial and percutaneous approaches to peripheral pulmonary lesions (PPL) are widely diffused, effective and safe diagnostic techniques, no standardised strategy yet exists that defines the specific role of each in this clinical setting. With the aim of defining the role of each approach and of verifying if the two techniques are alternative or may be integrated in a logical diagnostic sequence based on the advantages and the limits of each biopsy method, the authors analysed their experience with the integrated use of transbronchial and percutaneous approach to PPL performed on 1,680 consecutive patients affected by PPL. The procedure used was as follows: 1) bronchoscopy with exploration of the bronchial tree and transbronchial needle aspiration (TBNA) of hilar/mediastinal lympho nodes for staging N factor followed by TBNA and transbronchial pulmonary biopsy (TBPB) of the PPL under fluoroscopic guidance and immediate cytological assessment (ICA); 2) if TBNA was diagnostic, the procedure was stopped; if not, a second pass with the needle was performed and then the bronchoscope removed; 3) if the second TBNA was not diagnostic, percutaneous approach (PCNA) with ICA was performed up to a maximum of three needle passes. Diagnostic sensitivity for malignant lesions was: 50.0% for TBPB, 70.1% for TBNA, 76.0% for TBPB and TBNA together, 92.8% for PCNA, and 95.0% overall. The percentage of benign nodules correctly defined was 43.0% for TBPB, 16.7% for TBNA, 47.8% for PCNA. Examination of the upper airways and bronchial tree was positive for lesions endoscopically visible in 11.4% of cases. TBNA of hilar/mediastinal lympho nodes was positive for metastatic involvement in 43.9%. The authors' experience demonstrates that transbronchial and percutaneous approaches must be considered complementary and that their integrated use not only increases diagnostic yield but also permits important information to be obtained for the staging of lung cancer. The creation of teams able to utilise both approaches with the cytopathologist present for ICA should be encouraged in order to optimise the diagnostic management of PPL.

A longitudinal study of pulmonary involvement in primary Sjögren's syndrome: relationship between alveolitis and subsequent lung changes on high-resolution computed tomography.

Eighteen non-smoking women suffering from primary Sjögren's syndrome (pSS) with previously documented alveolitis were re-examined, clinically and by pulmonary function tests (PFT), bronchoalveolar lavage (BAL), chest X-ray and high-resolution computed tomography (HRCT) after a 2 yr follow-up period. Longitudinal evaluation revealed unchanged PFT. The final BAL study showed a normal differential count in six of 14 patients with initial lymphocyte alveolitis, and a persistent alveolar lymphocytosis in the remaining eight patients, associated with an increased percentage of neutrophils in one of them. In four patients with initial mixed alveolitis, the BAL cell profile was unchanged 2 yr later. Five of 18 patients (28%) had abnormal HRCT, represented by isolated septal/subpleural lines in three patients, ground-glass opacities with irregular pleural margins in one patient, and ground-glass opacities associated with septal/subpleural lines in another. All these patients had abnormal BAL results with an increased proportion of both neutrophils and lymphocytes. The presence of alveolar neutrophils was associated with a significantly (P=0.005) greater mean rate of reduction of carbon monoxide diffusing capacity (DLCO) -- more than four times the normal rate of loss of DLCO. Chest X-ray, repeated at the end of the 2 yr follow-up period, showed parenchymal abnormalities in only one patient who had evidence of fibrosis on HRCT. This study provides evidence that lung involvement is not an uncommon extraglandular manifestation of pSS and that a BAL neutrophilia may play an important role in the pathogenesis of pulmonary disease in this autoimmune disorder.

[Virtual bronchoscopy: the correlation between endoscopic simulation and bronchoscopic findings]. / Broncoscopia virtuale: correlazione tra simulazione endoscopica e reperti broncoscopici.

PURPOSE: We carried out a preliminary clinical validation of 3D spiral CT virtual endoscopic reconstructions of the tracheobronchial tree, by comparing virtual bronchoscopic images with actual endoscopic findings. MATERIALS AND METHODS: Twenty-two patients with tracheobronchial disease suspected at preliminary clinical, cytopathological and plain chest film findings were submitted to spiral CT of the chest and bronchoscopy. CT was repeated after endobronchial therapy in 2 cases. Virtual endoscopic shaded-surface-display views of the tracheobronchial tree were reconstructed from reformatted CT data with an Advantage Navigator software. Virtual bronchoscopic images were preliminarily evaluated with a semi-quantitative quality score (excellent/good/fair/poor). The depiction of consecutive airway branches was then considered. Virtual bronchoscopies were finally submitted to double-blind comparison with actual endoscopies. RESULTS: Virtual image quality was considered excellent in 8 cases, good in 14 and fair in 2. Virtual exploration was stopped at the lobar bronchi in one case only; the origin of segmental bronchi was depicted in 23 cases and that of some subsegmental branches in 2 cases. Agreement between actual and virtual bronchoscopic findings was good in all cases but 3 where it was nevertheless considered satisfactory. The yield of clinically useful information differed in 8/24 cases: virtual reconstructions provided more information than bronchoscopy in 5 cases and vice versa in 3. Virtual reconstructions are limited in that the procedure is long and difficult and needing a strictly standardized threshold value not to alter virtual findings. Moreover, the reconstructed surface lacks transparency, there is the partial volume effect and the branches < or = 4 pixels phi and/or meandering ones are difficult to explore. CONCLUSIONS: Our preliminary data are encouraging. Segmental bronchi were depicted in nearly all cases, except for the branches involved by disease. Obstructing lesions could be bypassed in some cases, making an indication for endoscopic laser therapy. Future didactic perspectives and applications to minimally invasive or virtual reality-assisted therapy seem promising, even though actual clinical applications require further studies.

Neurogenic diabetes insipidus: an unusual clinical presentation of small cell lung cancer.

A 61 year old man presented with chronic bronchitis, which he had been suffering from for many years, and reported the recent onset of polyuria with polydipsia. A chest X-ray showed a peripheral pulmonary nodule in the right lower lobe, that was diagnosed as small cell lung cancer following histological examination of the pulmonary tissue specimen, obtained with transbronchial biopsy. After establishing the central origin of the diabetes insipidus, its cause was revealed by magnetic resonance imaging of the brain, that demonstrated metastasis to the hypothalamic-neurohypophyseal area.

[Radio-urodynamic evaluation of stress urinary incontinence in women]. / Valutazione radio-urodinamica della incontinenza urinaria femminile da sforzo.

This work is aimed at demonstrating the validity of conventional radiological procedures, correlated with urodynamics, in the study of female urinary stress incontinence. In a study population of 110 patients with a clinical-urodynamic diagnosis of stress incontinence, radiological evaluation was performed by means of retrograde cystography, bead chain cystourethrography, and voiding cystourethrography. Radiographic findings were correlated with urodynamic data, and in particular with urethral pressure profile (functional length of the urethra, maximum closing pressure, maximum urethral pressure). In all patients the posterior urethro-vesical angle values were higher than 100 degrees; moreover, a correlation was proven to exist between an increase in the angle of front urethral inclination, the lowering and mobility of the urethrovesical junction, and the severity of urodynamic findings. Furthermore, in the different stages of urodynamic severity , urethral funneling was most frequent, and the flattening of the posterior vesical floor in voiding cystourethrography. The high reliability of the radiographic findings, although obtained by means of conventional techniques, and the variability of the morpho-dynamic results confirm the importance of a combined radiographic and urodynamic study in the evaluation of stress incontinence.

[Role of photon absorption densitometry of the bone in uremic osteodystrophy]. / Ruolo della densitometria ossea ad assorbimento fotonico nella osteodistrofia uremica.

The aim of this investigation is to evaluate the role of bone photonic densitometry in uremic osteodystrophy. Bone mineral content (BMC) and bone density (BD) have been measured in 80 hemodialyzed patients by double photonic emission densitometry. Photonic densitometry shows an higher sensibility to quantitative changes in bone mineral content than metacarpal index (IM). Photonic densitometry is unable to differentiate osteoporosis from osteomalacia; this differential diagnosis can be obtained by radiological analysis: low BD and low IM means osteoporosis, low BD and resorptive changes in cortical bone means osteomalacia and/or hyperparathyroidism. Photonic densitometry is particularly suitable for uremic osteodystrophy follow-up because of its easy repetitiveness and innocuousness and for its close correlation with iPTH variations.

[Nodular pulmonary lesions. Evaluation of the significance of the radiographic semeiotics correlated with the results of transbronchial fiberscopic pulmonary biopsy and transparietal needle aspiration]. / Lesioni polmonari nodulari. Valutazione della significatività della semeiotica radiografica in correlazione con i risultati della biopsia polmonare transbroncofibroscopica e dell'agoaspirato transparietale.

The results obtained in 148 patients affected by nodular lung lesions have been evaluated. Transbronchial pulmonary biopsies (TBPB) and/or transthoracic fine needle biopsies (NB) have been performed. Diagnostic yield of the performed procedures was 61.5% for TBPB and 91.5% for NB. Radiographic findings and their incidence rates in benign and malignant nodular lung lesions have been considered. Accuracy rate of radiographic features, evaluated by discriminant analysis, was 77.4%. Radiographic appearance has been more related to NB (87.6%) than to TBPB (72.5%).