Idiopathic Pulmonary Fibrosis: Data-driven Textural Analysis of Extent of Fibrosis at Baseline and 15-Month Follow-up.

Purpose To evaluate associations between pulmonary function and both quantitative analysis and visual assessment of thin-section computed tomography (CT) images at baseline and at 15-month follow-up in subjects with idiopathic pulmonary fibrosis (IPF). Materials and Methods This retrospective analysis of preexisting anonymized data, collected prospectively between 2007 and 2013 in a HIPAA-compliant study, was exempt from additional institutional review board approval. The extent of lung fibrosis at baseline inspiratory chest CT in 280 subjects enrolled in the IPF Network was evaluated. Visual analysis was performed by using a semiquantitative scoring system. Computer-based quantitative analysis included CT histogram-based measurements and a data-driven textural analysis (DTA). Follow-up CT images in 72 of these subjects were also analyzed. Univariate comparisons were performed by using Spearman rank correlation. Multivariate and longitudinal analyses were performed by using a linear mixed model approach, in which models were compared by using asymptotic χ2 tests. Results At baseline, all CT-derived measures showed moderate significant correlation (P < .001) with pulmonary function. At follow-up CT, changes in DTA scores showed significant correlation with changes in both forced vital capacity percentage predicted (ρ = -0.41, P < .001) and diffusing capacity for carbon monoxide percentage predicted (ρ = -0.40, P < .001). Asymptotic χ2 tests showed that inclusion of DTA score significantly improved fit of both baseline and longitudinal linear mixed models in the prediction of pulmonary function (P < .001 for both). Conclusion When compared with semiquantitative visual assessment and CT histogram-based measurements, DTA score provides additional information that can be used to predict diminished function. Automatic quantification of lung fibrosis at CT yields an index of severity that correlates with visual assessment and functional change in subjects with IPF. © RSNA, 2017.

CT Imaging Phenotypes of Pulmonary Fibrosis in the MUC5B Promoter Site Polymorphism.

BACKGROUND: To determine the effect of the MUC5B promoter polymorphism (rs35705950) on the CT imaging appearance of pulmonary fibrosis. METHODS: High-resolution CT scans of 1,764 subjects were scored as part of a, genomewide association study with institutional review board approval; 1,491 of these had pulmonary fibrosis on CT scans and were included in the study. Two thoracic radiologists independently scored CT scans systematically. Discrepancies were resolved by a third thoracic radiologist. All patients were genotyped specifically for the rs35705950 single-nucleotide polymorphism (SNP). Two-tailed Fisher exact or χ(2) tests and Student t tests or Mann-Whitney U tests were used to compare proportions and means, respectively. RESULTS: The major and minor alleles at the rs35705950 SNP are guanine (G) and thymine (T), respectively: 514 were homozygous for the major allele (G group), and 977 were heterozygous or homozygous for the minor allele (T group). The G group had a higher proportion than the T group with ground-glass opacity (62.1% vs 54.2%; P = .04). There was no significant difference between the G and T groups regarding presence of honeycombing. The T group showed a significantly higher subpleural axial distribution of fibrosis than did the G group (62.3% vs 42.2%; P < .0001). The T group showed a lower proportion of diagnoses inconsistent with usual interstitial pneumonitis (UIP; 20.3% compared with 30.5% for the G group) and a greater proportion of confident (probable UIP and UIP) UIP diagnoses (43.8% compared with 32.6% for the G group). CONCLUSIONS: The MUC5B promoter polymorphism identifies a pattern of fibrosis that is different from other causes of fibrosis and may respond differently to potential therapies.

Clinical findings and outcomes in patients with possible usual interstitial pneumonia.

BACKGROUND: Patients with possible usual interstitial pneumonia (UIP) constitute a substantial group, and their clinical characteristics and outcomes are not well defined. We compared the clinical characteristics and survival between patients with possible UIP and the UIP pattern. METHODS: We evaluated 62 patients with possible UIP and 544 patients with the UIP pattern. Both groups were diagnosed by clinical characteristics and high-resolution computed tomography (HRCT) findings. Two radiologists performed radiological evaluation based on the new idiopathic pulmonary fibrosis (IPF) guidelines. Two risk-stratification methods were used to compare UIP pattern and possible UIP patients. RESULTS: The groups had similar demographic and clinical characteristics. Pulmonary function tests revealed no significant differences in lung volumes between the 2 groups. However, DLCO was significantly lower with the UIP pattern than with possible UIP (p = 0.004). Multivariate analysis showed age, sex, and carbon monoxide diffusing capacity (DLCO) as important independent variables for survival. The UIP HRCT pattern did not affect survival (hazard ratio, 0.83; 95% confidence interval, 0.51-1.24; p = 0.32). Possible UIP was not associated with prognosis when independent predictors for survival rate and propensity score were considered. In the case-control study, the 3-year survival rate was 44.6% in the UIP pattern group and 56.8% in the possible UIP group (p = 0.16). CONCLUSIONS: Clinical characteristics and outcomes were similar in possible UIP and UIP patients, except for differences in DLCO. The UIP pattern itself did not affect survival.

Small airway-centered granulomatosis caused by long-term exposure to polytetrafluoroethylene.

To date, there have been no reports of chronic pulmonary granulomatosis associated with exposure to polytetrafluoroethylene (PTFE). Here, we report three cases of small airway-centered granulomatous lesions in workers employed at facilities that apply coatings to pans and other utensils. The workers were repeatedly exposed to PTFE particles that were probably generated by the drying process when PTFE coatings are dried in a convection oven at high temperatures (380-420 °C). The duration of inhalational PTFE exposure was between 7 and 20 years. We found granulomatous lung lesions around the small airways in lung biopsy specimens obtained from the workers. Scanning electron microscopy/energy-dispersive x-ray spectroscopy analysis was performed focusing on areas where the PTFE particles were suspected to be located in macrophages. The scanning electron microscopy/energy-dispersive x-ray spectroscopy analyses revealed fluorine in the particles. Lung tissue samples from all cases were analyzed using a fully automated Fourier transform infrared spectrometer. Analysis of the spectrum extracted from the position of the foreign particles enabled precise identification of the foreign bodies as PTFE. Fourier transform infrared revealed that all of the lung tissue samples had bands at 1,202 to 1,148 cm(-1) and 1,202 to 1,146 cm(-1), which are characteristic of the asymmetric and symmetric stretching vibrations of the C-F bonds of PTFE. These cases suggest that recurrent inhalational exposure to PTFE particles causes chronic pulmonary granulomatosis.

Leukocytes and systemic inflammatory response syndrome as prognostic factors in pulmonary embolism patients.

BACKGROUND: Hemodynamic status and cardiac function are important factors for predicting pulmonary embolism (PE) prognosis. Although inflammation is considered a risk factor for deep vein thrombosis, the prognostic significance of both systemic inflammatory response syndrome (SIRS) and leukocytosis has not been elucidated. This study evaluates PE prognostic factors, including SIRS and leukocytes. METHODS: This retrospective cohort study included 667 PE patients. Risk evaluation included SIRS and leukocytosis. A prediction model was developed based on independent predictors of 30-day mortality. RESULTS: Fifty-seven patients (8.5%) died within 30 days of PE. Multivariate analysis showed that SIRS satisfying the WBC criteria (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.5-5.4), altered mental status (OR, 4.0; 95% CI, 1.8-8.7), shock (OR, 2.6; 95% CI, 1.0-7.1), and right-to-left ventricle diameter ratio (OR, 1.7; 95% CI, 1.0-2.8) were associated with 30-day mortality. SIRS criteria, including body temperature (OR, 4.6; 95% CI, 1.4-14.8), heart rate (OR, 2.0; 95% CI, 1.1-3.6), respiratory rate (OR, 2.5; 95% CI, 1.4-4.6), and white blood cells (WBC) count (OR, 1.9; 95% CI, 1.2-3.5) predicted short-term mortality following PE. The area under the receiver operating characteristic curve for the prognostic model performance was 0.76 (95% CI, 0.66-0.85); pulmonary embolism severity index (PESI) and PESI + WBC count were 0.72 (95% CI, 0.68-0.75) and 0.76 (95% CI, 0.72-0.79, P < 0.001 versus PESI), respectively. CONCLUSIONS: Leukocytosis and SIRS are important factors in determining short-term outcomes in PE patients.

Isolated cervical lymph node sarcoidosis presenting in an asymptomatic neck mass: a case report.

Sarcoidosis, a systemic granulomatous disease of unknown etiology. The presentation of sarcoidal granuloma in neck nodes without typical manifestations of systemic sarcoidosis is difficult to diagnose. We describe the case of a 37-year-old woman with an increasing mass on the right side of neck. The excisional biopsy from the neck mass showed noncaseating epithelioid cell granuloma of the lymph nodes. No evidence of mycobacterial or fungal infection was noted. Thoracic evaluations did not show enlargement of mediastinal lymph nodes or parenchymal abnormalities. Immunohistochemistry showed abundant expression of tumor necrosis factor-α in the granuloma. However, transforming growth factor-ß was not expressed, although interleukin-1ß was focally expressed. These immunohistochemical findings supported characterization of the granuloma and the diagnosis of sarcoidosis. Sarcoidosis can present with cervical lymph node enlargement without mediastinal or lung abnormality. Immunohistochemistry may support the diagnosis of sarcoidosis and characterization of granuloma.

Acute respiratory distress due to methane inhalation.

Inhalation of toxic gases can lead to pneumonitis. It has been known that methane gas intoxication causes loss of consciousness or asphyxia. There is, however, a paucity of information about acute pulmonary toxicity from methane gas inhalation. A 21-year-old man was presented with respiratory distress after an accidental exposure to methane gas for one minute. He came in with a drowsy mentality and hypoxemia. Mechanical ventilation was applied immediately. The patient's symptoms and chest radiographic findings were consistent with acute pneumonitis. He recovered spontaneously and was discharged after 5 days without other specific treatment. His pulmonary function test, 4 days after methane gas exposure, revealed a restrictive ventilatory defect. In conclusion, acute pulmonary injury can occur with a restrictive ventilator defect after a short exposure to methane gas. The lung injury was spontaneously resolved without any significant sequela.

Male predominance of pneumonia and hospitalization in pandemic influenza A (H1N1) 2009 infection.

BACKGROUND: Pandemic influenza A (H1N1) disproportionately affects different age groups. The purpose of the current study was to describe the age and gender difference of pandemic influenza A (H1N1) cases that lead to pneumonia, hospitalization or ICU admission. METHODS: Data were collected retrospectively between May 2009 and December 2009. All of the diagnoses of H1N1 were confirmed by real-time reverse-transcription polymerase chain reaction (RT-PCR). RESULTS: During the study period there were 3402 cases of RT-PCR positive H1N1, among which 1812 were males and 1626 were adults (> 15 years of age). 6% (206/3402) of patients required hospitalization, 3.6% (122/3402) had infiltrates on chest radiographs, and 0.70% (24/3402) were admitted to intensive care unit (ICU). The overall fatality rate was 0.1% (4/3402). The rate of hospitalization was sharply increased in patients ≥ 50 years of age especially in male. Out of 122 pneumonia patients, 68.8% (84 patients) were male. Among the patients admitted to the ICU, 70.8% (17 patients) were male. Approximately 1 of 10 H1N1-infected patients admitted to the ICU were ≥ 70 years of age. CONCLUSIONS: Among the confirmed cases of H1N1, the ICU admission rate was < 1% and the case fatality rate was 0.1%. Male had a significantly higher rate of pneumonia and hospital admission. These findings should be taken into consideration when developing vaccination and treatment strategies.

Myopericytoma of the neck: sonographic appearance and sonographically guided needle biopsy.

We report the imaging and pathologic findings of a case of myopericytoma of the neck in a 70-year-old woman, which was diagnosed by ultrasound-guided core-needle biopsy. The mass demonstrated homogeneous intense enhancement on contrast-enhanced CT and was markedly hypervascular on power Doppler sonography. The histopathological findings of the core biopsy were consistent with myopericytoma.

Estimated incidence of acute pulmonary embolism in a Korean hospital.

Patients with acute pulmonary embolism (PE) were identified retrospectively from patients hospitalized during a 2-year period from 2005 to 2007. Among adult patients (≥20 years), the incidence of established acute PE was 88 (0.17%) of 50 882 in Dongsan Hospital. The incidence of acute PE at Dongsan Hospital was 26% lower than that at Henry Ford Hospital (P < .01). Among patients more than 50 years of age, PE was more frequent in women (0.32%; 95% CI, 0.24-0.4) than in men (0.15%; 95% CI, 0.1-0.21; P < .01). Among all patients with PE older than 20 years of age, 68 (0.21%) of 31 869 (95% CI, 0.17-0.26) were from the medical service and 18 (0.08%) of 23 139 (95% CI, 0.04-0.11; P < .01) were from the surgical service. The estimated incidence of PE in a university teaching hospital in Korea was 0.17%, it was about two thirds of that in North America.

Azygos Vein Aneurysm - A Case for Elective Resection by Video-assisted Thoracic Surgery.

An azygos vein aneurysm is a very rare cause of a posterior mediastinal mass. Once the diagnosis has been confirmed, no treatment is usually required. However, the aneurysm can thrombose, and this may lead pulmonary thromboembolism, or the aneurysm may rupture. In these instances, the excision of the mass is recommended. Video-assisted thoracic surgery techniques have considerably improved. If it is necessary to remove the aneurysm, video-assisted thoracic surgery may be a good option for surgical treatment. We report a case of an aneurysm of the azygos arch that was successfully resected by video-assisted thoracic surgery.

Hürthle cell neoplasm: correlation of gray-scale and power Doppler sonographic findings with gross pathology.

BACKGROUND: To describe gray-scale and power Doppler (PD) sonographic (US) findings of Hürthle cell neoplasms (HCNs) of the thyroid gland, and to determine if there is any correlation between US and gross pathologic features. METHOD: This retrospective study included 30 pathologically proven HCNs in 30 subjects who underwent preoperative gray-scale and PD US examinations. The size, shape, margin, echogenicity, echotexture, presence or absence of cystic change, calcifications and halo sign, and vascularity at PD US were evaluated. RESULT: The longest diameter of HCNs ranged from 12 mm to 63 mm. The shape and margins of the mass were ovoid and smooth, respectively, in all cases. The echogenicity was hypoechoic, isoechoic, hyperechoic, or mixed in 43.3%, 33.3%, 10.0%, and 13.3%, respectively. The echotexture was heterogeneous in 73.3% and homogeneous in 26.7%. Cystic change was present in 56.7% and involved less than 25% of the volume of the mass in 50.0% and 26-50% of the volume in 6.7%. Coarse calcifications were present in 20.0%. Halo sign was present in all cases. The vascularity was combined peri- and intranodular in all cases: predominantly intranodular in 50.0%, predominantly perinodular in 46.7%, and of the "inferno" type in 3.3%. All HCNs were encapsulated on gross pathologic examination. CONCLUSION: Although many of the US features we observed were nonspecific, HCNs tend to have a halo sign and combined peri- and intranodular vascularity on US, which raises the possibility of an association. The US halo sign corresponds to tumor capsule ongross pathologic examination.

Follicular thyroid adenoma with eggshell calcification presenting as an intensely hypermetabolic lesion on 18F-FDG PET/CT.

We report herein a case of follicular thyroid adenoma with an eggshell calcification presenting as an intensely hypermetabolic lesion on combined (18)F-fluorodeoxyglucose whole-body PET and CT ((18)F-FDG PET/CT) performed for staging work-up in a 68-year-old woman who had undergone distal gastrectomy with Billroth II anastomosis for early gastric carcinoma. The mass was intensely hypermetabolic (SUV(max) = 21.3 g/mL) on combined (18)F-FDG PET/CT, hypoechoic with an interrupted eggshell calcification on gray-scale ultrasonography (US), and showed intranodular vascularity on power Doppler US. Follicular adenoma should be considered in the differential diagnosis of a mass with an eggshell calcification on US and intense hypermetabolism on (18)F-FDG PET/CT.

A case of aortopulmonary fistula caused by a huge thoracic aortic aneurysm.

Aortopulmonary fistula is an uncommon but often fatal condition resulting as a late complication of an aortic aneurysm. The most common cause is erosion of a false aneurysm of the descending thoracic aorta into the pulmonary artery, resulting in the development of a left-to-right shunt and leading to acute pulmonary edema and right heart failure. We report an our experience with aortopulmonary fistula as a rare complication associated with thoracic aortic aneurysm and high output heart failure.

Follicular thyroid carcinoma with an eggshell calcification: report of 3 cases.

OBJECTIVE: The purpose of this series is to report 3 cases of follicular thyroid carcinoma with an eggshell calcification along with their imaging findings. METHODS: Imaging findings on gray scale and power Doppler (PD) sonography (n = 3), computed tomography (CT; n = 3), and integrated fluorodeoxyglucose F 18 ((18)F-FDG) whole-body positron emission tomography (PET)/CT (n = 1) were assessed. RESULTS: Of the 3 cases, two 75-year-old women had bone metastasis, and one 54-year-old woman had a thyroid incidentaloma on sonography. All 3 cases had a spherical mass with an interrupted eggshell calcification on gray scale sonography and CT; 2 revealed intranodular vascularity on PD sonography, and 1 showed intense hypermetabolism (maximum standardized uptake value, 7.9 g/mL) on integrated (18)F-FDG whole-body PET/CT. CONCLUSIONS: Follicular carcinoma should be considered in the differential diagnosis of a thyroid nodule with an eggshell calcification.

Parotid incidentaloma identified by combined 18F-fluorodeoxyglucose whole-body positron emission tomography and computed tomography: findings at grayscale and power Doppler ultrasonography and ultrasound-guided fine-needle aspiration biopsy or core-needle biopsy.

Twelve parotid incidentalomas in 10 consecutive subjects (nine with a known malignancy elsewhere and one presumptively healthy subject) identified by combined 18F-fluorodeoxyglucose whole-body positron emission tomography and computed tomography (18F-FDG PET/CT) were investigated, with the aim of calculating maximum standardized uptake value (SUV(max)) of each FDG-avid focus, and identifying corresponding sonographic and pathologic findings. The results of ultrasound-guided fine-needle aspiration biopsy (FNAB) (n = 9) and core-needle biopsy (CNB) (n = 3) were Warthin tumor in 10 cases, and pleomorphic adenoma and chronic inflammation in one each. SUV(max) was 7.0-21.0 g/mL (average 13.7 g/mL) for Warthin tumor, 6.8 g/mL for pleomorphic adenoma, and 7.3 g/mL for chronic inflammation. Each FDG-avid focus corresponded to ovoid (n = 11) or lobulated (n = 1) hypoechoic mass on grayscale ultrasonography (US) and hypervascular mass, except one with chronic inflammation, on power Doppler (PD) US. Parotid incidentaloma identified by 18F-FDG PET/CT during workup of various malignancies elsewhere does not necessarily signify primary or metastatic malignancy, but indicates a high likelihood of benign lesions, particularly Warthin tumor. Such lesions should be evaluated thoroughly by US and ultrasound-guided FNAB or CNB if parotid disease would change the patient's treatment plan.