Effect of emphysema on AI software and human reader performance in lung nodule detection from low-dose chest CT.

BACKGROUND: Emphysema influences the appearance of lung tissue in computed tomography (CT). We evaluated whether this affects lung nodule detection by artificial intelligence (AI) and human readers (HR). METHODS: Individuals were selected from the "Lifelines" cohort who had undergone low-dose chest CT. Nodules in individuals without emphysema were matched to similar-sized nodules in individuals with at least moderate emphysema. AI results for nodular findings of 30-100 mm3 and 101-300 mm3 were compared to those of HR; two expert radiologists blindly reviewed discrepancies. Sensitivity and false positives (FPs)/scan were compared for emphysema and non-emphysema groups. RESULTS: Thirty-nine participants with and 82 without emphysema were included (n = 121, aged 61 ± 8 years (mean ± standard deviation), 58/121 males (47.9%)). AI and HR detected 196 and 206 nodular findings, respectively, yielding 109 concordant nodules and 184 discrepancies, including 118 true nodules. For AI, sensitivity was 0.68 (95% confidence interval 0.57-0.77) in emphysema versus 0.71 (0.62-0.78) in non-emphysema, with FPs/scan 0.51 and 0.22, respectively (p = 0.028). For HR, sensitivity was 0.76 (0.65-0.84) and 0.80 (0.72-0.86), with FPs/scan of 0.15 and 0.27 (p = 0.230). Overall sensitivity was slightly higher for HR than for AI, but this difference disappeared after the exclusion of benign lymph nodes. FPs/scan were higher for AI in emphysema than in non-emphysema (p = 0.028), while FPs/scan for HR were higher than AI for 30-100 mm3 nodules in non-emphysema (p = 0.009). CONCLUSIONS: AI resulted in more FPs/scan in emphysema compared to non-emphysema, a difference not observed for HR. RELEVANCE STATEMENT: In the creation of a benchmark dataset to validate AI software for lung nodule detection, the inclusion of emphysema cases is important due to the additional number of FPs. KEY POINTS: • The sensitivity of nodule detection by AI was similar in emphysema and non-emphysema. • AI had more FPs/scan in emphysema compared to non-emphysema. • Sensitivity and FPs/scan by the human reader were comparable for emphysema and non-emphysema. • Emphysema and non-emphysema representation in benchmark dataset is important for validating AI.

Mucinous Adenocarcinoma of the Prostate With Normal Prostate-Specific Antigen Levels, Pulmonary Metastasis, and the Absence of Nodal Disease: A Case Report.

A 74-year-old man was suffering from nine months of perineal pain and progressive worsening of urinary symptoms including nocturia and urgency. His prostate-specific antigen (PSA) levels were 1.48 ng/mL at the time of referral. Initially, a differential diagnosis of prostatitis or seminal vesicle inflammation was made, and four weeks of antibiotics were prescribed, which were later extended to six weeks due to failure of symptoms to resolve. Magnetic resonance imaging (MRI) of the prostate was then conducted. The impression was that there was ejaculatory duct obstruction caused by enlarged seminal vesicles with no evidence of significant prostate cancer. The prostate-specific antigen density (PSAd) was 0.04, and the prostate imaging reporting and data system (PIRADS) score was I-II. A CT chest with contrast was conducted for further investigation of pulmonary nodules found on the CT urogram. It revealed multiple calcified pulmonary nodules which were suspicious of malignancy. A CT-guided biopsy of one of the pulmonary nodules was taken, and histopathological analysis revealed a mucinous adenocarcinoma. A transurethral resection of the prostate (TURP) was then performed. Histopathological analysis of the prostatic surgical specimen revealed invasive mucinous adenocarcinoma. Based on the findings, a diagnosis of mucinous adenocarcinoma of the prostate with atypical lung metastasis without osseous or regional lymph node involvement was made, stage T4 N0 M1a. The patient is currently on a treatment regimen consisting of carboplatin, pemetrexed, and pembrolizumab.

Shape-Sensing Robotic-Assisted Bronchoscopy in the Multiple Pulmonary Nodule Diagnosis during a Single Anesthetic Event.

INTRODUCTION: The widespread use of computed tomography as a screening tool for early lung cancer has increased detection of pulmonary lesions. It is common to encounter patients with more than one peripheral pulmonary nodule (PPN) of uncertain etiology. Shape-sensing robotic-assisted bronchoscopy (ssRAB) emerges as a potential alternative to biopsy multiple PPN, in addition to mediastinal staging in single anesthetic procedure. METHODS: This is a single-center, retrospective review of 22 patients who underwent ssRAB for evaluation of two or more PPN, between November 2021 and April 2023 at Mayo Clinic, FL, USA. RESULTS: A total of 46 PPNs were biopsied in 22 patients. All lesions were ≤2 cm with a median minimum and maximum cross-sectional lesion size of 1.40 cm and 1.05 cm, respectively. Diagnostic yield was 86.9% (n = 40), and target reach was 91.3% (n = 42). Most lesions were in the upper lobes, a solid pattern was found in 78.3% (n = 36), bronchus sign was present in 82.6% of cases (n = 38), 54.4% (n = 25) were malignant nodules, and 32.6% (n = 15) were benign. Fourteen patients had at least one malignant lesion out of two or more nodules sampled, and 10 patients had a malignant diagnosis for all sampled lesions. The complication rate was 9% (n = 2) with one case of bleeding and one of pneumothorax. CONCLUSION: This study is, to our knowledge, the first to assess the use and safety of ssRAB for diagnosis of multiple PPN in a single anesthetic event. This procedure will mainly impact management decisions and subsequently shorten the time from diagnosis to treatment.

Multiple pulmonary nodules with diffuse idiopathic pulmonary neuroendocrine cell hyperplasia and minute pulmonary meningothelial-like nodules.

A 78-year-old woman presented with multiple pulmonary nodules, mixed with solid and ground-glass nodules. We pathologically confirmed that the multiple pulmonary nodules were a combination of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) and multiple pulmonary meningothelial-like nodules (MPMNs). This is the first case report of concurrent DIPNECH and MPMNs.

Enhancing a deep learning model for pulmonary nodule malignancy risk estimation in chest CT with uncertainty estimation.

OBJECTIVE: To investigate the effect of uncertainty estimation on the performance of a Deep Learning (DL) algorithm for estimating malignancy risk of pulmonary nodules. METHODS AND MATERIALS: In this retrospective study, we integrated an uncertainty estimation method into a previously developed DL algorithm for nodule malignancy risk estimation. Uncertainty thresholds were developed using CT data from the Danish Lung Cancer Screening Trial (DLCST), containing 883 nodules (65 malignant) collected between 2004 and 2010. We used thresholds on the 90th and 95th percentiles of the uncertainty score distribution to categorize nodules into certain and uncertain groups. External validation was performed on clinical CT data from a tertiary academic center containing 374 nodules (207 malignant) collected between 2004 and 2012. DL performance was measured using area under the ROC curve (AUC) for the full set of nodules, for the certain cases and for the uncertain cases. Additionally, nodule characteristics were compared to identify trends for inducing uncertainty. RESULTS: The DL algorithm performed significantly worse in the uncertain group compared to the certain group of DLCST (AUC 0.62 (95% CI: 0.49, 0.76) vs 0.93 (95% CI: 0.88, 0.97); p < .001) and the clinical dataset (AUC 0.62 (95% CI: 0.50, 0.73) vs 0.90 (95% CI: 0.86, 0.94); p < .001). The uncertain group included larger benign nodules as well as more part-solid and non-solid nodules than the certain group. CONCLUSION: The integrated uncertainty estimation showed excellent performance for identifying uncertain cases in which the DL-based nodule malignancy risk estimation algorithm had significantly worse performance. CLINICAL RELEVANCE STATEMENT: Deep Learning algorithms often lack the ability to gauge and communicate uncertainty. For safe clinical implementation, uncertainty estimation is of pivotal importance to identify cases where the deep learning algorithm harbors doubt in its prediction. KEY POINTS: • Deep learning (DL) algorithms often lack uncertainty estimation, which potentially reduce the risk of errors and improve safety during clinical adoption of the DL algorithm. • Uncertainty estimation identifies pulmonary nodules in which the discriminative performance of the DL algorithm is significantly worse. • Uncertainty estimation can further enhance the benefits of the DL algorithm and improve its safety and trustworthiness.

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.

Pathological diagnosis and immunohistochemical analysis of minute pulmonary meningothelial-like nodules: A case report.

BACKGROUND: Minute Pulmonary Meningothelial-like Nodules (MPMNs) are rare benign pulmonary nodules, which are more common in elderly women and have a higher detection rate in lung tissues of patients with lung malignant diseases. Its origin is not yet clear. At present, there are few reports on the diagnostic methods such as imaging and pathological manifestations of MPMNs. This article reports a 70-year-old female patient with pulmonary adenocarcinoma combined with MPMNs and reviews of the relevant literature. CASE SUMMARY: A 70-year-old women was admitted to our institution with feeling sour in her back and occasional cough for more than 2 mo. Computerized electronic scanning scan and 3D reconstruction images in our institution showed there were multiple ground-glass nodules in both of her two lungs. The biggest one was in the apicoposterior segment of left upper lobe, about 2.5 mm × 9 mm in size. We performed thoracoscopic resection of the left upper lung apicoposterior segment of the patient, and the final pathological report was minimally invasive adenocarcinoma. Re-examination of high resolution computed tomography 21 mo after surgery showed multiple ground-glass nodules in both lungs, and a new ground-glass nodule was found in the superior segment of the right lower lobe. We took pathological biopsy of the right upper lung and right lower lung nodules for the patient under thoracoscopy. The histomorphology of the right lower lobe nodule showed multiple lesions in the lung tissue, and the small foci in the alveolar septum were distributed in mild form of the aggregation of short spindle cells. The immunohistochemistry showed that the lesion was epithelial membrane antigen (EMA) (+), somatostatin receptor 2a (SSTR2a) (+), S-100 (-), chromogranin A (-), Syn (-), cytokeratin (-) and HMB-45 (-). The final diagnosis was minimally invasive adenocarcinoma, accompanied by MPMNs. We recommend that patients continue to receive treatment after surgery and to do regular follow-up observations. CONCLUSION: The imaging manifestations of MPMNs are atypical, histomorphology and immunohistochemistry can assist in its diagnosis. This article reviews the relevant literature of MPMNs immunohistochemistry and shows that MPMNs are positive for EMA, SSTR2a, and progesterone receptor.

[Feasibility and safety of one-stage bilateral video-assisted thoracic surgery for resection of bilateral multiple pulmonary nodules].

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.

Trends in the incidence of pulmonary nodules in chest computed tomography: 10-year results from two Dutch hospitals.

OBJECTIVE: To study trends in the incidence of reported pulmonary nodules and stage I lung cancer in chest CT. METHODS: We analyzed the trends in the incidence of detected pulmonary nodules and stage I lung cancer in chest CT scans in the period between 2008 and 2019. Imaging metadata and radiology reports from all chest CT studies were collected from two large Dutch hospitals. A natural language processing algorithm was developed to identify studies with any reported pulmonary nodule. RESULTS: Between 2008 and 2019, a total of 74,803 patients underwent 166,688 chest CT examinations at both hospitals combined. During this period, the annual number of chest CT scans increased from 9955 scans in 6845 patients in 2008 to 20,476 scans in 13,286 patients in 2019. The proportion of patients in whom nodules (old or new) were reported increased from 38% (2595/6845) in 2008 to 50% (6654/13,286) in 2019. The proportion of patients in whom significant new nodules (≥ 5 mm) were reported increased from 9% (608/6954) in 2010 to 17% (1660/9883) in 2017. The number of patients with new nodules and corresponding stage I lung cancer diagnosis tripled and their proportion doubled, from 0.4% (26/6954) in 2010 to 0.8% (78/9883) in 2017. CONCLUSION: The identification of incidental pulmonary nodules in chest CT has steadily increased over the past decade and has been accompanied by more stage I lung cancer diagnoses. CLINICAL RELEVANCE STATEMENT: These findings stress the importance of identifying and efficiently managing incidental pulmonary nodules in routine clinical practice. KEY POINTS: • The number of patients who underwent chest CT examinations substantially increased over the past decade, as did the number of patients in whom pulmonary nodules were identified. • The increased use of chest CT and more frequently identified pulmonary nodules were associated with more stage I lung cancer diagnoses.

[Clinical diagnosis and treatment of multiple pulmonary nodules].

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.

A case of idiopathic multicentric Castleman disease with pulmonary hyalinizing granuloma-like multiple pulmonary nodules.

A 41-year-old man presented with chronic cough and chest pain. Laboratory tests revealed anemia, inflammation, hypoalbuminemia, polyclonal hypergammaglobulinemia, and elevated interleukin-6 levels. Computed tomography revealed diffuse bilateral pulmonary nodules and multicentric lymphadenopathy. Histopathology of the pulmonary nodule resembled pulmonary hyalinizing granuloma (PHG), whereas lymph node histopathology was consistent with idiopathic multicentric Castleman disease (iMCD). The patient was diagnosed with iMCD involving PHG-like pulmonary nodules. Little is known about the association between these two diseases, and the present case provides insights regarding the relationship between PHG and iMCD.

Robustness of pulmonary nodule radiomic features on computed tomography as a function of varying radiation dose levels-a multi-dose in vivo patient study.

OBJECTIVE: Analysis of textural features of pulmonary nodules in chest CT, also known as radiomics, has several potential clinical applications, such as diagnosis, prognostication, and treatment response monitoring. For clinical use, it is essential that these features provide robust measurements. Studies with phantoms and simulated lower dose levels have demonstrated that radiomic features can vary with different radiation dose levels. This study presents an in vivo stability analysis of radiomic features for pulmonary nodules against varying radiation dose levels. METHODS: Nineteen patients with a total of thirty-five pulmonary nodules underwent four chest CT scans at different radiation dose levels (60, 33, 24, and 15 mAs) in a single session. The nodules were manually delineated. To assess the robustness of features, we calculated the intra-class correlation coefficient (ICC). To visualize the effect of milliampere-second variation on groups of features, a linear model was fitted to each feature. We calculated bias and calculated the R2 value as a measure of goodness of fit. RESULTS: A small minority of 15/100 (15%) radiomic features were considered stable (ICC > 0.9). Bias increased and R2 decreased at lower dose, but shape features seemed to be more robust to milliampere-second variations than other feature classes. CONCLUSION: A large majority of pulmonary nodule radiomic features were not inherently robust to radiation dose level variations. For a subset of features, it was possible to correct this variability by a simple linear model. However, the correction became increasingly less accurate at lower radiation dose levels. CLINICAL RELEVANCE STATEMENT: Radiomic features provide a quantitative description of a tumor based on medical imaging such as computed tomography (CT). These features are potentially useful in several clinical tasks such as diagnosis, prognosis prediction, treatment effect monitoring, and treatment effect estimation. KEY POINTS: • The vast majority of commonly used radiomic features are strongly influenced by variations in radiation dose level. • A small minority of radiomic features, notably the shape feature class, are robust against dose-level variations according to ICC calculations. • A large subset of radiomic features can be corrected by a linear model taking into account only the radiation dose level.

Lung nodule pre-diagnosis and insertion path planning for chest CT images.

Medical image processing has proven to be effective and feasible for assisting oncologists in diagnosing lung, thyroid, and other cancers, especially at early stage. However, there is no reliable method for the recognition, screening, classification, and detection of nodules, and even deep learning-based methods have limitations. In this study, we mainly explored the automatic pre-diagnosis of lung nodules with the aim of accurately identifying nodules in chest CT images, regardless of the benign and malignant nodules, and the insertion path planning of suspected malignant nodules, used for further diagnosis by robotic-based biopsy puncture. The overall process included lung parenchyma segmentation, classification and pre-diagnosis, 3-D reconstruction and path planning, and experimental verification. First, accurate lung parenchyma segmentation in chest CT images was achieved using digital image processing technologies, such as adaptive gray threshold, connected area labeling, and mathematical morphological boundary repair. Multi-feature weight assignment was then adopted to establish a multi-level classification criterion to complete the classification and pre-diagnosis of pulmonary nodules. Next, 3-D reconstruction of lung regions was performed using voxelization, and on its basis, a feasible local optimal insertion path with an insertion point could be found by avoiding sternums and/or key tissues in terms of the needle-inserting path. Finally, CT images of 900 patients from Lung Image Database Consortium and Image Database Resource Initiative were chosen to verify the validity of pulmonary nodule diagnosis. Our previously designed surgical robotic system and a custom thoracic model were used to validate the effectiveness of the insertion path. This work can not only assist doctors in completing the pre-diagnosis of pulmonary nodules but also provide a reference for clinical biopsy puncture of suspected malignant nodules considered by doctors.

Ultrasound-Guided Bilateral Sequential Thoracic Paravertebral Block for Simultaneous Bilateral Uniportal Video-Assisted Thoracoscopic Surgery: Study Protocol for a Randomized Controlled Trial.

Purpose: Simultaneous bilateral pulmonary resection via uniportal video-assisted thoracoscopic surgery (UVATS) was safe and feasible for the treatment of bilateral multiple pulmonary nodules. But, it should be noted that considerable postoperative pain at the bilateral surgical site was a crucial issue. The safety and efficacy of bilateral thoracic paravertebral block (TPVB) have been reported for postoperative analgesia. But, whether bilateral sequential TPVB can be safely and effectively used in simultaneous bilateral UVATS remains unknown. Therefore, this study aimed to determine the analgesic efficacy and safety of bilateral sequential TPVB after simultaneous bilateral UVATS. Study Design and Methods: In this study, 80 participants scheduled for UVATS will be randomly allocated to the bilateral sequential TPVB group (G2) and the control group (G1). The patient of G2 will be performed bilateral TPVB at 2 time-points: before the start of the first side of pulmonary resection and before the start of the contralateral pulmonary resection. G1 will only receive standard analgesia protocol. The primary outcome is the numeric rating scale score during coughing at 24 h postoperatively. The secondary outcomes include the Prince Henry Pain Score scores, sufentanil consumption, postoperative nausea and vomiting, levels of inflammatory factors, and the Quality of Recovery-40 scores at different time points, as well as chronic pain at postoperative day (POD) 90. Discussion: This is the first prospective trial to determine the safety and effectiveness of ultrasound-guided bilateral sequential TPVB for postoperative analgesia following simultaneous bilateral UVATS. This study also intended to evaluate the effect of this intervention on postoperative quality of recovery and inflammation levels. The final results will provide clinical evidence related to bilateral sequential TPVB, and promote the application of that acting as a more appropriate analgesic method for simultaneous bilateral UVATS.

Case report: identification of EGFR R776H and FANCE R381H germline mutations in a patient with multiple pulmonary nodules.

Pulmonary nodules evaluation is clinically crucial because they may be the early predictors of lung cancer. Except for CT screening and serum tumor biomarkers testing, genetic alteration analysis by next-generation sequencing (NGS) technology can also help to find cancer earlier. In this study, we report a case of multiple pulmonary nodules patient with EGFR R776H and FANCE R381H germline mutations. Her father, paternal aunt, and elder uncle harbored either one or both two mutations and were found with multiple pulmonary ground-glass or sub-solid nodules. Her 7-year-old daughter also inherited the same two mutations.

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.

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.

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.