Spectrum of pleuropulmonary paragonimiasis: An analysis of 685 cases diagnosed over 22 years.

OBJECTIVES: Paragonimiasis is a global foodborne zoonosis. Overlapping clinical and imaging features with other lung pathologies hamper correct diagnosis and require differential diagnosis. METHODS: During 1982-2003, 49,012 samples were referred for immunodiagnosis of helminthiases. We detected paragonimiasis cases by enzyme-linked immunosorbent assay (ELISA). We assessed clinical, radiographical and laboratory characteristics, and diagnostic dilemmas associated with delayed diagnosis. RESULTS: We analyzed 685 pleuropulmonary paragonimiasis cases. ELISA-positive was 665. Eggs were detected in 50. Symptom duration correlated well with the appearance of chest radiographs; 359 pleural, 33 pleuroparenchymal, and 264 parenchymal lesions (P < 0.001). Twenty-nine had normal chest images. Eosinophilia, seen in 304, was common in pleural and pleuroparenchymal patients (P < 0.05). Chest pain and dyspnea were characteristic for pleurisy patients. Sputum (odds ratios [OR]: 6.79; 95% CI: 4.41-10.47), blood-tinged sputum (OR: 5.62; 95% CI: 3.75-8.42), and foul-odor (OR: 2.70; 95% CI: 1.42-5.16) were significant in parenchymal patients. Delayed diagnosis (119) for ≥ 25 weeks was attributed mainly to misdiagnosis as tuberculosis, malignancy, or chronic obstructive pulmonary disease (COPD) (OR: 111.75; 95% CI: 43.25-288.74). CONCLUSIONS: Variable symptoms and radiographs of pleuropulmonary paragonimiasis depended on the stage of infection. Suspicion of tuberculosis, malignancy, or COPD was major cause of delayed diagnosis.

Inter-observer agreement in identifying traction bronchiectasis on computed tomography: its improvement with the use of the additional criteria for chronic fibrosing interstitial pneumonia.

PURPOSE: To assess inter-observer variability in identifying traction bronchiectasis on computed tomography (CT) using additional criteria for chronic fibrosing interstitial pneumonia. METHODS: Seven experts categorized CT image set representing 39 patients into three groups on the basis of the presence of traction bronchiectasis, using a three-point scale: 3-definitely/probably yes; 2-possibly yes; and 1-definitely/probably no. This scale served as a reference standard. The image set included cases of chronic fibrosing interstitial pneumonia, non-interstitial lung disease, and difficult-to-determine cases. Forty-eight observers similarly assessed the same image set, first according to the Fleischner Society definition, and second with additional criteria, in which traction bronchiectasis was observed exclusively in chronic fibrosing interstitial pneumonia. The agreement level between the reference standard and each observer's evaluation in each session was calculated using weighted kappa values which were compared between the two sessions using a paired t test. RESULTS: The mean weighted kappa value for all observers was significantly higher in the second reading session (mean 0.75) than in the first reading session (mean 0.62) (p < 0.001). CONCLUSION: Inter-observer agreement in identifying traction bronchiectasis improves when using the additional criteria which specify chronic fibrosing interstitial pneumonia as the underlying disease.

Tree-in-Bud Pattern of Pulmonary Tuberculosis on Thin-Section CT: Pathological Implications.

The "tree-in-bud-pattern" of images on thin-section lung CT is defined by centrilobular branching structures that resemble a budding tree. We investigated the pathological basis of the tree-in-bud lesion by reviewing the pathological specimens of bronchograms of normal lungs and contract radiographs of the post-mortem lungs manifesting active pulmonary tuberculosis. The tree portion corresponds to the intralobular inflammatory bronchiole, while the bud portion represents filling of inflammatory substances within alveolar ducts, which are larger than the corresponding bronchioles. Inflammatory bronchiole per se represents the "tree" (stem) and inflammatory alveolar ducts constitute the "buds" or clubbing. "Clusters of micronodules", seen on 7-mm thick post-mortem radiographs with tuberculosis proved to be clusters of tree-in-bud lesions within the three-dimensional space of secondary pulmonary lobule based on radiological/pathological correlation. None of the post-mortem lung specimens showed findings of lung parenchymal lymphatics involvement.

The optimum chest compression site with regard to heart failure demonstrated by computed tomography.

BACKGROUND: To determine the optimum chest compression site during cardiopulmonary resuscitation (CPR) with regard to heart failure (HF) by applying three-dimensional (3D) coordinates on computed tomography (CT). METHODS: This retrospective, cross-sectional study involved adults who underwent echocardiography and CT on the same day from 2007 to 2017. Incomplete CT images or information on HF, cardiac medication between echocardiography and CT, or thoracic abnormalities were excluded. Cases were checked whether they had HF through symptom/sign assessment, N-terminal pro-B type natriuretic peptide, and echocardiography. We set the xiphisternal joint's midpoint as the reference (0, 0, 0) to draw a 3D coordinate system, designating leftward, upward, and into-the-thorax directions as positive. The coordinate of the maximum LV diameter's midpoint (P_max.LV) was identified. RESULTS: Enrolled were 148 patients (63.0±15.1 years) with 87 females and 76 HF cases. P_max.LV of HF cases was located more leftwards, lower, and deeper than non-HF cases (5.69±0.98, -1.51±1.67, 5.76±1.09 cm vs. 5.00±0.83, -0.99±1.36, 5.25±0.71 cm, all p<0.05). Fewer HF cases had their LV compressed than non-HF cases (59.2% vs. 77.8%, p=0.025) when being compressed according to the current guidelines. The aorta (vs. LV) was compressed in 85.5% and 81.9% of HF and non-HF cases, respectively, at 3 cm above the xiphisternal joint. At 6cm above the joint, the highest allowable position according to the current guidelines, all victims would have their aorta compressed directly during CPR rather than the LV. CONCLUSIONS: The lowest possible sternum just above the xiphisternal joint should be compressed especially for HF patients during CPR.

Outcomes of Esophageal Arterial Embolization for Treatment of Hemoptysis.

PURPOSE: To investigate safety and efficacy of esophageal arterial embolization (EAE) in addition to bronchial arterial embolization (BAE) for treatment of hemoptysis as well as the importance and characteristics of esophageal arteries in patients with hemoptysis. MATERIALS AND METHODS: Between January 2013 and December 2014, 20 patients (13 men and 7 women, mean age 58.4 y) underwent EAE in addition to BAE for hemoptysis. Retrospective review of patient records was performed to evaluate major causes of hemoptysis, treatment indications based on CT findings, esophageal angiography findings, and outcomes after embolization including clinical success rate and complications. RESULTS: Hemoptysis was caused by bronchiectasis (12 patients), tuberculosis (7 patients), and lobectomy (1 patient). CT showed lower lobe lung lesions in all (100%) patients. The esophageal arteries originated from the aorta between the carina and diaphragm (18 patients) or from the inferior phrenic arteries (2 patients) and were tortuous with longitudinal off-midline courses. Communications between the esophageal and the bronchial or inferior phrenic arteries were present in 12 patients. One patient who was treated using N-butyl cyanoacrylate developed dysphagia that resolved with medical treatment. Repeat BAE was performed in 2 patients 5 days and 20 days later, and the clinical success rate was 90% (18/20). CONCLUSIONS: EAE in addition to BAE is safe in the treatment of hemoptysis and should be considered for lower lobe lesions.

Sequential morphological changes in follow-up CT of pulmonary mucormycosis.

PURPOSE: We aimed to describe the computed tomography (CT) features of pulmonary mucormycosis including sequential changes between follow-ups. MATERIALS AND METHODS: Between June 2001 and May 2011, five patients (three males and two females; median age, 43 years; age range, 13-73 years) who had been pathologically diagnosed with pulmonary mucormycosis constituted our study population. Their clinical and CT features including sequential changes over follow-ups were evaluated retrospectively. RESULTS: All patients were immunocompromised due to either hematologic diseases (n=3), diabetes mellitus (n=1), or steroid administration for autoimmune hepatitis (n=1). All patients had symptoms such as fever (n=5), tachycardia (n=1), or pleuritic chest pain (n=1) on admission. Regarding the clinical outcome after treatment, one patient died, and the remaining four recovered from the disease. In terms of initial CT features, the morphologies of pulmonary mucormycosis included a single mass (n=3), consolidation (n=1), or multiple masses (n=1). There were seven pulmonary lesions in total, 3-7 cm in size, which showed a CT halo sign (n=3), reversed-halo sign (n=2), or air-fluid levels (n=2). On follow-up CTs, the lesions of all patients contained necrosis. All three patients with a mass or masses with a CT halo sign on initial CT had a decreased surrounding halo followed by central necrosis, and the lesions gradually decreased in size on recovery. CONCLUSION: Pulmonary mucormycosis usually manifests as a mass or masses with a halo or reversed-halo sign on the initial CT scan followed by a decreased extent of surrounding ground-glass opacities with the development of internal necrosis during follow-up.

Adaptive 4D volume perfusion CT of lung cancer: effects of computerized motion correction and the range of volume coverage on measurement reproducibility.

OBJECTIVE: The purpose of this study was to determine whether measurement reproducibility can be improved using computerized motion correction and whole-tumor coverage in adaptive 4D perfusion CT of lung cancer. SUBJECTS AND METHODS: Perfusion CT covering the entire z-axis of a mass was performed of 40 patients with lung cancer. Each perfusion CT study was performed in 93.5 seconds and included 17 repeated dynamic CT scans obtained using the Adaptive 4D Spiral mode. Tumor blood flow (BF), blood volume (BV), and permeability were measured in four different manners: in the entire tumor (whole-tumor coverage) without the use of motion correction; in the entire tumor with motion correction; in a small volume of interest (VOI) of tumor without motion correction; and in a small VOI with motion correction. Intra- and interobserver reproducibility were assessed through Bland-Altman analyses. RESULTS: The 95% limits of intraobserver reproducibility for BF, BV, and permeability were as follows: -52.1% to 48.0%, -22.4% to 27.8%, and -33.2% to 38.5%, respectively, in the whole tumor without motion correction; -53.3% to 45.6%, -17.7% to 20.6%, and -31.5% to 37.0% in the whole tumor with motion correction; -107.8% to 97.4%, -98.3% to 93.7%, and -132.3% to 100.7% in a small VOI of tumor without motion correction; and -74.9% to 98.6%, -74.5% to 88.1%, and -109.8% to 114.1% in a small VOI with motion correction. The 95% limits of interobserver reproducibility for BF, BV, and permeability were as follows: -57.0% to 62.5%, -36.8% to 52.6%, and -47.7% to 66.0%, respectively, in the whole tumor without motion correction; -55.7% to 55.8%, -25.8% to 42.0%, and -35.3% to 46.7% in the whole tumor with motion correction; -146.6% to 165.1%, -117.1% to 137.7%, and -143.2% to 149.8% in a small VOI of tumor without motion correction; and -106.2% to 133.6%, -99.5% to 122.4%, and -108.6% to 170.0% in a small VOI of tumor with motion correction. Overall, the best reproducibility was obtained when measurements were obtained in the entire tumor (i.e., whole-tumor coverage) and when motion correction was used. CONCLUSION: Measurement reproducibility of perfusion parameters improved when measurements in the entire tumor (i.e., whole-tumor coverage) were obtained and computerized motion correction was used. The best reproducibility in parameter values was obtained with motion correction and whole-tumor coverage.

A new classification of adenocarcinoma: what the radiologists need to know.

The International Association for the Study of Lung Cancer, American Thoracic Society, and European Respiratory Society recently introduced a new classification of lung adenocarcinoma addressing the latest advances in oncology, molecular biology, pathology, radiology, and surgery of lung adenocarcinoma. In this classification, new uniform terminology and diagnostic criteria are described, including the introduction of adenocarcinoma in situ as a second preinvasive lesion, as well as the concept of minimally-invasive adenocarcinoma and new subtyping of invasive adenocarcinomas stratified according to predominant patterns. In addition, the previously widely-used term bronchioloalveolar carcinoma is no longer considered valid and has been recategorized. This classification also provides, for the first time, guidance for small biopsies and cytology specimens. This new classification has profound implications for radiology, as much investigation will be needed to correlate these newly introduced concepts (such as histologic subtypes) with radiologic features. Understanding the newly described concept of minimally-invasive adenocarcinoma will be essential in determining sublobar resection for adenocarcinomas. In this manuscript, we briefly review the new classification of lung adenocarcinoma and discuss its radiologic relevance to the reporting, biopsy, and future studies of adenocarcinoma.

Computed tomography features of extensively drug-resistant pulmonary tuberculosis in non-HIV-infected patients.

OBJECTIVE: To describe the computed tomography (CT) findings of pulmonary extensively drug-resistant tuberculosis (XDR-TB) in non-HIV-infected patients and to compare them with those of non-XDR multidrug-resistant tuberculosis (MDR-TB). METHODS: Retrospective review of microbiological results and drug-susceptibility tests of 260 non-HIV-infected patients who had been diagnosed with pulmonary MDR-TB from 1994 to 2005 revealed that 47 patients had XDR-TB, whereas the other 213 patients had non-XDR MDR-TB. Twenty of the 47 XDR-TB patients and 85 of the 213 non-XDR MDR-TB patients with available CT examinations were included in this study. Two radiologists reviewed the CT studies in consensus for the presence and extent of micronodules, tree-in-bud appearance, lobular consolidation (<2 cm), consolidation, cavity, bronchiectasis, emphysema, pleural effusion, lymphadenopathy, bronchopleural fistula, and empyema. We then compared the CT features of XDR-TB with those of non-XDR MDR-TB. RESULTS: Micronodules and tree-in-bud appearance were the most frequent CT abnormalities and were seen in all XDR-TB patients (100%). Consolidations, cavities, bronchiectasis, and lobular consolidations were found in 85%, 85%, 80%, and 70% of XDR-TB patients, respectively. The extents of micronodules, tree-in-bud appearance, lobular consolidation, consolidation, cavity, bronchiectasis, and emphysema were 3.60, 3.55, 1.35, 1.85, 1.65, 1.45, and 0.25 lobes, respectively. Compared with non-XDR MDR-TB, XDR-TB showed a significantly larger extent of tree-in-bud appearance and consolidation (P < 0.05). With respect to other CT features, there were no significant differences between XDR-TB and non-XDR MDR-TB. CONCLUSION: Computed tomography findings of pulmonary XDR-TB are similar to those of non-XDR MDR-TB; however, XDR-TB tends to have more extensive consolidation and tree-in-bud appearance.

FN13762 murine breast cancer: region-by-region correlation of first-pass perfusion CT indexes with histologic vascular parameters.

PURPOSE: To investigate the correlation between first-pass perfusion computed tomographic (CT) indexes and histologic vascular parameters in FN13762 breast cancer in rats by using region-by-region correlation methods. MATERIALS AND METHODS: The Animal Care and Use Committee approved this study. FN13762 murine breast cancer cells were implanted in 14 female Fischer 344 rats, and first-pass perfusion CT was performed. CT perfusion maps depicting blood flow, blood volume, mean transit time (MTT), and permeability-surface area (PSA) product were generated by using commercial perfusion software. The entire tumor area was divided into six separate regions on perfusion maps, and the regional perfusion indexes were quantified. Histologic vascular parameters, including microvessel density (MVD), luminal vessel number, luminal vessel area, and luminal vessel perimeter, were measured in the histologic region corresponding to the perfusion maps. Correlation analysis was performed between regional tumor perfusion indexes and histologic vascular parameters of the corresponding tumor region. Additionally, mean perfusion values of the entire tumor were correlated with histologic vascular parameters of the hot spot within the tumor. Among 14 rats, four were excluded from the analysis, and results were based on a final total of 10 rats. RESULTS: In tumors, blood flow, blood volume, and PSA product were significantly higher and MTT was significantly shorter (P < .05 for all) than these values in normal neck muscles. At region-by-region correlation, regional blood flow (r = 0.476), blood volume (r = 0.348), and MTT (r = -0.506) were significantly correlated with MVD in the corresponding tumor region (P < .01 for all). After adjustment for biologic variability between rats, regional blood flow (r = 0.614), blood volume (r = 0.515), MTT (r = -0.524), and PSA product (r = 0.228) remained significantly correlated with MVD in the corresponding tumor region. Correlation analysis between CT perfusion indexes of the entire tumor and histologic vascular parameters of the hot spot did not show significant correlations (P > .05). CONCLUSION: Regional blood flow, blood volume, and MTT are significantly correlated with MVD in the corresponding tumor region.

Efficacy of computer-aided detection system and thin-slab maximum intensity projection technique in the detection of pulmonary nodules in patients with resected metastases.

OBJECTIVES: To evaluate the efficacy of the computer-aided detection (CAD) system and thin-slab maximum intensity projection (MIP) technique in the detection of pulmonary nodules at multidetector computed tomography (CT) in patients who underwent metastatectomy. MATERIALS AND METHODS: This retrospective study was approved by the institutional review board and patients' informed consent was waived. Forty-nine consecutive patients who underwent pulmonary metastatectomy were enrolled. Four chest radiologists analyzed preoperative 1-mm section CT images and recorded the locus of each nodule candidate. Afterward, they reevaluated the images once using CAD software and once with thin-slab MIP given the results of 1-mm section CT alone. The reference standard for nodule presence was established by a consensus panel and pathologic records for malignant nodules. RESULTS: A total of 514 nodules were identified by a consensus panel. Of 212 nodules surgically removed, 121 nodules were malignant. The sensitivity of each observer in detecting malignant nodules with thin-section CT scans alone was 91%, 88%, 87%, and 86% for observers A- to D, respectively. With CAD, sensitivity increased significantly to 95%, 95%, 94%, and 95% (P< 0.05 for observer B-D), and using MIP increased to 94%, 96%, 91%, and 92% (P < 0.05 for observer B-D), respectively. There were no significant differences in sensitivity between CAD and MIP for the detection of malignant nodules. The average number of false-positive findings per patient was 0.8 with thin-section CT alone, 1.1 with CAD, and 1.4 with MIP. CONCLUSIONS: In candidates for metastatectomy, reading with the aid of either CAD or MIP significantly improved the detection of malignant nodules compared with using thin-section CT alone.

Vision of the korean association of medical colleges.

The Korean Association of Medical Colleges (KAMC) has launched as a corporate aggregate in August 2008, since the inauguration meeting as "Korean Association of Medical School Deans" 24 years before. The mission of KAMC is to be the representing agency of medical education in Korea, producing policies and strategies, suggesting and influencing government agencies related to medical education. The KAMC will consolidate its basic role and continue to expand its role as well; evaluation of basic medical education, representative of graduate medical education, policy making of medical manpower education system.