Edoardo Cavigli

Operator-dependent Reproducibility of Size Measurements of Small Phantoms and Lung Nodules Examined With Low-dose Thin-section Computed Tomography

Objective:We sought to assess the reproducibility of size measurements of small lung nodules examined with low-dose thin-section computed tomography (LDTSCT). Materials and Methods:Three radiologists measured volume with a semiautomatic tool and diameters manually of 20 (equivalent diameter range, 5.3–11 mm) phantom nodules and 37 (mean diameter range, 5–8.5 mm) lung nodules in subjects undergoing LDTSCT. Results:In phantoms, the worst 95% limits of agreement (95% LA) for volume were −3.0% and 3.0% within operator and −3.1% and 2.8% between operators. The coefficient of repeatability (CR) for diameter ranged between 0.51 and 0.67 mm within operator and the 95% LA were from −0.71 to 0.71 mm between operators. In nodules, the worst intraoperator 95% LA for volume were −14.4% and 17.6% within operator and −13.1% and 14.2% between operators. The CR for diameter ranged between 0.48 and 0.73 mm within operator and the 95% LA were from −1.16 to 1.16 mm between operators. Conclusion:Operator-dependent variability of size measurements of small nodules examined with LDTSCT is not negligible and should be considered in lung cancer-screening studies.

Thin-section and low-dose volumetric computed tomographic densitometry of the lung in systemic sclerosis.

Objective: To correlate lung density measurements with the results of visual assessment of thin-section computed tomography (CT) and of pulmonary function tests (PFT) in Systemic Sclerosis (SSc). Methods: Thirty-nine SSc patients underwent sequential thin-section CT and spiral low-dose whole-lung acquisitions. The thin-section CT scans were evaluated with a dedicated visual scale. Mean lung density, skewness, and kurtosis were calculated from the lung density histogram. In addition from the spiral low-dose acquisition, the lung volume was computed. The visual score, the densitometric parameters, and the lung volume were correlated with the PFT. Results: Mean lung density, skewness, and kurtosis computed from thin-section (R = 0,66; R = −0,74; R = −0,75) and low-dose volumetric (R = 0,72; R = −0,71; R = −0,71) CT and the lung volume (R = −0.54) correlated with the visual score. Densitometric values and lung volume consistently better correlated with PFT than the visual score. Conclusions: In SSc the histogram results are more closely correlated to PFT than the visual score. The low-dose spiral CT seems ideal for longitudinal studies.

BODE-index, modified BODE-index and ADO-score in Chronic Obstructive Pulmonary Disease: Relationship with COPD phenotypes and CT lung density changes

Abstract COPD is a heterogeneous disorder whose assessment is going to be increasingly multidimensional. Grading systems such as BODE (Body-Mass Index, Obstruction, Dyspnea, Exercise), mBODE (BODE modified in grading of walked distance), ADO (Age, Dyspnea, Obstruction) are proposed to assess COPD severity and outcome. Computed tomography (CT) is deemed to reflect COPD lung pathologic changes. We studied the relationship of multidimensional grading systems (MGS) with clinically determined COPD phenotypes and CT lung density. Seventy-two patients underwent clinical and chest x-ray evaluation, pulmonary function tests (PFT), 6-minute walking test (6MWT) to derive: predominant COPD clinical phenotype, BODE, mBODE, ADO. Inspiratory and expiratory CT was performed to calculate mean lung attenuation (MLA), relative area with density below-950 HU at inspiration (RAI-950), and below -910 HU at expiration (RAE-910). MGS, PFT, and CT data were compared between bronchial versus emphysematous COPD phenotype. MGS were correlated with CT data. The prediction of CT density by means of MGS was investigated by direct and stepwise multivariate regression. MGS did not differ in clinically determined COPD phenotypes. BODE was more closely related and better predicted CT findings than mBODE and ADO; the better predictive model was obtained for CT expiratory data; stepwise regression models of CT data did not include 6MWT distance; the dyspnea score MRC was included only to predict RA-950 and RA-910 which quantify emphysema extent. BODE reflect COPD severity better than other MGS, but not its clinical heterogeneity. 6MWT does not significantly increase BODE predictivity of CT lung density changes.

Atypical HRCT manifestations of pulmonary sarcoidosis

PurposeTo present our experience of cases of pulmonary sarcoidosis with atypical HRCT patterns found during 2016 focusing on the differential diagnosis to contribute to the difficult role of the radiologist in the disease identification and to help the clinicians to reach the diagnosis.Materials and methodsThe HRCT examinations of 47 patients with sarcoidosis were studied retrospectively. All patients had a histopathological confirm of the disease. 29 (61.7%) show a typical pulmonary pattern and 18 (38.3%) an atypical pattern. The latter were evaluated by three experienced radiologists dedicated to thoracic disease to radiologically define the predominant pattern of presentation.ResultsIn the 18 patients (38.3%) with atypical sarcoidosis, the following parenchymal patterns were observed: four patients (22.2%) had interstitial fibrotic alterations, three patients (16.6%) with reticular pattern with inter–intralobular septal thickening, two patients (11.1%) with small-airway involvement with mosaic oligoemia, two patients (11.1%) with pleural involvement (pneumothorax and pleural plaques), one patient (5.5%) with fibrocystic changes, 1 (5.5%) with halo-sign, 1 (5.5%) with diffuse bilateral ground-glass opacities, and 1 (5.5%) with isolated lung mass; in addition, three patients (16.6%) with atypical lymph node pattern were also found.Conclusions and DiscussionThe atypical pulmonary alterations found in CT examination can be confused with other lung diseases and they are always a challenge even for the most experienced radiologist. In our experience, cases with atypical pulmonary sarcoidosis patterns evaluated in the study are consistent with similar cases described in the literature, both in lymph node and atypical parenchymal involvement. All the atypical characteristics of the work should alert the radiologist to consider sarcoidosis among the possible differential diagnoses, always correlating the results of the computed tomography examination with appropriate clinical-laboratory evaluations.

Lung/Pleural Injuries

Thoracic trauma account for about 25% of all trauma deaths and may produce injuries to endothoracic organs that play a vital role in normal physiology and homeostasis; some injuries to the chest and its contents, if unrecognized or untreated, may produce death within minutes. In the diagnostic algorithm of thoracic trauma, clinical data are of extreme importance and must be well recognized by the emergency physician. But, because of the low specificity of most of them consisting mainly in dyspnea, cough, hemoptysis, chest pain and, in very critical cases, in severe hypoxia or shock, imaging plays an essential role in the diagnostic work-up of these events permitting in most cases a fast and definite diagnosis and, therefore, a prompt adequate treatment. In an emergency context, three imaging modalities are helpful in the diagnosis of a thoracic trauma: chest X-ray, ultrasound (US) examination, and multidetector computed tomography (MDCT). Chest plain film and US examination play an important role in the initial emergency work-up of post-traumatic thoracic injuries as they are cheap and bedside available. Actually, MDCT has established itself as the preferred imaging method for the evaluation of polytrauma patients. This chapter will consider the main pleural and lung lesions and the injuries caused by open trauma.

Pulmonary hypertension nosography: are all patients classifiable?

Elena Torricelli, Chiara Cresci A 73-year-old never smoking woman was admitted for exertional dyspnoea to the Respiratory Medicine Section of our hospital in June 2014. The patient’s past clinical history revealed systemic arterial hypertension, persistent atrial fibrillation, non-insulin dependent diabetes, hypothyroidism, and hypercholesterolemia. She was taking in treatment with acenocoumarol and metformin. The patient had progressive exercise dyspnoea (NYHA class II) and ankle swelling since 2011. She had been diagnosed with interstitial lung disease with pulmonary hypertension (PAPs of 60 mmHg by transthoracic echocardiography) and hypoxemic respiratory insufficiency. She was referred to our hospital following further worsening of dyspnoea and reduction in exercise tolerance despite long-term oxygen therapy (1 L/min). At admission, she had dyspnoea on minor activities (modified Medical Research Council— mMRC = 3, NYHA class III), cyanosis, increased respiratory rate (22 breaths/min), and ankle swelling. She had systemic pressure at lower limits of normality (105/ 65 mmHg) and a BMI of 28 (158 cm, 71 kg). At physical examination, fine crackles were audible at both lung bases. She had low (54 mmHg) arterial oxygen tension in oxygen therapy with 1 L/min with CO2 tension of 50 mmHg, in a framework of compensated respiratory acidosis (HCO3 33 mmHg). No alterations of serum electrolytes were found. We got sufficient correction of hypoxia (PaO2 63 mmHg) by increasing flow oxygen support at 3 L/min with a modest increase of hypercapnia (PaCO2 54 mmHg). The chest radiograph showed increased cardiac size, bulging of the second arch on the left mediastinal border compatible with enlargement of the pulmonary artery common trunk (Fig. 1). No signs of pulmonary congestion were observed. The electrocardiogram showed atrial fibrillation with average ventricular rate of 77 beats per minute, intraventricular conduction delay, and right axial deviation. Transthoracic echocardiography showed severe tricuspidal regurgitation with TAPSE (tricuspid annular plane systolic excursion) of 15 mm, PAPs of 70 mmHg, right and left atrial enlargement, interventricular septum paradoxical movement, inferior vena cava dilatation with no change on inspiration, mild pericardial effusion, and normal size and wall thickness of the left ventricle, without alteration on the segmental kinesis. Cardiac ejection fraction was preserved (61%). No diastolic relaxation abnormalities were detected. E/A ratio [early transmitral flow (E) and the late flow with atrial contraction (A)] was 0.8 and the ratio E/e0 [early filling velocity on transmitral Doppler (E) with the early relaxation velocity on tissue Doppler (e0)] was 7. Only mild mitral regurgitation was described. Calcification of the cusps of the aortic valve with normal opening was described. Aortic valve peak gradient was 22 mmHg. We decided to treat the patient with furosemide 20 mg iv TID, oxygen therapy (3 L/min) with a partial clinical & Elena Torricelli e.torricelli@alice.it

Radiological Patterns of Lung Involvement in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a form of chronic inflammation of the gastrointestinal tract, including two major entities: ulcerative colitis and Crohns disease. Although intestinal imaging of IBD is well known, imaging of extraintestinal manifestations is not extensively covered. In particular, the spectrum of IBD-associated or related changes in the chest is broad and may mimic other conditions. The common embryonic origin of intestine and lungs from the foregut, autoimmunity, smoking, and bacterial translocation from the colon may all be involved in the pathogenesis of these manifestations in IBD patients. Chest involvement in IBD can present concomitant with or years after the onset of the bowel disease even postcolectomy and can affect more than one thoracic structure. The purpose of the present paper is to present the different radiological spectrum of IBD-related chest manifestations, including lung parenchyma, airways, serosal surfaces, and pulmonary vasculature. The most prevalent and distinctive pattern of respiratory involvement is large airway inflammation, followed by lung alterations. Pulmonary manifestations are mainly detected by pulmonary function tests and high-resolution computed tomography (HRCT). It is desirable that radiologists know the various radiological patterns of possible respiratory involvement in such patients, especially at HRCT. It is essential for radiologists to work in multidisciplinary teams in order to establish the correct diagnosis and treatment, which rests on corticosteroids at variance with any other form of bronchiectasis.

Gorham-Stout Disease Management during Pregnancy

Gorham-Stout Disease (GSD) is a rare lymphatic disorder affecting children or young adults with no predilection of sex. It is generally associated with vanishing bone osteolytic lesions, thoracic and abdominal involvement, and diffuse pulmonary lymphangiomatosis. Chylous effusions and chylothorax, consequent to the abnormal proliferation of lymphatic vessels, may induce respiratory failure with a high mortality risk. Extrapulmonary alterations may include chylous ascites, lymphopenia, and destructing bone disease for overgrowth of lymphatic vessels. Here, we report the case of a young woman who developed a severe and recalcitrant GSD with persistent unilateral chylothorax during pregnancy. The complex management of this patient during and after pregnancy was discussed and compared with literature data to contribute to the definition of a correct diagnostic and therapeutic approach to this rare lymphatic disease.